Multiple Minds: 12/31/2006

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Multiple personality disorderClassifications and external resources
ICD-10 F44.81
ICD-9 300.14

Dissociative identity disorder (DID) is a diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Revised, as the existence in an individual of two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. At least two of these personalities are considered to routinely take control of the individual's behavior, and there is also some associated memory loss, which is beyond normal forgetfulness. This memory loss is often referred to as "losing time". These symptoms must occur independently of substance abuse, or a general medical condition.

Dissociative identity disorder was initially named multiple personality disorder (MPD), and, as referenced above, that name remains in the International Statistical Classification of Diseases and Related Health Problems. Regardless of whether the disorder is termed dissociative identity disorder or multiple personality disorder, it is in no way related to schizophrenia. Although schizophrenia and dissociative identity disorder are commonly linked in the minds of lay people, it is a misconception.

While dissociation is a demonstrable psychiatric condition that is tied to several different disorders, specifically those involving early childhood trauma and anxiety, multiple personality remains controversial. Despite the controversy, many mental health institutes[citation needed], such as McLean Hospital [1], have wards specifically designated for dissociative identity disorder.

Contents
1 DSM-IV-TR diagnostic criteria
2 A definition of dissociation
3 Defining the controversy
3.1 The DSM re-dress
3.2 Other positions
4 Potential causes of dissociative identity disorder
5 Symptoms
6 Diagnosis and treatment
6.1 Diagnosis
6.2 Prognosis
6.3 Treatment
7 See also
8 References
9 External links

DSM-IV-TR diagnostic criteria

Due to copyright infringement issues and editorial concerns, the American Psychiatric ssociation has requested that specific reference to the DSM-IV-TR by Wikipedia be outlinked. The current diagnostic criteria for Dissociative identity disorder published in the Diagnostic and Statistical Manual of Mental Disorders may be found here:

DSM-IV-TR Diagnostic Criteria: Dissociative identity disorder (DID)

A definition of dissociation
Dissociation is a complex mental process that provides a coping mechanism for individuals confronting painful and/or traumatic situations. It is characterized by a dis-integration of the ego. Ego integration, or more properly ego integrity, can be defined as a person's ability to successfully incorporate external events or social experiences into their perception, and to then present themselves consistently across those events or social situations. A person unable to do this successfully can experience emotional dysregulation, as well as a potential collapse of ego integrity. In other words, this state of emotional dysregulation is, in some cases, so intense that
it can precipitate ego dis-integration, or what, in extreme cases, has come to be referred to diagnostically as dissociation.

Dissociation describes a collapse in ego integrity so profound that the personality is considered to literally break apart. For this reason, dissocation is often referred to as "splitting" or altering". Less profound presentations of this condition are often referred to clinically as disorganization or decompensation. The difference between a psychotic break and a dissociation, or dissociative break, is that, while someone who is experiencing a dissociation is technically pulling away from a situation that s/he cannot manage, some part of the person remains connected to reality. While the psychotic "breaks" from reality, the dissociative disconnects, but not all the
way.

Because the person suffering a dissociation does not completely disengage from his/her reality, s/he may appear to have multiple "personalities". In other words, different people" (read: personalities) to deal with different situations, but generally speaking, no one person (read: personality) who will retreat altogether.

Defining the controversy
Main article: Multiple personality controversy

One of the primary reasons for the on-going re-categorization of this condition is that there ere so few documented cases (research in 1944 showed only 76[2]) of what was then referred to as multiple personality. Conversely, dissociation is now recognized as a symptomatic presentation in response to trauma, extreme emotional stress, and, as noted, in association with emotional
dysregulation and borderline personality disorder [3]. Often regarded as a dynamic sub-symptomology, it has become more frequent as an ancillary diagnosis, rather than a primary diagnosis. [citation needed] A full blown DID diagnosis, that intends an individual is evidencing
quantifiable multiple personalities and presents itself independently of a primary personality disorder, remains rare. [citation needed]

The DSM re-dress
There is considerable controversy over the validity of the Multiplepersonality profile as a diagnosis. Unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient, and the treatment provider. The relationship between dissociation and multiple personality creates conflict regarding the MPD diagnosis. While other disorders do, indeed, require a certain amount of subjective interpretation, those disorders more readily present with generally accepted, objective symptomology. The controversial nature of the dissociation hypothesis evidences itself quite clearly by the manner in which the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has addressed, and re-dressed, the categorization over the years.

The second edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to this diagnostic profile as Multiple Personality Disorder. The 3rd Edition of the DSM Manual grouped Multiple Personality Disorder in with the other 4 major dissociative disorders. The current edition, the DSM-IV-TR, categorizes the disorder as Dissociative Identity Disorder. The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as multiple personality disorder.

Other positions
The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable (see Multiple
personality controversy). Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder. This makes the disorder itself subjective, as well as its diagnosis.

The main points of disagreement are:

Whether MPD/DID is a real disorder or just a fad.
If it is real, is the appearance of multiple personalities real or delusional.
If it is real, should it be defined in psychoanalytic terms.
Whether it can, or should, be cured.
Who should primarily define the experience -- therapists, or those who believe that they have multiple personalities.

Skeptics claim that people who present with the appearance of alleged multiple personality may have learned to exhibit the symptoms in return for social reinforcement. One case cited as an example for this viewpoint is the "Sybil" case , popularized by the news media. Psychiatrist Herbert Spiegel [citation needed] stated that "Sybil" had been provided with the idea of multiple personalities by her treating psychiatrist, Cornelia Wilbur, to describe states of feeling with which she was unfamiliar.

Potential causes of dissociative identity disorder
Dissociative identity disorder is attributed to the interaction of several factors: overwhelming
stress, dissociative capacity (including the ability to uncouple one's memories, perceptions, or identity from conscious awareness), the enlistment of steps in normal developmental processes as defenses, and, during childhood, the lack of sufficient nurturing and compassion in response to hurtful experiences or lack of protection against further overwhelming experiences. Children are not born with a sense of a unified identity — it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have blended into a relatively unified identity remain separate. North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of dissociative disorder. Although these data establish childhood abuse as a major cause among North American patients (in some cultures, the consequences of war and disaster play a larger role), they do not mean that all such patients were abused or that all the abuses reported by patients with dissociative identity disorder really happened. Some aspects of some reported abuse experiences may prove to be
inaccurate. Also, some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other very stressful events. For example, a patient who required many hospitalizations and operations during childhood may have been severely overwhelmed but not abused.[4]

Human development requires that children be able to integrate complicated and different types of information and experiences successfully. As children achieve cohesive, complex appreciations of themselves and others, they go through phases in which different perceptions and emotions are kept segregated. Each developmental phase may be used to generate different selves. Not every child who experiences abuse or major loss or trauma has the capacity to develop multiple personalities. Patients with dissociative identity disorder can be easily hypnotized. This capacity, closely related to the capacity to dissociate, is thought to be a factor in the development of the disorder. However, most children who have these capacities also have normal adaptive mechanisms, and most are sufficiently protected and soothed by adults to prevent development of dissociative identity disorder.[4]

Symptoms
Patients often have a remarkable array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic and mood psychoses, and seizure disorders. Symptoms of this particular disorder can include:

depression
anxiety
(sweating, rapid pulse, palpitations)
phobias
panic attacks
physical
symptoms (severe headaches or other bodily pain)
fluctuating levels of function, from highly effective to disabled
time distortions, time lapse, and amnesia
sexual dysfunction
eating disorders
post traumatic stress
suicidal preoccupations and attempts
episodes of self-mutilation
psychoactive substance abuse[4]

Other symptoms include: Depersonalization, which refers to feeling unreal, removed from one's self, and detached from one's physical and mental processes. The patient feels like an observer of his life and may actually see himself as if he were watching a movie. Derealization refers to experiencing familiar persons and surroundings as if they were unfamiliar and strange or unreal.

Again, doctors must be careful not to assume that a client has MPD or DID simply because they present with some or all of these symptoms. Another factor in the diagnosis is the all squares are rectangles but not all rectangles are squares idea, which is to say that although many of these symptoms may be present in an individual, he or she may not necessarily have DID. For example, someone may have severe PTSD (one symptom) and self mutilate with suicidal
ideas, which is 3 of the above symptoms, but will not have DID. In order for DID to be diagnosed, there must be two or more distinctly present personalities.

Persons with dissociative identity disorder are often told of things they have done but do not remember and of notable changes in their behavior. They may discover objects, productions, or handwriting that they cannot account for or recognize; they may refer to themselves in the first person plural (we) or in the third person (he, she, they); and they may have amnesia for events that occurred between their mid-childhood and early adolescence. Amnesia for earlier events is normal and widespread.

Diagnosis and treatment

Diagnosis
If symptoms seem to be present, the patient should first be evaluated by performing a complete medical history and physical examination. The various diagnostic tests, such as X-rays and blood tests are used to rule out physical illness or medication side effects as the cause of the symptoms. Certain conditions, including brain diseases, head injuries, drug and alcohol
intoxication, and sleep deprivation, can lead to symptoms similar to those of dissociative disorders, including amnesia. If no physical illness is found, the patient might be referred to a psychiatrist or psychologist. Psychiatrists and psychologists use specially designed interview and personality assessment tools to evaluate a person for a dissociative disorder.[5]

Prognosis
Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and post traumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of other serious psychiatric disorders, such as personality disorders, mood disorders, eating
disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration. Sometimes therapy helps a patient with a poorer prognosis make
rapid strides toward recovery.[4]

Treatment
Perhaps the most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual, and to reconnect the different identities into one well-functioning identity. There are, however, other equally respected treatment modalities that do not depend upon integrating the separate identities. Treatment also aims to help the person safely express and process painful memories, develop new coping and life skills, restore functioning, and
improve relationships. The best treatment approach depends on the individual and the severity of his or her symptoms. Treatment is likely to include some combination of the following methods: