Definition
Dissociation is a mental process in which there is a lack of connection in thoughts, memories, feelings, actions or identity. While dissociating, certain information is not associated with other information as it normally would be. Some believe that dissociation exists on a continuum ranging from daydreaming to Dissociative Identity Disorder at the other. (IBID) However there is great overlap between the different dissociative disorders (DD), including DID (IBID).
DID was previously called multiple personal disorder but in 1994 the name was changed to reflect the changes in understanding of the disorder. It involves a disturbance in identity whereby two or more separate personalities or identities, known as alters, control an individual's behavior. "Personality" here is defined as "enduring patterns of perceiving, relating to, and thinking about the environment and oneself" (American Psychiatric Association, 1994, p. 270). When under the control of one alter, they may exhibit different behaviors, mannerisms, personalities, gender orientation, and physical properties (such as handedness, allergies and eyesight) and might not remember what transpired when another personality was in control. They may have as many as 100 alters or as few as two, though the average is 10 distinct ones, and they are stable over time. It is sometimes known as "disaggregate self state" because it is dissociated parts of the mind influencing behavior in DID patients.
Personalities may be aware of each other to some degree though only one will be in control at a given time; transitions are typically sudden and precipitated by stress (Morrison, 1995). Usually personalities are aware of loss of time when another personality is interacting with the environment. (Morrison, 1995).
Symptoms
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Multiple personalities, on average 10 though there can be as few as two and as many as 100
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Exhibits different personalities, behavior and even physical characteristics
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Episodes of amnesia or time loss (i.e.: don't remember people, places etc)
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Often they are depressed or suicidal
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Self-mutilation is common
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1/3 of patients experience visual or auditory hallucinations
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The average age for the development of alters is 5.9 years
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Depressive symptoms
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An inability to focus in school (in childhood)
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Conduct problems (in childhood)
To be clinically diagnosed with DID, the following symptoms must be identified:
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The presence of at least two distinct personalities with their own relatively enduring pattern of sensing, thinking about, and relating to self and environment
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At least two of these personalities assume control of behavior repeatedly
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Extensive inability to recall major personal information cannot be attributed to common forgetfulness
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This behavior is not caused directly by substance abuse or a general medical condition
(American Psychiatric Association, 1994; Morrison, 1995)
Diagnosis
In children, the symptoms are often misdiagnosed as schizophrenia. Diagnosis is more readily made by the time the children reach adolescence.
Standardized tests have been developed to supplement the clinician's judgment, and to aid in the tailoring of treatment plans. A diagnosis is reached by a mental status examination supplemented by questions concerning dissociative symptoms. Among the questions the patient should be asked about include episodes of amnesia, fugue, depersonalization, derealization, identity confusion, and identity alteration, age regressions, autohypnotic experiences and auditory hallucinations. Screening tools (i.e.: Dissociative experience scale, dissociative questionnaire, questionnaire of experiences of dissociation) and psychological tests, such as the Rorschach, have been used to establish a diagnosis. The existence of DID may also unexpectedly be revealed during hypnotherapeutic treatment of another condition.
Causes
Some types of depression run in families, suggesting that a biological vulnerability can be inherited. This seems to be the case with bipolar disorder. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder will have the illness. Apparently additional factors, possibly stresses at home, work, or school, are involved in its onset.
In some families, major depression also seems to occur generation after generation. However, it can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with changes in brain structures or brain function.
Treatment
Treatment is mainly psychotherapy with hypnosis. The goal is to deconstruct the different personalities and unite them into one. The therapist attempts to make contact with as many alters as possible and tries to understand their roles and functions in the person's life. The therapist seeks to make a connection with personalities that especially display violent or self-destructive tendencies. Another goal of the therapist is to set up a communication among the personalities to retrieve traumatic memories from the past. Generally treatment is as an outpatient, though inpatient treatment may be used to achieve a specific goal. Behavior analysis has not been demonstrated to be effective (IBID).
Prognosis
Following diagnosis of DID, most therapists see 3-5 years as a minimum length of treatment, though more complex patient may require six or more years of therapy for the patient to be stabilized and unite their different personalities.