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Dissociative Identity Disorder

Source: Abnormal Psychology Textbook (Dozois and Firestone) pages 125-128 Patient presents two or more distinct personality states which often take control over the patients behaviour One personality is the host, the others are the alters Host may or may not be aware of the alters Process is called switching (going from one personality to another) May occur under stressful situations or in therapy during hypnosis 3 to 9 times more frequent in women than men May occur simultaneously with depression and anxiety Due to the nature of the disorder, multiple diagnoses follow as well including: depression, PTSD, borderline personality disorder etc

Etiology Much debate exists Two competing models: trauma model and socio-cognitive model 1. Trauma Model: Suggests that it is a result of severe childhood trauma, sexual, physical, and emotional abuse Uses dissociation as a defence mechanism or coping strategy According to this model, people have certain personality traits such as high hypnotisability, fantasy proneness and openness to altered states of consciousness are more prone to dissociating These personality traits increase the risk of dissociating when faced with stress or trauma Some data to suggest genetics involved as well (bottom of page 126) May also be explained by insecure attachment style of infant, disorganized attachment may be a risk factor for the development of pathological dissociation 2. Socio-cognitive Model: Belief that it is possible to alter ones personality in order to suggest one has DID Leading questions during therapy may contribute to this Merskey argues that it is an iatrogenic disorder (caused by treatment) People may develop DID through learning about this disorder (playing a social role)

Treatment: Psychotherapy Goal is to integrate the various personalities First stage: establishment of trust, so that the patient feels safe to open up Second stage: learning coping strategies when discussion of abuse/sexual abuse comes up

Agreements between alters may be necessary Focus of therapy is then remembering the abuse or traumatic experience Next stage is the integration of personalities May occur through the alters working together as a unit or awareness of the other personalities Hypnosis: part of the treatment to reveal the patients past and diagnose the alters Medication: may be helpful in the presence of other disorders such as depression or anxiety (need more specifics I guess)

Source: Academic Literature on Treatment

1. 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, 12:2, 188-212 - Specialized Measures of Dissociation The Guidelines describe several types of psychometric instruments for assessing dissociation: 1. Comprehensive clinician-administered structured interviews: Structured Clinical Interview for DSMIV Dissociative DisordersRevised (SCID-D), Dissociative Disorders Interview Schedule (DDIS) 2. Comprehensive self-report instruments: Multidimensional Inventory of Dissociation (MID) 3. Brief self-report instruments used for screening purposes: Dissociative Experiences Scale (DES), Dissociation Questionnaire (DIS-Q), Somatoform Dissociation Questionnaire-20 (SDQ-20) and its shorter form (SDQ-5) Treatment: main goal is integration of all alternate identities help all other identities to be aware of each other and negotiate and resolve conflicts is the core of this therapeutic process integration: all work on dissociated mental processes throughout treatment fusion: is the point where the two or more identities experience themselves as joining together with no separateness final fusion: a unified self is established Phase Oriented Treatment Approach: Phase 1: Establishing Safety, Stabilization, and Symptom Reduction: goal is to create a safe environment Phase 2: Confronting, Working Through, and Integrating Traumatic Memories Phase 3: Integration and Rehabilitation

Types of Treatment: - Most common type of treatment is the individual psychodynamically oriented psychotherapy which works alongside the following techniques as well: - Cognitive behaviour therapy techniques to help patients change dysfunctional trauma based beliefs or cognitions to manage stressful experiences or impulsive behaviour

Hypnosis used along as a facilitator of psychotherapy for purposes such as calming, soothing, containment, and ego strengthening. In addition to individual psychotherapy, patients benefit from the following specialized interventions as well: family or expressive therapy, dialectical behaviour therapy, eyemovement desensitization and reprocessing (EMDR) and sensorimotor psychotherapy (maha has details regarding EMDR) Other information regarding inpatient therapy, group therapy, and pharmacotherapy

2. Gold et al. (2012). Contextual Treatment of Dissociative Identity Disorder. Journal of Trauma and Dissociation, 2:4, 5-36. - Proposes the contextual therapy (an alternate to the phase-oriented treatment approach) which aims at remediation of deficits that stem from having grown up in an inadequate interpersonal context, or people with prolonged childhood abuse (PCA) - These deficits can be conceived of as falling into the three major areas: (a) interpersonal relating, (b) conceptual understanding, and (c) instrumental functioning. Contextual therapy thus consists of three primary components corresponding to each of these three spheres of difficulty: (a) collaborative relating, (b) collaborative conceptualization, and (c) skills transmission. - this view regards DID to be caused as a reflection of the chaotic and inconsistent interpersonal environment in which the individual with DID was reared. - So DID is a consequence of deprivation in childhood from the needs required to establish a cohesive sense of self - This process aims to integrate the identities

3. Richard P. Kluft M.D. (2000): The Psychoanalytic Psychotherapy of Dissociative Identity Disorder in the Context of Trauma Therapy, Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 20:2, 259-286 - Freud argued strongly against the possibility of more than one unconscious and believed that splitting of consciousness was better described as an alteration between the unconscious and the conscious states - Dismissed the idea of dissociation and focused on repression - This is why it has been a challenge to study DID through a psychoanalytic perspective - Authors solution: when we treat DID patients, we should be aware that Often, repression, dissociation, resistance, and reluctance are all operative in a particular clinical incident - active efforts prove necessary both to explore the patients psyche, engage the patient in a more
thoroughgoing therapeutic alliance, and provide a treatment more likely to lead to a successful outcome.

4. LAKSHMANAN et al. (2010). Collaborative Effort of Psychotherapy and Psychopharmacology. Psychiatry, 733-37. - Collaborative method necessary when the patient has another comorbid disorder such as bipolar. - Medication helps to stabilize any other disorders (bipolar, depression, anxiety) and this allows one to focus on DID and better access painful childhood memories - This better access is the path to the main goal of treating DID which is integration - Only once barriers to memory retrieval are overcome is integration of the personalities possible through memory retrieval - Therefore, close work between the psychologist and psychiatrist is essential Source: Academic Literature on Brain Regions Involved in DID 1. Vermetten et al. (2006). Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder. The American Journal of Psychiatry, 163, 630-636. - Small Hippocampal volume has often been associated with stress-related psychiatric disorders, PSTD, borderline personality disorder - Patients with borderline have also been reported to have smaller Amygdalar volume - Results: Hippocampal volume was 19.2% smaller and Amygdalar volume was 31.6% smaller in patients with DID compared to healthy patients 2. Sar et al. (2006). Frontal and occipital perfusion changes in dissociative identity disorder. Psychiatry Research: Neuroimaging, 156, 217-223. - Regional cerebral blood flow (rCBF) was studied using single photon emission computed tomography (SPECT) during the host personality of the patient - rCBF ratio was decreased among patients with DID when compared to controls in the orbitofrontal region bilaterally and increased in median and superior frontal regions and occipital regions bilaterally - First of all, this study demonstrated bilateral perfusion differences in frontal and occipital regions among patients with dissociative identity disorder compared with a group of nontraumatized healthy volunteers. - Overall, anterior and posterior regions were effected in DID - Interesting: no significant differences found between the blood flow in the alter and host personalities in another SPECT study (Sar et al., 2001)