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Dissociative Identity Disorder

These days Multiple Personality Disorder (MPD) is known as ‘Dissociative Identity Disorder’ (DID). At least it is if you refer to DSM-IV-TR. If you refer to ICD-10, it’s still classified as MPD. But the DSM’s DID is not the same as MPD. It is more than just a ‘rename’ - as there is, in fact, a quite profound change in the philosophical basis of the illness.


Unfortunately, as Ralph Allison partly explains in ‘What's in a Name? - Dual Personality...Multiple Personality...Dissociative Identity Disorder’ (2006), the history of the classification of this mental illness is littered with confusion, ideology and petty politics. This does little to create a universally-accepted understanding of the illness and, therefore, even less to develop standard and replicable ways of treating it. There are many in Psychiatry and Clinical Psychology who contend that MPD as such cannot exist because it is impossible for someone to have more than one personality. Therefore, the illness is not one of having developed completely different multiple personalities within one body; but of having dissociated aspects of the personality from each other to the point where the individual believes they are representative of different personalities and, thus, acts as if they have different personalities. There are even some commentators who doubt that DID is a valid psychiatric condition at all. Allison, however, holds that DID and MPD are 2 qualitatively different forms of dissociation.


However, reflecting on the very concepts of MPD and DID, we are in immediate trouble in trying to define either or both conditions because psychologists cannot agree on a consistent definition of ‘personality’!


The DID View

DSM-II included the categorisation of ‘Multiple Personality Disorder’. In DSM-III MPD was grouped with 4 other major dissociative disorders - including Dissociative Amensia and Depersonalisation Disorder. The change of categorisation to DID came with DSM-IV in 1994.


DSM-IV-TR lists the following characteristics as typical of DID:-

  1. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). 
  2. At least two of these identities or personality states recurrently take control of the person's behaviour. 
  3. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. 
  4. The disturbance is not due to the direct physiological effects of a substance - eg: blackouts or chaotic behaviour during alcohol Intoxication - or a general medical condition - eg: complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.


Dissociation is a complex mental process that provides a coping mechanism for individuals confronting severely painful and/or traumatic situations. It is characterised by a dis-integration of the ego or,as preferred in Integrated SocioPsychology, the selfplex. Selfplex integration, or more properly selfplex 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 selfplex integrity. In other words, this state of emotional dysregulation is, in some cases, so intense that it can precipitate selfplex dis-integration, or what, in extreme cases, has come to be referred to diagnostically as dissociation.


Dissociation describes a collapse in selfplex 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 disorganisation 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 they 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 their reality, they 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.


To sum up the DSM view, DID occurs when the personality fragments so that the client acts as though they have 2 or more personalities. In Integrated SocioPsychology terms, the selfplex has fractured to the point where vMEMES are operating without reference to the self as a whole.The result is that someone may behave totally differently in different contexts - so much so they cannot conceive as themselves as one person carrying out such radically different behaviours. Certainly the operation of vMEMES (or harmonics of vMEMES) operating in a severely-fractured selfplex could account for DSM-IV-TR’s characteristics A and B.


The MPD View

The view of Ralph Allison and others such as Philip Coons (1983) and Daniel Dennett (1991) is that MPD involves a complete rupturing of the personality, resulting in different personalities running the person at different times. Effectively the selfplex no longer exists as a confluence of schemas about one self; rather now there are a number of mini-selfplexes which are applied in different circumstances.


For Allison, Coons, Dennett, etc, DID is the lesser form of dissociation and MPD the more extreme form.


The distinction by Allison, etc, between MPD and DID is more than just semantic. It is important because it means different treatment strategies are required:-


While it is important to be cautious about taking a position on such a contentious issue, Integrated SocioPsychology can, conceptually, lend some support to the stance  of Allison, etc, and the MPD concept.


In DID it could be that the the selfplex is weak and, therefore, the vMEMES jousting for dominance in the selfplex seem to be acting at odds with a united sense of self - leading to a sense of dissociation and the feeling that there are multiple ‘me’s’.


In MPD, it may be that the selfplex ruptures completely, then all it may need, following the principles of Stanley Schachter & Jerome Singer's (1963) Cognitive Labelling Theory, is for each vMEME's 'personality' to be given a name - eg: 'Joe', 'Jessica', etc - and imagination may indeed start to attribute personality characteristics to the vMEME's way of thinking.


Children are not born with a selfplex, a sense of a unified identity - it develops from many sources and experiences. 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. According to MPD theory, each developmental phase may be used to generate different selves as defences against overwhelming trauma - and, during childhood, the lack of sufficient nurturing and compassion in response to such hurtful experiences or lack of protection against further overwhelming experiences.  In overwhelmed children, the development of the selfplex 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 with DID or MPD report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with extreme dissociation. 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.


For Allison, the key to whether someone develops DID or MPD is whether the traumatic event which results in the dissociation occurs before the child is approximately 7 years old and has a robust enough sense of self. According to many developmental psychologists - eg: William Damon & Daniel Hart (1986) and Susan Harter (1998) - most children first consolidate a basic sense of self - ie: they can conceptualise who they are - between 6 and 8. Thus, it would seem that the selfplex does indeed come together around this age and trauma before it is fully formed might produce more extreme results than trauma once it is in place.

Other DID/MPD controversies

There is considerable controversy over the validity of the Multiple Personality profile as a diagnosis. Unlike the more empirically verifiable personality and mood disorders, dissociation is primarily subjective for both the patient, and the treatment provider. 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 DSM has addressed, and re-adressed, the categorisation over the years.One of the primary reasons for the ongoing re-categorisation of this condition is that, until 1944, there were only 79 documented cases of what was then referred to as ‘Multiple Personality’. Although the condition does have a long history stretching back in the literature some 300 years, it remains a rare disorder, affecting less than 1% of the population.


The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the client or a case of unconscious collusion on the part of the client and the professional is considerable. Unlike other diagnostic categorisations, 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:

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. This point of view was the original evidence that called into question the overall efficacy of the ‘Sybil’ case , made popular by the media, where the covering psychiatrist  stated his position that ‘Sybil’ had been provided with the idea of ‘personalities’ by her treating psychiatrist to describes state of feeling with which she was unfamiliar.


Another view is that multiplicity is not always a disorder and that it can be normal to experience oneself as multiple, so that it is possible to be multiple without being clinically classifiable as DID or MPD. From Carl Gustav Jung’s Analytic Psychology through NLP to Spiral Dynamics, etc, the idea of the selfplex having differing ‘parts’ is actively promoted and people taaught to respect, honour and manage multiplicity in both themselves and others. Clearly, though, in DID or MPD such multiplicity has become pathological.


Another factor which may influence whether someone dissociates as a result of childhood trauma is a strong susceptibility to suggestion and hypnosis. Psychiatrists and psychologists also talk about ‘dissociative capacity’  - which includes the ability to uncouple one's memories, perceptions, or identity from conscious awareness.


Diagnosis & Treatment

Diagnosis

If symptoms seem to be present, the client should first be evaluated by performing a complete medical history and physical examination. Various diagnostic tests, such as X-rays and blood tests, can be 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.


Diagnosis should be performed by a psychiatrist or psychologist who may use specially designed interviews such as the Dissociative Disorders Interview Schedule and personality assessment tools to evaluate a person for a dissociative disorder.


Conditions which may present with similar symptoms include  the dissociative conditions of Dissociative Amnesia and Dissociative Fugue. The clearest distinction is the lack of discrete formed personalities in these conditions.

Prognosis

DID does not resolve spontaneously; and symptoms vary over time. Clients 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 usually 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 co-existing 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.


Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives. Individuals with the condition commonly attempt suicide


Treatment

Perhaps the most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual and, with DID, 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 - more likeley if the therapist views the condition as MPD.. 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 their symptoms. Treatment is likely to include some combination of the following methods:-

People with DID generally respond well to treatment; however, treatment can be a long and painstaking process. To improve a person's outlook, it is important to treat any other problems or complications, such as Depression, anxiety or substance abuse.



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Multiple Personality Disorder?