Dissociative Identity Disorder (DID) DSM-5 300.14 (F44.81)

Dissociative Identity Disorder (DID) DSM-5 300.14 (F44.81)

DSM-5 Category: Dissociative Disorders

Introduction

Dissociative Identity Disorder (DID), previously referred to as multiple personality disorder, is one of several dissociative disorders, as described in DSM-5. The key element in this diagnosis is the presence of at least two distinct and separate personalities within an individual. Although multiple personalities (alters) exist within a single person, only one is manifested at a time; each with its own memories, behaviors and life preferences. At least two of these identities take control of a person’s conduct at any given time. Lastly, it is critical that the observed disturbances are not a consequence of a substance (drug addiction and/or alcohol addiction) or a general medical condition, e.g., epileptic seizure (Spiegel, Loewenstein, Lewis-Fernandez, Sar, Simeon, Vermetten, et al, 2011).

The diagnosis of DID has been controversial for many years, with many mental health professionals alternatively attributing the disorder to misdiagnosis, social contagion or simply hypnotic suggestion. As a result, only a handful of specialized psychiatrists are responsible for most DID diagnoses (Gillig, 2009).

Symptoms of Dissociative Identity Disorder

The diagnosis of DID may be complicated by the ambiguity of its presentation; many symptoms experienced by patients with DID may resemble other physical or mental disorders, to include post-traumatic stress disorder, substance abuse or seizure disorders. The most commonly observed symptoms include:

  • Inability to recall large memories of childhood;
  • Lack of awareness of recent events, and if they do remember, inability to explain them, for example not being able to explain how the patient got somewhere, or how the acquired a possession;
  • “lost time,” or frequent memory loss;
  • Flashbacks or sudden return of memories;
  • Feelings of disconnection or detachment from body or thoughts;
  • Hallucinations or voices;
  • So called “out of body ” experiences;
  • Self-harm or suicidal thoughts;;
  • Changes in handwriting;
  • Functional changes: from nearly disabled to highly functioning
  • Less commonly observed manifestations observed in patients with DID:
  • Mood swings or depression;
  • Anxiety, nervousness, panic attacks or phobias;
  • Eating and food issues;
  • Unexplained sleep disorders;
  • Headaches or general body pain;
  • Sexual issues, sex addiction or sexual avoidance (AAMFT, 2014).

Prevalence

Likely due to the difficulties in diagnosing DID, it is not straight forward to determine the frequency of its occurrence. While the number of psychiatric patients with DID may range from 0.4% to 7.5%, the general population prevalence may range from 0.4% to 3.1%. While these figures represent a very wide range in their estimates, they also indicate that the population of diagnosed and undiagnosed DID is quite large, and is deserving of broader research efforts to better focus its diagnosis and treatment (Johnson 2012).

Presentation

The DID population appears to be somewhat homogeneous, with many common traits shared by diagnosed patients. DID is typically manifested in females, often in their 3rd decade of life. Their psychiatric history is likely to show that the onset of dissociative symptoms appeared between the ages of 5-10, with the appearance of alters by the age of 6. As the patient ages, the numbers of alters increases, with adult DID patients reporting up to 16 separate and distinct alters. As many as 24 alters have been reported in adolescents, though in both cases, many of these will fade, if effective treatment is provided (Gillig 2009).

A reported history of childhood abuse is common, with a high frequency of sexual abuse. Suicidal ideation with attempts at suicide is commonly reported. While sexual promiscuity is unremarkable, many patients report a decreased libido and inability to reach orgasm. Further to that, patients sometimes dress in clothing appropriate for the opposite gender or state that they, themselves, are of the opposite gender (Gillig 2009).

Patients with DID sometimes experience hallucinations, report hearing voices, amnesia and periods of depersonalization. On many occasions, when referring to themselves, they may use the plural “we” instead of “I” (Gillig 2009).

Treatment for Dissociative Identity Disorder

The cardinal objective of therapy is integrated functioning. As such, the DID patient should be viewed as a whole adult person with multiple identities sharing in the responsibilities of life. Switches among identities may occur at any time, usually in response to changes in the patient’s mental state or to environmental demands. As such, the therapist must constantly contend with the alters’ competing points of view. Since the identity in control may be unaware of the others or disown them, it is critical that the therapist helps the identities become aware of each other, legitimize them, negotiate and resolve their conflicts. It would be counterproductive for the therapist to tell patients to ignore or get rid of the different identities. It is critical that the therapist not play favorites among the alternate identities, or try to eliminate the disruptive or unlikable alters. At the same time, there is no reason to try and have the patient create additional identities, name them or suggest that they function differently (International Society for the Study of Trauma and Dissociation, 2011).

With regard to an optimum therapeutic outcome, an intermediate goal is to achieve integration; a state where the identities can harmoniously coexist. The next goal of therapy is referred to as fusion, a point in time when the alternate identities join together, with a total loss of subjective separateness. At the time when the patient’s sense of self totally shifts from having multiple identities to that of a unified self, final fusion has occurred. Since the definitions of fusion and final fusion are similar and can be confusing, some clinicians have advocated for the use of the term unification to avoid potential mis-characterizations (International Society for the Study of Trauma and Dissociation, 2011).

It is critical to note that final fusion may not be achievable or desired by some patients. A variety of factors can contribute to this inability, including stress, unresolved painful life issues, lack of adequate treatment, comorbidities. In these cases, it may be more realistic to broker a cooperative arrangement designed to permit optimum functioning. Nonetheless, it is critical to note that such patients are likely to be at increased risk of later decompensation if sufficiently stressed (International Society for the Study of Trauma and Dissociation, 2011).

The most successful treatment modality for DID is likely to be individual psychotherapy. A reasonable generalized therapeutic approach would employ a phased treatment strategy, broadly described, below:

Phase 1: Establish safety, stabilization and reduction of symptoms

Phase 2: Confronting, working through and integration of traumatic memories

Phase 3: Integration and rehabilitation (International Society for the Study of Trauma and Dissociation, 2011).

In addition to psychotherapy, some individuals may also benefit from cognitive therapy, family systems therapy, creative therapy (art and/or music therapy) or clinical hypnosis. Since the basis of DID is not biochemical in nature, it cannot be treated with medication. Nonetheless, if a patient with DID also suffers from depression or anxiety, they could benefit from a psychopharmacologic approach to those disorders (Cleveland Clinic, 2014).

References

American Association for Marriage and Family Therapy (2014). AAMFT Therapy Topics: Dissociative Identity Disorder. AAMFT.org. Retrieved 17 February 2014 from http://www.aamft.org/imis15/content/consumer_updates/Dissociative_identity_disorder.aspx

Cleveland Clinic (2012). Dissociative Identity Disorder (multiple personality disorder). Myclevelandclinic.org. Retrieved 17 February 2014 from http://my.clevelandclinic.org/disorders/dissociative_disorders/hic_dissociative_identity_disorder_
multiple_personality_disorder.aspx

Gillig, P.M. (2009). Dissociative Identity Disorder. Psychiatry (Edgmont), 6, 24-29.

International Society for the Study of Trauma and Dissociation (2011). Guidelines for treating dissociative identity disorder in adults, third revision: summary version. Journal of Trauma & Dissociation, 12, 188-212. DOI: 10.1080/15299732.2011.537248

Johnson, K. (2012). The problem of prevalence- how common is Dissociative Identity Disorder?. PODS: Positive Outcomes for Dissociative Survivors. Retrieved 17 February 2014, from http://www.pods-online.org.uk/problemofprevalence.html

Spiegel, D., Loewenstein, R.J., Lewis-Fernandez, R., Sar, V., Simeon, D., Vermetten, E., et al (2011). Dissociative Disorders in DSM-5. Depression and Anxiety, 28, 824-852. DOI 10.1002/da.20874


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