Dissociative identity disorder

Overview
Dissociative identity disorder, or DID (previously known as multiple personality disorder), is a psychological disorder characterized by the presence of multiple distinct identities or personality states, also called "alters." People who have this disorder can have as few as two alters or more than 100. About half of the cases reported in the United States involve people who have 10 or fewer alters. These alters take recurrent control of the person's behavior, producing significant changes in speech, mannerisms, attitudes and thoughts. The alters may re-emerge or become exacerbated with increased stress, trauma or substance abuse. Alters may take on different gender orientations and even differ in physical properties, such as allergies, left- or right-handedness, or the need for vision correction. People who have DID often can't recall important personal information that goes beyond ordinary forgetfulness. The most common complaint is the loss of time. For some people, the time to switch between alters can be a matter of seconds. In other cases, it may be more gradual.
Dissociative identity disorder is a rare condition that may have been grossly overdiagnosed in the last 25 years. Most researchers believe DID occurs when a person detaches parts of himself or herself and conceptualizes different personalities as a way to psychologically disconnect from severe childhood trauma. It's thought to be the result of a failure to integrate identity, memory and consciousness. The most common type of trauma reported by people who have DID is physical or sexual abuse. Others include a direct experience with war or a major disaster, a significant early loss (such as the death of a parent) or a serious medical illness.

People who have DID often experience changes in consciousness. Some may induce such changes through substance use. They tend to project any disowned personality qualities onto other discrete alters to experience them as separate from themselves. There is a tendency for multiple hospitalizations, therapists, trials of psychiatric medications, diagnoses and courses of therapy. People who have DID don't often report dissociative symptoms and behaviors in clinical settings. People who have DID are often creative and highly imaginative. They are highly suggestible and easily hypnotized.

Dissociative identity disorder tends to have a fluctuating, chronic and recurrent course. Prognosis is related to the severity of the disorder:

Least severe: The person only has characteristics of DID and not another psychiatric disorder. He or she generally functions well and recovers completely with specific treatment.

Moderate: The person also has symptoms of other psychiatric or substance abuse disorders and generally improves slowly. Treatment may be longer, more crisis-ridden and less successful.

Most severe: The person has severe psychological problems, displaying symptoms of other psychiatric disorders in addition to dissociative symptoms. Treatment is generally long and chaotic. The goal is generally symptom reduction, rather than integration of alters.
Dissociative identity disorder may seem similar to a personality disorder, but there are several distinctions. People who have DID report more severe childhood trauma, particularly physical and sexual abuse. They tend to have a verifiable history of dissociative behavior before receiving treatment, as well as a consistent history of sudden shifts in identity states and identity-specific demeanors and behaviors over time. People who have DID tend to experience more severe symptoms than people who have borderline personality disorder, a specific type of personality disorder. They also tend to elaborate defensively on and imaginatively alter their experiences and symptoms, while people who have borderline personality tend to simplify and minimize their experiences.

Several other dissociative conditions are related to DID. For example:

Dissociative amnesia
This condition involves the inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. There are several types of dissociative amnesia. Localized amnesia is the inability to recall events that occurred within a specific time period, usually within the first few hours after a disturbing event. Selective amnesia occurs when you can recall some, but not all, of the events in a specific time period. Generalized amnesia occurs when the failure to recall information encompasses your entire life. People who have generalized amnesia are generally discovered by police or end up in the emergency room. Continuous amnesia is the inability to recall events for a specific time up to and including the present. Finally, systematized amnesia is the loss of memory for certain categories of information, such as memories relating to your family or a particular person. Generalized, continuous and systematized amnesia are relatively rare.

Dissociative fugue
This condition is characterized by episodes of amnesia involving sudden, unexpected travel away from home or your customary place of daily activities, with the inability to recall some or all of your past. People who have DID may experience dissociative fugue, but not all people who experience dissociative fugue have DID. In a fugue state, you may experience identity loss and assume a new name, but do not necessarily form a totally new identity (as would happen with DID). You may carry out complex social interactions that last anywhere from hours to months, but have no memory of the activity afterward. You may wake up in a strange place without any memory of how you got there.

Depersonalization disorder
This condition involves persistent or recurrent feelings of depersonalization, such as feeling detached or estranged from yourself, or feeling that you're an observer in your own life. A sense of reality generally remains intact, although you may experience familiar things as unfamiliar or artificial as well.

Dissociative trance disorder
This condition involves being in an involuntary trance state that's not accepted as a normal part of your collective cultural or religious practice (as contrasted with a voluntary trance state, which may be culturally appropriate in certain situations). In a normative trance, you experience temporary but significant changes in your state of consciousness or a loss of your customary sense of personal identity. In addition, you may experience either a narrowing of awareness of immediate surroundings or an unusually narrow and selective focusing on environmental stimuli. During a normative trance, behaviors or movements are experienced as being beyond your control. A possession trance, on the other hand, is a single or occasional alteration in your state of consciousness characterized by the replacement of a customary sense of personal identity with a new identity. This type of trance is often attributed to the influence of a spirit, power, deity or other person. You'll experience behaviors or movements as being controlled by the possessing agent. You may not be able to recall parts of the event or the entire trance.


Characteristics
Again, sometimes a person who has DID will differ in physical properties from one alter to the next. For example, there may be differences in visual acuity, pain tolerance, asthma symptoms, sensitivity to allergens, or response of blood glucose to insulin. Sometimes people who have DID have scarring or impairment from self-inflicted injuries.
Psychological characteristics may include amnesia, disruption in the person's train of thought associated with identity switches, hallucinations, time distortions or lapses, or the inability to recall important personal information.

Behaviorally, a person may experience disruption in social functioning or disturbances in personal relationships. Some people discover objects, work or handwriting that cannot be accounted for. At times, multiple identities or personalities may take control of the person's behavior. Significant changes in the person's behavior may be associated with identity switches. Some people have a preoccupation with control of others or themselves, some may harm themselves physically, and some abuse substances.

As with all physical symptoms, consult a medical health care provider to rule out a medical condition. If these or any other symptoms cause distress that doesn't seem to improve, seek additional help and support from a mental health care professional.


Coping strategies
Medication can help a person who has DID manage specific symptoms of the condition. Psychotherapy with a well-trained, seasoned clinician is also needed to specifically address the dissociative identity disorder. Typically, psychotherapy for people who have DID addresses the following three tasks:
Achieving safety, stabilization and strength, as well as mapping out the person's personality system. (Dissociation is often triggered by a person, event, surrounding, smell or perception that is perceived as unsafe.) A treatment plan and primary interventions will also be established.

Addressing the reasons for the dissociation by processing painful memories and working through the grief process. Learning how to maintain healthy boundaries may be helpful for people dealing with abuse issues. Moving toward integrating the identities may also be encouraged at this point.

Integration of the multiple personalities. This is normally done through conversation, imagery or hypnotic suggestion. Effective coping skills are taught as well.
Psychiatric hospitalization may be needed in cases of severe dissociative symptoms or suicidal or homicidal behavior.