As early as the 19th century there were people that were considered of having “two faces,” this was believed to be a demonic possession. However today this is now known as Dissociative Identity Disorder (DID). Formerly known as Multiple Personality Disorder, Dissociative Identity Disorder has remained a highly controversial disorder over the years. Dissociative Identity Disorder reflects a failure to integrate various features of identity, memory, and consciousness. Through media, this disorder has become more recognized from movies such as Sybil, The Three Faces of Eve, or even on the soap opera One Life to Live. Researchers have done numerous amounts of studies from diagnostic interviews to a MRI scan to compare the linkage between the low volume levels of the Hippocampal and Amygdalar with DID. After the interviews and scans, the results to make their way back to the main cause, early childhood trauma. Throughout this paper I will discuss the disorder, early childhood-onset, comorbid disorders, the disorders prevalence in women, etiology, controversy, and treatment. The DSM states the criteria for Dissociative Identity Disorder is:
C) Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D) The disturbance is not due to the direct physiological effect of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. (DSM IV TR, 2000, p.529)
DID is accompanied with dissociative amnesia, depersonalization, and derealization. When the “alters” come out, the original person has no memory of what occurred during that time, let alone that another “personality” took place. Seligman, Walker, and Rosenhan (2001) explained the presence of unexplained amnesia-hours or days each week that are missing-is a crucial clue to the undetected presence of dissociative identity disorder (p. 239). The course of DID appears to have a unpredictable clinical course that tends to be chronic and recurrent. The average period of time from the first symptom to diagnosis is between six and seven years. Although that the disorder is unlikely to manifest in an individual after their 40s, but possibly can recur due to stress, trauma, or substance abuse. Most patients with dissociative identity disorder are women. Not only is this disorder more prevalent in women, women also have more alters than men do. These individuals are highly susceptible to hypnotism. Each personality has their own wishes, desires, age, heart rate, sexual orientation and more. Each alter has their own identity. The disorder has been idealized as a childhood-onset posttraumatic development disorder. With this, there have been studies using an MRI scan that have revealed that individuals with DID that have been exposed to early child abuse have smaller volume levels of the hippocampal and the amygdalar. Vermetten, Schmahl, Lindner, Loewenstein, and Bremner (2006) found smaller hippocampal volume in DID could this be related to stress exposure and could present a neurobiological finding that dissociative identity disorder shares with other stress-related psychiatric disorders such as PTSD (p. 633). Through studies, patients who are diagnosed with dissociative identity disorder also have a previous medical history of severe early childhood trauma, between ages four and eight.
The child is generally sexually, physically, and mentally abused repeatedly multiple times and therefore results to creating the personalities. As a result, these personalities are created as a self-defense mechanism to have the other personality cope with the trauma and emotional distress that the original individual cannot handle. Seligman et al. (2001) explain that a child of four to six is unusually capable of self-hypnosis creates a new identity- an imaginary companion and ally-to help her deal with the anxiety generated by a possible traumatic experience (p. 242). Unfortunately, the child repeatedly uses this coping mechanism to create more personalities to deal with new stress that she may encounter in his or her adult life, which causes more problems for themselves. The alters are experienced in taking control in situations that may be in expense of the other, and possible deny the knowledge of other alters. Some of the alters can be angry or hostile, and they may interrupt at times during activities or places the others in uncomfortable situations. The dissociative symptoms and reactions can become chronically worse if the trauma is not successfully processed and integrated. The validity of these childhood memories have been debated, and therefore the patients accusations of maltreatment were identified outside by using family history, medical charts, and social services. Dissociative Identity Disorder is perhaps the best-documented example of the claims that child abuse has effects that last into adulthood (Lewis, Yeager, Swica, Pimcus, and Lewis, 1997, p. 237).
Patients who suffer from DID also have one if not several comorbid disorders also. In a study, Frauke et al. (2011) discovered that patients with dissociative identity disorder averagely suffered from five comorbid disorders (para 1). The most common comorbid disorder that the individuals encountered was posttraumatic stress disorder. Other comorbids that were found frequently in this study were major depressive disorder, erratic mood swings, and suicide attempts. Also, Frauke et al (2011) found that 50-65% of patients with DID report acute substance abuse or previous psychiatric treatment related to a substance abuse or addiction (para 10). Self-mutilation, suicide, and aggressive behavior may also occur in these patients. Individuals may also have symptoms that meet criteria for Mood, Substance-Related, Sexual, Eating, or Sleep Disorders also. Vermetten et al. (2006) found that in clinical studies most patients with DID have also been found to meet the DSM-IV TR criteria for posttraumatic stress disorder (p.630). Also somatoform symptoms and disorders, anxiety disorders, major depression, obsessive-compulsive disorder, and specific and social phobias were common comorbid disorders. Some individuals may have a frequent pattern of relationships involving sexual and physical abuse.
Dissociative identity disorder is more prevalent is women, and these studies were conducted mostly on women with a few men. The DSM states the disorder is diagnosed three to nine times more frequently in adult females than in adult males; in childhood, the female to male ratio may be more even, but data are limited (DSM IV TR, 2000, p. 528). The hippocampus and amygdalar study found that there is no relationship between the ages of the women with dissociative identity disorder. Women are passive, wounded and even childlike. Women have a known tendency to have fits, hysterics, and cry while men are more patient and wait until everything is resolved. Another reason that women may be more susceptible to dissociative identity disorder some believe is the women’s movement. Joan Acocella (1999) believes that in the post-sixties period, they were also deprived of the protections their mothers had: a strong family structure and, with the rise of feminism, the belief that their fate was women’s fate (p. 133). These women were deprived of false consciousness. Surrounding these women on television shows, they saw women who didn’t share the same “fate” as them. They felt deprived and with a sense of failure and bitterness which added to their stress load.
Dissociative Identity Disorder has had an interesting history. Not only is it one of the most questionable disorders throughout time, it was also known as Multiple Personality Disorder. It has been found in individuals from different cultures all around the world. It is believed that DID is part of the history of hysteria. Hysteria is the appearance of physical symptoms (usually, convulsions, paralyses, numbness, pain, breathing problems) or psychological symptoms (anxiety, emotional outbursts), or both. Hysteria has also been viewed as a women’s disorder, same with the focus on women and DID. These women odd female complaints ere seen as the work of the devil. “Some of the women burned as witches during the sixteenth and seventeenth centuries…” (Acocella,1999,p.29). As mentioned above, an individual between the ages of four and six experiences an emotional traumatizing event. These traumatizing events can range from extreme neglect to sexual and physical abuse produced by a trusting caregiver. As a result, dissociative identity disorder patients normally have a poor recollection of memories of the traumatizing even. Cohen (2004) stated that these clients experience dissociation, which means that the memories of personal history are split up amongst parts, or the part that has the memories is not readily accessible (p. 220). Because an individual who had DID is more susceptible to hypnotism, it is debated that the physician forces these memories on the person, therefore creating false memories. Dissociation is a reasonable way for a child to cope with the traumatizing experiences. Although not every child who suffers through traumatizing events manifests DID. The rise of reported cases of dissociative identity disorder in the United States recently has been subject to different reasoning’s. Some may believe that the disorder was being undiagnosed or misdiagnosed and that there is greater awareness for the disorder and is now being properly diagnosed. Also, another possible reason for the rise in the diagnosis is that cases and frequency of child abuse and sexual abuse could be more prevalent than in the past.
Dissociative Identity Disorder invokes repression of childhood memories relating to abuse as its cause. This however, is the most significant justification for doubt or concern in the disorder. Not only do Physicians argue the disorder is not valid, but courts and judges second it. DID is sometimes used as a plea to excuse a serious crime, so many court cases have to decide between the validity and invalidity. An individual can also fake the symptoms, so the question whether the person is malingering will always be raised. There are also concerns about potentially damaging a person with memory retrieval. Seligman et al. (2001) stated:
Before the repressed memories were retrieved in therapy, 10 percent had suicidal ideation, 7 percent had been hospitalized, and 3 percent had self-mutilated. After the memories were recovered, 67 percent had suicidal ideation, 37 percent had been hospitalized, and 27 percent had self-mutilated. Ninety seven percent claimed they had been abused by family members... (p. 244). Whether these memories were true or not, recovering them made many of their lives significantly worse. There is also a belief that therapists could make their patient more subjective to malingering by hypnotizing them and repeatedly encouraging them to talk about their memories.
Treatment for dissociative identity disorder is difficult to diagnose. It must be distinguished from malingering situations in which they might gain financial or forensic gain, or from Factitious Disorder in which there may be a pattern of help-seeking behavior. DID was commonly misdiagnosed with Schizophrenia. This happened because the occurrence of more than one personality state may be mistaken for a delusion or an auditory hallucination, leading to the confusion with Psychotic Disorders. A diagnostic test that is used to diagnose the disorder is called SCID-D (Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised). SCID-D is a semi-structured clinical interview that has one of the highest recommendations in the assessment of dissociative disorders. The test contains questions about the symptoms requires by the DSM-IV TR for the disorder. It assesses the presence and severity of five core dissociative symptoms such as amnesia, depersonalization, derealization, identity confusion, and identity alteration. Not only does it assess the presence of symptoms, but also the degree of distress and functional impairment, which are necessary to make the diagnosis. After the diagnosis is made, therapy for the disorder has been conceptualized both in psychodynamic terms and in a cognitive therapy approach to get the patient integrated. Seligman et al. (2001) states that in the cognitive approach, the therapist identifies the automatic thoughts of the patient, teaches skills of disputing and challenging irrational thoughts, and tries to find the basis for why these irrational thoughts were credible to the patient (p. 242). The first step in psychodynamic treatment is to make the patient aware of their problem. A person with this disorder might have been living with it for years with the amnesia and waking up somewhere not knowing how they got there, being told about her bizarre behavior by others, because she has not confronted her other identities. Then the patient undergoes hypnosis where the therapist calls upon the alters and asks them to speak freely while the patient is asked to listen and remember what is said. After the rediscovery of what has happened, the patient goes under a lot of distress with the memories. Therapists of a patient with DID encourage them to talk about their memories and help them work through the problems that occur through the process. When the patient is aware of his or her many identities, the therapist informs the patient that they were created by self-hypnosis created at an early age with no conscious or cruel intent. Seligman et al. (2001) stated that in a survey of 305 clinicians who treat dissociative identity disorder, Putnam Loewenstein (1993) found that the average patient is in treatment for almost four years (p. 243). Psychodynamic and cognitive therapy and hypnosis were most widely used. Antidepressant and anti-anxiety medications were also prescribed. The patients who had achieved integration in therapy showed the most long-term improvement. Although even then as Merskey and Piper (1998) stated that the alter personalities may enter “inner hibernation,” sometimes for lengthy periods in which state they do not manifest themselves to the outside observer (para. 4).
Throughout the reading I have done for this essay, I noticed all the articles involved studies that mainly involved women, the readings said the disorder was more prevalent in women, and the only factor that I came across was Joan Acocella’s feminist theory. I found her theory interesting of how women in the 60s felt they had an image they had to maintain and if they didn’t they felt failure. Although I don’t believe that is enough stress to cause DID. The articles never went into detail why they chose women over men to study or why women are more likely to have comorbid disorders with the dissociative identity disorder also. Dissociative Identity Disorder is stemmed from an early childhood trauma relating to sexual and physical abuse. Sexual abuse is more common in female children so that could be a reason why DID is more common in women. However, sexual abuse does occur in male children, it’s just not reported as frequently. Men and women manifest their emotions differently. Men are more likely to act out, show anger, or cause problems whereas women tend to hold their emotions inside. These could be reasons why the disorder is more prevalent in women. Also a lot of the studies and results seemed extremely negative of the disorder. For example, Rifkin, Ghisalbert, Dimatou, Jin, and Sethi (1998) stated:
We interviewed 100 subjects (63%) of 158 approached. We could not interview 58 subjects for the following reasons: 30 patients were discharged before the fifth day, nine were too psychotic to be interviewed, nine refused, nine could not be interviewed for administrative reasons, and one patient was transferred to a medical ward. We found subject (1%) with dissociative identity disorder. Both interviewers concurred in the diagnosis (p. 845).
Dissociative Identity Disorder is extremely fascinating to me and I had expected a better prognosis from research, treatment and the cause of the disorder. Since the number of cases of DID have grew, I thought there would a lot more current research then what I found. I found only a few articles and a book that was in within the last 10 years. All my other sources were from 1998 because that’s all that was there. It was a little disappointing with the technology and knowledge we have today that there isn’t more available for this disorder.
Dissociative Identity Disorder is complicated and controversial condition that still has a long way to come to be better understood. Throughout this paper I have discussed the disorder, the causes and early childhood, history, controversy, diagnosis and treatment, and my opinion. Dissociative Identity Disorder as of now is mainly seen in women who have experienced a emotionally traumatic event and then in turn they unconsciously self-hypnotize themselves and create an alternate personality to cope with the stresses of their life. It is then considered to be an early childhood-onset posttraumatic development disorder. As mentioned above, the childhood memories are questioned of malingering and this raises the controversy over the validity of the dissociative identity disorder as a diagnosis and disorder. Critics claim that people who present with the appearance of suspected dissociative identity disorder may have learned to display the symptoms in return for social reinforcement. DID is now seen not only in the United States but also Turkey, Netherlands, Germany, China, Switzerland, and India. Research is still being done today, and hopefully one day Physicians across the world will recognize Dissociative Identity Disorder as a valid disorder and not just created to for financial gain and or attention.
Acocella, Joan. (1999). Creating hysteria: women and multiple personality disorder. San Francisco, CA: Jossey-Bass Publishers.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author.
Cohen, Avraham. (2004). Dissociative identity disorder: perspectives and alternatives. Ethical Human Psychology and Psychiatry, 6(3), Retrieved from http://0-web.ebscohost.com.sable.jefferson.lib.co.us/ehost/pdfviewer/pdfviewer?sid=dbde1e26-7260-427f-9069- f981b029b49c%40sessionmgr114&vid=5&hid=111 doi: ebscohost
Rifkin, Arthurt, Ghisalbert, Dione, Dimatou, Sonia, Jin, Charles, & Sethi, Mohammed. (1998). Dissociative identity disorder in psychiatric inpatients. The American Journal of Psychiatry, 155(6), Retrieved from http://ajp.psychiatryonline.org
Rodewald, Frauke, Wilhem-Goling, Claudia, Emrich, Hinderk M, Reddemann, Luise, & Gast, Ursula. (2011). Axis-i comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. Journal of Nervous and Mental Disease, 199(2), Retrieved from http://ovidsp.tx.ovid.com/sp-3.31a/ovidweb.cgi doi: 10.1097/NMD.0b013e318208208314e
Seligman, Martin E.P., Walker, Elaine F., & Rosenhan, David L. (Ed.). (2001). Abnormal psychology fourth edition. New York, NY: W.W Norton & Company.
Vermetten, Eric, Schmahl, Christian, Lindner, Sanneke, Loewenstein, Richard J., & Bremner, J. Douglas. (2006). Hippocampal and amygdalar volumes in dissociative identity disorder. The American Journal of Psychiatry, 163(4), Retrieved from http://ajp.psychiatryonline.org doi: 10.1176/appi.ajp.163.4.630