Dissociative identity disorder (Multiple personality disorder)

In dissociative disorders auditory hallucinations are perceived as originating from within the person, commenting in their head instead of behind their back. 

Only 6% of patients with DID present with multiple or dissociated identities publicly and in the obvious manner.

Majority of patients do not have dramatic shifts in personality and only persons very close to them are aware of the personality changes.

Headaches are the most frequent somatic complaint of patients with DID(60%).

Somatic symptoms such as headaches, joint pain, back pain, pelvic pain, extremity pain are more common in patients with DID than controls.

Dissociative amnesia is defined as an ability to recall autobiographical data beyond normal forgetfulness, and the condition may involve bewildered wondering or a fugue state.

Depersonalization / derealization disorder manifest by clinically significant persistent or recurrent depersonalization with detachment from the mind, self, or body, and or derealization, which is detachment from the surroundings.

Dissociative identity disorder is a complex psychological condition in which a person’s sense of identity is fragmented, leading to the development of multiple distinct personalities.

The alters may have different names, voices, mannerisms, and even memories, and can sometimes coexist within the same person, each with its own set of thoughts, feelings, and behaviors.

This disorder often stems from severe emotional trauma, such as childhood abuse or neglect. 

It is believed to be a coping mechanism that the mind creates to protect itself from overwhelming psychological pain. 

Treatment for dissociative identity disorder usually involves a combination of therapy and medication to help the person to overcome the underlying trauma that led to the disorder.

 Other conditions that often occur in people with DID include:  post-traumatic stress disorder, personality disorders, especially borderline and avoidant, depression, substance use disorders, conversion disorder, somatic symptom disorder, eating disorders, obsessive–compulsive disorder, and sleep disorders.

Self-harm, non-epileptic seizures, flashbacks with amnesia for content of flashbacks, anxiety disorders, and suicidality are also common.

DID is the result of repeated or long-term childhood trauma of child abuse or neglect, that is combined with an insecure or disorganized attachment.

DID does not form after ages 6-9 years, as individuals older than these ages have an integrated self identity and history. 

Trauma that occurs later in life can lead to post-traumatic stress disorders other dissociative disorders including other specified dissociative disorder, somatic symptom disorders, or possibly borderline personality disorder.

DID requires an unintegrated mind to form. 

DID is also related to genetic and biological factors.

Substance use disorder, seizures, other mental health problems, imaginative play in children, or religious practices may confuse the diagnosis.

Treatment:

Supportive care and psychotherapy.

The  condition usually persists without treatment.

DID is diagnosed about six times more often in women than in men.

Increased rates of the disorder may be due to better recognition or sociocultural factors such as mass media portrayals.

Presenting symptoms in different regions of the world may vary depending on culture: identities taking the form of possessing spirits, deities, ghosts, or mythical figures in some cultures.

The dissociative identity disorder is involuntary and distressing.

DID occurs in a way that violates cultural or religious norms.

DSM-5 symptoms of DID include the presence of two or more distinct personality states accompanied by the inability to recall personal information beyond what is expected through normal memory issues, loss of identity as related to individual distinct personality states, loss of one’s subjective experience of the passage of time, and degradation of a sense of self and consciousness.

The clinical presentation varies by individual and the level of functioning can change from severe impairment to minimal.

DID patients may experience distress from both the symptoms of DID such as intrusive thoughts or emotions, and the consequences of the symptoms, rendering them unable to remember specific information.

Amnesia between identities may be asymmetrical, in that they may or may not be aware of what is known by another identity.

DID patients may experience time disturbances.

Around half of patients  with multiple personality disorder  have fewer than 10 identities and most have fewer than 100; although as many as 4,500 have been reported.

The average number of identities has increased over the past few decades, from two or three to now an average of approximately 16. 

The patient’s psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures.

DID’s most common presenting complaint is depression.

Headaches are   a common neurological symptom. 

Comorbid disorders include:  substance use disorder, eating disorders, anxiety disorders, bipolar disorder, personality disorders, borderline personality disorder and post-traumatic stress disorder (PTSD).

There is a high rate of dissociative auditory hallucinations.

Other disorders found to be comorbid with DID: somatization disorders, major depressive disorder, as well as history of a past suicide attempt.

Individuals diagnosed with DID demonstrate the highest hypnotizability of any clinical population.

DID has significant overlap with borderline personality disorder, and can be difficult to distinguish between the two.

DID is multifactorial in its etiology: 

Psychosocial etiologies of DID include developmental traumatization and sociocognitive sequelae, biological factors include trauma-generated neurobiological responses, biologically derived traits and epigenetic mechanisms. 

It is regarded as the most severe form of a childhood onset post-traumatic stress disorder (PTSD) because it is virtually impossible to find a DID patient without a history of PTSD. 

DID is associated with overwhelming traumatic events, and/or abuse during childhood.

Other risk factor include childhood neglect, childhood medical procedures, war, terrorism, and childhood prostitution.

Disturbed and altered sleep, and  alterations in environments also largely affecting the DID patient.

People diagnosed with DID often report that they have experienced physical or sexual abuse during childhood, overwhelming stress, serious medical illness or other traumatic events during childhood.

Patients with DID also report more historical psychological trauma than those diagnosed with any other mental illness.

It is theorized severe sexual, physical, or psychological trauma in childhood results in the removal of awareness, memories and emotions of such harmful actions or events from consciousness, and alternate personalities or subpersonalities form with differing memories, emotions and behavior.

The process is attributed to extremes of stress or disorders of attachment: it may be expressed as post-traumatic stress disorder (PTSD) in adults may become DID when occurring in children, due possibly to their greater use of imagination as a form of coping.

Childhood abuse, disorganized attachment, and lack of social support are thought to be a necessary component of DID.

The prevailing post-traumatic model of dissociation and dissociative disorders is contested, and has been hypothesized that symptoms of DID may be created by therapists attempting to “recover” memories on suggestible individuals.

This sociocognitive model proposes that DID is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes, and unwitting therapists providing cues through improper therapeutic techniques.

The bizarre dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of DID who, through the process of eliciting, conversing with and identifying alters, shape or possibly create the diagnosis. 

The characteristics of people diagnosed with DID: hypnotizability, suggestibility, frequent fantasization and mental absorption contribute to these concerns of the validity of recovered memories of trauma.

Only a small subset of doctors are responsible for diagnosing the majority of individuals with DID.

Some suggest that in addition to therapy caused cases, DID may be the result of role-playing rather than alternative identities.

Arguments suggesting therapy can cause DID: include the lack of children diagnosed with DID, the sudden spike in rates of diagnosis after 1980, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities such as those claiming to be animals or mythological creatures and an increase in the number of alternate identities over time, as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy.

These cultural and therapeutic causes occur within a context of pre-existing psychopathology: borderline personality disorder, which is commonly comorbid with DID.

Psychotherapy as a cause of DID is suggested by its strong linked to psychotherapy, often involving recovered memories or false memories, and that such therapy could cause additional identities. 

Such memories could be used to make an allegation of child sexual abuse. 

Supporters of therapy as a cause of DID suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position.

However, the  higher rates of diagnosis in specific countries like the United States may be due to greater awareness of DID. 

Lower rates in other countries may be due to artificially low recognition of the diagnosis.

The false memory syndrome per se is not regarded by mental health experts as a valid diagnosis.

The rarity of DID diagnosis in children is cited as a reason to doubt the validity of DID.

The initial description of DID was that dissociative symptoms were a means of coping with extreme stress, particularly childhood sexual and physical abuse, but this belief has been challenged by the data of multiple research studies.

The traumagenic hypothesis claims the high correlation of child sexual and physical abuse reported by adults with DID corroborates the link between trauma and DID.

However, the DID–maltreatment link often relies on self-reporting  rather than independent corroborations, and these results may be worsened by selection and referral bias.

Most studies of trauma and dissociation are cross-sectional rather than longitudinal.

In addition, studies rarely control for the many disorders comorbid with DID, or family maladjustment.

The popular association of DID with childhood abuse is relatively recent.

Despite studies on DID: structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potential, and electroencephalography, there are no neuroimaging findings that identify DID.

DID patients show deficiencies in tests of conscious control of attention and memorization and increased and persistent vigilance and startle responses to sound. 

Patients also show evidence of being more fantasy-prone, which in turn is related to a tendency to over-report false memories of painful events.

DID is often initially misdiagnosed.

DID is rarely diagnosed in children, despite the average age of appearance of the first alter being three years old.

The criteria require that an individual be recurrently controlled by two or more discrete identities or personality states, accompanied by memory lapses for important information that is not caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures: the symptoms can not be better explained by imaginary playmates or other fantasy play.

Diagnosis is normally performed through clinical evaluation, interviews with family and friends, and consideration of other ancillary material. 

Most of the symptoms depend on self-report and are not concrete and observable, there is a degree of subjectivity in making the diagnosis

The diagnosis has been criticized as it is believes to be a culture-bound and often health care induced condition.

The condition may be under-diagnosed due to skepticism, lack of awareness from mental health professionals, lack of specific and reliable criteria for diagnosing DID as well as a lack of prevalence rates.

People with DID are diagnosed with five to seven comorbid disorders,  on average, which is much higher than other mental illnesses.

Differential diagnosis includes : schizophrenia, bipolar disorder, epilepsy, borderline personality disorder, and autism spectrum disorder.

DID diagnosis must be distinguished from, or determined if comorbid disorders including mood disorders, psychosis, anxiety disorders, PTSD, personality disorders, cognitive disorders, neurological disorders, epilepsy, somatoform disorder, factitious disorder, malingering, other dissociative disorders, and trance states.

Persistence of identities and behavior, amnesia, measures of dissociation or hypnotizability and reports from family members or other associates indicating a history of such changes can help distinguish DID from other conditions. 

Auditory hallucinations are common in DID, and complex visual hallucinations may also occur.

Patients with DID generally have adequate reality testing.

Patients with DID perceive any voices heard as coming from inside their heads, while patients with schizophrenia experience them as external.

Individuals with psychosis are much less susceptible to hypnosis than those with DID.

People with DID typically exhibit confusion, distress and shame regarding their symptoms and history.

The majority of those diagnosed with DID would also meet the criteria for either borderline personality disorder or more generally borderline personality.

Many features of dissociative identity disorder can be influenced by the individual’s cultural background. 

Individuals with DID may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. 

Similarly, in the developing world, among certain religious groups the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. 

Acculturation may shape the characteristics of identities.

Possession-forms of  dissociative identity disorder can involve conflict between the individual and his or her surrounding family, social, or work milieu, violating the norms of the culture or religion.

DID is among the most controversial of psychiatric disorders.

It is a dispute is between those who believe DID is caused by traumatic stresses forcing the mind to split into multiple identities, each with a separate set of memories, or the belief that the symptoms of DID are produced by certain psychotherapeutic practices or patients playing a role they believe appropriate for a person with DID.

Some believe that DID symptoms are created by therapists themselves via hypnosis. 

Those with DID are more susceptible to manipulation by hypnosis and suggestion than others

Treatment aims to increase integrated functioning, or harmony among alternate identities.

Therapists have few patients that achieve a unified identity.

Common treatment methods include psychotherapy techniques, cognitive behavioral therapy (CBT), insight-oriented therapy,dialectical behavioral therapy (DBT), hypnotherapy and eye movement desensitization and reprocessing.

Medications sre used for comorbid disorders or targeted symptom relief, for example antidepressants or treatments to improve sleep.

Suicidal ideation, suicide attempts, and self-harm also may occur.

Individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic relationship.

Treatment generally lasts years.

Different personalities may appear based on their greater ability to deal with specific situational stresses or threats.

It is important for the therapist to become familiar with at least the more prominent personality states, as specific alters may react negatively to therapy, fearing the therapist’s goal is to eliminate the alter, particularly those associated with illegal or violent activities.

A goal of treatment is to integrate adaptive responses to abuse, injury or other threats into the overall personality structure.

The first phase of therapy focuses improving the patient’s capacity to form and maintain healthy relationships, and improving general daily life functioning. 

Comorbid disorders such as substance use disorder and eating disorders are addressed in this phase of treatment.

The second phase focuses on exposure to traumatic memories and prevention of re-dissociation. 

Finally, a phase focuses on reconnecting the identities of disparate alters into a single functioning identity.

Little is known about prognosis of untreated DID.

Symptoms may resolve from time to time or wax and wane spontaneously.

Patients with mainly dissociative and post-traumatic symptoms have  a better prognosis than those with comorbid disorders.

The 12-month prevalence of DID among adults in the US is estimated at 1.5%, with similar prevalence between women and men.

Reported rates in the community vary from 1% to 3% with higher rates among psychiatric patients.

There a prevalence of DID of 2–5% among psychiatric inpatients, 2–3% among outpatients, and 1% in the general population, with rates reported as high as 16.4% for teenagers in psychiatric outpatient services.

Dissociative disorders in general have a prevalence of 12.0%–13.8% for psychiatric outpatients.

DID diagnoses are extremely rare in children,

DID occurs more commonly in young adults and declines in prevalence with age.

There is a significant overlap of symptoms between borderline personality disorder and DID.

Rates of diagnosed DID were increasing in the late 20th century, reaching a peak of diagnoses at approximately 40,000 cases by the end of the 20th century.

In addition, this rise was associated with an increase in the number of alters, rising from only the primary and one alter personality in most cases, to an average of 13 in the mid-1980s:  the increase in both factors has resulted in professional skepticism regarding the diagnosis.

The use of inappropriate therapeutic techniques in highly suggestible individuals, may account for DID increase in incidence

The incidence may be due to increased recognition of the disorder.

DID is considered a controversial diagnosis and condition, with much of the literature being generated and published in North America, to the extent that it was once regarded as a phenomenon confined to that continent.

DID is not a multitude of personalities, but rather a lack of a single, unified identity and an emphasis on identities as centers of information processing.

Personality term is used to refer to characteristic patterns of thoughts, feelings, moods, and behaviors of the whole individual, but for a patient with DID, the switches between identities and behavior patterns is the personality.

While the patient may name and personalize alters, they lack independent, objective existence.

Amnesia was central to DID.

There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990, and  40,000 cases were diagnosed from 1985 to 1995.

Scientific publications regarding DID peaked in the mid-1990s then the diagnosis of DID rapidly declined.

Most people with DID are believed to downplay or minimize their symptoms rather than seeking fame, often due fear of the effects of stigma and shame.

The dissociative disorders are more frequently found to occur in the aftermath of trauma.

Many of the symptoms of DD include embarrassment and confusion about the symptoms or a desire to hide them, are influenced by the proximity to trauma. 

Both acute stress disorder and post-traumatic stress disorder contain dissociative symptoms, such as amnesia, flashbacks, numbing, and depersonalization/derealization.