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By Elaine Ducharme, Ph.D., APBB
Table of Contents
Section I: Introduction to Dissociative Identity Disorder (DID)
Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder, (MPD), is defined in the DSM-5 as:
Disruption of Identity “characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory perception, cognition and or sensory functioning.” (American Psychiatric Association 2013)
Recurrent gaps in the recall of everyday events, important personal information and or traumatic events that are consistent with ordinary forgetting.
Symptoms which cause clinically significant distress or impairment in social, occupational and other important areas of functioning.The disturbance is not a normal part of a broadly accepted cultural or religious practice. (Note: In children, the symptoms are better explained by imaginary playmates or fantasy play.)
Symptoms which are not attributable to the direct physiological effects of a substance (e.g. blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g. complex partial seizures).
The rationale for these changes for diagnostic criteria from the DSM-IV TR include a clarification of language including that different states can be reported or observed. The hope is that this will reduce the use of the diagnosis of DID NOS. It was felt that mentioning the “experience of possession” and utilizing criteria for Dissociative Trance Disorder, which was part of DSM-IV, increases global utility. The new criteria notes that amnesia for everyday events is a common feature.
There are descriptions of similar disorders that go back as far as religious beliefs and behaviors can be traced which were often considered to be evidence of “possession states”. However, it wasn’t until 1980 that Multiple Personality was officially classified in the DSM III as a legitimate and separate diagnostic category. It was renamed Multiple Personality Disorder in the DSM-III-R. In 1994, the DSM-IV changed the name to Dissociative Identity Disorder. Understanding the dissociative phenomenon provides insight into the incredible strength and determination to survive of individuals who have experienced enormous trauma. It also helps clinicians understand the impact of severe trauma during early childhood on development and consolidation of the sense of self.
Definitions and Principles of Dissociation
Most experts agree that dissociation can occur in pathological and non-pathological forms. Some liken it to a continuum from minor dissociations such as daydreaming to the major pathological form of DID. Steinberg & Schnall (2000) describe dissociation as a state of fragmented consciousness involving amnesia, a sense of unreality, and feelings of being disconnected from oneself or one’s environment. They see it as a standard human response to trauma, a near universal reaction to a life-threatening event. Courtois (2012) describes dissociation as a skill and a defense. She sees dissociation as occurring on a spectrum.
All of us have experienced a form of dissociation at one time or another. When we drive home from work we often are thinking about what we have been doing during the day or what we may want to do during the evening. Suddenly we realize that we don’t remember passing the gas station or some other landmark that we know is on the way home. And yet, we have arrived safely at our destination. This is occasionally unsettling as we realize that we seemed to have “spaced out” when driving. But then we recognize that, somehow, a part of our brain was concentrating enough to drive safely and clearly, and we did have our eyes on the road. In spite of a momentary sense of disconnect we can account for our time and if someone spoke to us while we were driving we would respond appropriately. We would know we had been driving and where we were going. The patient with DID has spent much of their life having similar kinds of experiences. However, they often may not arrive at the intended destination. They may “wake up” in a strange city or find unfamiliar clothes in their closet. They really don’t know where they have been or even with whom they might have spoken. They often feel scared and until correctly diagnosed, may even feel “crazy”. A very important key here is that although the ability to dissociate during early traumatic experiences was highly functional and potentially life-saving, continuation of these coping skills is generally inappropriate and exposes the client to further danger both physical and emotional.
West (1967) defined dissociation as a psychophysiological process whereby information-incoming, stored or outgoing- is actively deflected from integration with its usual or expected associations. In essence, dissociation is a state of experience or behavior wherein dissociation produces a discernable alteration in a person’s thoughts, feelings and actions, so that for a period of time certain information is not associated or integrated with other information as it normally or logically would be.
Three basic principles can be used to characterize most forms of dissociation (Nemiah, 1981).The first is that the disturbance of identity may take a variety of forms. For example, the individual can have complete amnesia about the self-including name and age which can occur in psychogenic amnesia or fugue states, or the existence of the alternating identities seen in DID. The second principle is that there will be a disturbance in the individual’s memory for events occurring during the period of dissociation. The third principle is that the vast majority of dissociative disorders are traumatically induced. Christine Courtois, in a presentation for Psychotherapy Networker, noted that dissociation has also been linked to studies of attachment and family dynamics. However, It is generally accepted that for DID to develop, severe recurrent trauma generally has occurred during early childhood, generally before the age of 8 or 9. Waseem, Aslam, Switzer & Perales (2007) identify the origin of DID as occurring between 2.5-8 years and issues around this arising in early adolescence.
Although men and women who have experienced horrific trauma during wartime may experience dissociative episodes, they generally do not develop DID. Rather, they may experience psychogenic amnesia or fugue reactions. However, because the trauma has occurred after the individual has reached young adulthood, their sense of individual self was established well before the traumatic incident.
History of DID
Pierre Janet, a French scholar born in 1859, was a professor at the Lyceum in Le Havre, France when he was introduced to a patient, Leonie. Leonie was able to be hypnotized from a distance. Janet then began a set of experiments with this patient and others suffering from amnesias, fugues and “successive existences” (his description of alter personalities) and conversion symptoms. He postulated that these symptoms were attributable to the existence of split-off parts of the personality which he conceptualized as “subconscious fixed ideas” capable of independent life and development. He demonstrated that the dissociated elements associated with the patient’s behaviors had their origin in traumatic experiences and could be treated by bringing into consciousness the split-off memories and affects. In the United States, Boris Sidas pursued the question of suggestibility in both normal and abnormal subjects. He concluded that there is within every person two streams of consciousness that constitute two separate selves, the waking self and the subwaking self (Crabtree, 1986). Sidis believed that the subwaking self was devoid of morality, willing to carry out any act, very susceptible to the emotional forces aroused by crowds and mobs, and without will or goals of its own.
Morton Prince, founder of the Journal of Abnormal Psychology continued Janet’s work on dissociation but suggested replacing the term subconscious with coconscious which he felt more clearly expressed the coactivity of the second consciousness. He de-emphasized the importance of amnesia and made the simultaneous activity of two or more systems within one individual the crucial factor in his model of dissociation. He is best known for his work with the MPD patient “Miss Beauchamp” (Crabtree, 1986) which he describes in detail in Dissociation of a Personality (Prince, 1906).
Others who worked in this area were William James and Frederick Myers. James felt that the “mind seemed to embrace a confederation of psychic entities” (quoted in Taylor, 1982). Myers postulated that there was a second self which he termed “subliminal self”. The second self was the individual’s true or greater self. The conscious self or “supraliminal self” was merely a subordinate stream of consciousness required to exercise those activities necessary for existence in the world. James synthesized these two formulations of dissociation into a model that accounted for hypnotism, automatisms, hysteria, multiple personality, demonic possession, witchcraft and genius (Taylor, 1982).
Although these men took an experimental approach toward the phenomena of dissociation, most of their work was based on studies of single individuals. Prince’s primary experimental interest was in establishing that simultaneous “coconscious” processes were in fact conscious and not merely purely automatic physiological processes. However, he did recognize that one of the coconscious processes might influence the functioning of the other. In the late 1920’s Messerschmidt demonstrated the existence of a significant amount of interference between simultaneous conscious and subconscious tasks.
During the 1930’s dissociation no longer was considered to be appropriate for legitimate scientific investigation. Psychoanalysts such as Freud and Breuer reported that the cases of MPD reported by clinicians were artifacts hypnotically induced and unwittingly or deliberately induced by their therapists. It is important to know that even today there are therapists who continue to believe this to be the case. Nicholas Spanos, in his last book written before his death; Multiple Identities and False Memories: A Sociocognitive Perspective, (1996) presents a very critical and controversial view of DID and argues that DID and the recovery of repressed memories of childhood physical and sexual abuse is not a naturally occurring disorder but rather a social construct that exists in a particular cultural and historical framework. I recently ran into a difficult situation when a patient I a 38 year old DID patient I was treating, became very paranoid and self-destructive after experiencing a serious trauma and was briefly hospitalized. Unfortunately things went badly in the hospital. On her first day of admission, a first year medical resident told me that she thought the client was faking. She admitted she had never seen or treated a patient with DID but had on one occasion seen a scenario on the internet where the individual (the Hillside Strangler) had made up the diagnosis/behaviors to avoid criminal prosecution. Ultimately the unit’s chief psychiatrist tried to convince the patient that her alters did not exist and that she should ignore them. Needless to say, this caused a fair amount of trauma to this patient who had come to terms with her DID symptoms and while not thrilled with her diagnosis initially, felt , for the first time, that there was an explanation of her behaviors and experiences that made sense to her.
Interest in the dissociative process returned in the 1970′ and 1980’s. Interest in hypnosis also rose. The increased public awareness of severe sexual, physical and emotional abuse of children provided an interest in the effects of trauma on the individual. This proved to be both positive and negative. The positive was clearly the fact that patients suffering from dissociative disorders were being recognized and receiving treatment. The negative evolved from overzealous or poorly trained therapists who began to identify abuse when it didn’t always exist which led to the False Memory Syndrome (FMS). Some people are highly suggestible and can come up with forgotten abuse as an explanation for their problems if led, especially under hypnosis, to believe this. Patients with DID are particularly hypnotizable. So it is critically important to never use hypnosis to go on a search and find mission when looking for an explanation of symptoms. Courtois (2012) points out that much of what was studied about memory was related to normal events. More recently, research is indicating that when memory is related to trauma, there may be difficulty with coding, retaining and recall. People often have believed that therapists triggered the recalled memories of abuse. However, there are a variety of things which can trigger recall of trauma, including life circumstances and media events, such as discussions of current sexual abuse cases, movies, etc. It is critical, if patients don’t remember something that therapists don’t try to fill in the gap.
Types of Dissociative Reactions
It is important to recognize that there are other types of dissociative responses and/ or altered states. Hypnoid or trance-like states appear to be an ego defense to trauma and have been identified as a powerful predictor of early DID in children and adolescents. Somnambulism or sleep walking is common in childhood and generally disappears by around age 10. However, sleepwalking that continues into adulthood often has a later age of onset and is more frequently accompanied by the presence of psychopathology. In fact, somnambulism in adults may be part of the clinical picture of DID. I have several patients who have reported unexplained messes in the house, family members finding them cleaning, drawing or writing, bathing, showering, or engaged in other behaviors of which they have no memory in the morning. One woman’s husband often found her trying to make sandwiches or cookies and seeming confused as to how to proceed once the ingredients were on the counter. Upon investigation, it turned out that a very young alter was out and trying to cook.
Dissociative amnesia, previously called psychogenic amnesia, is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness and is not associated with an organic mental disorder (American Psychiatric Association, 2013). Most often the missing personal information involves the individual’s identity and may include name, age, marital status, occupational information and personal life history (Rapaport, 1971). Individuals with dissociative amnesia are usually aware of the fact that they are unable to recall important personal information, though they may exhibit classic la belle indifference toward their impairment. Dissociative Amnesia can be diagnoses with or without dissociative fugue.
Localized amnesia, a failure to recall events during a circumscribed period of time, is the most common type of dissociative amnesia. Localized amnesia may be broader than amnesia for a single traumatic event. In selective amnesia, the individual can recall some, but not all, of the events during a circumscribed period of time. Thus the individual may remember part of a traumatic event, but not other parts. Generalized amnesia, a complete loss of memory for one’s life history, is rare. Individuals with generalized amnesia may forget personal identity. Some lose previous knowledge about the world and can no longer access well-learned skills. Generalized amnesia has an acute onset. The perplexity, disorientation and purposeless wandering of individuals with generalized amnesia usually bring them to the attention of the police or some emergency services.
I worked with a teenager who had been abused by an uncle while on a trip. The extended family did not believe her and the loss of the affection of so many people was devastating for her. She ran into a grandparent several months after the incident and the individual acted as if the girl did not exist. The next day the police found her lying in the snow dressed only in her pajamas. She could not recall her name, did not recognize her house, family or friends. During the course of a week, she seemed to regain very little information. During several hypnosis sessions, she was able to recall the events leading up to the amnesia. It took several weeks for her to gain total recall of the more intimate details of her life. She did recover fully.
Dissociative Fugue is described in the DSM-5 (American Psychiatric Association, 2013) as apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information. They may appear quite normal to the average observer. In contrast to individuals experiencing psychogenic amnesia, fugue victims are usually unaware of their loss of self-referential information (Rapaport, 1971). Fugue states are common in patients with DID.
Depersonalization/Derealization Disorder is the presence of persistent or recurrent experiences of depersonalization, derealization, or both. Depersonalization includes experiences of unreality, detachment or being an outside observer with respect to one’s thoughts, feelings, sensations, body or actions (e.g. Perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing. (American Psychiatric Disorder, 2013). The person may report that she/he feels unreal, as if he or she were in a dream, like a machine, dead, self-estranged or otherwise changed from his or her normal state. Depersonalization is only considered to be a diagnosable disorder when it occurs in the absence of another disorder that includes feelings of depersonalization (Putnam, 1989). Depersonalization occurs in approximately 53% of patients with DID. Some patients with severe anxiety report having these experiences.
Derealization refers to experiences of unreality or detachment with respect to surroundings (e.g. Individuals or objects are experiences as unreal, dreamlike, foggy, lifeless or visually distorted. In both depersonalization disorder and derealization disorder reality testing remains intact.
Depersonalization/Derealization is only considered to be a diagnosable disorder when it occurs in the absence of another disorder that includes feelings of depersonalization (Putnam, 1989).
Dissociative Disorder Unspecified in the DSM-5 applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational or other areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders category. The unspecified dissociative disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific dissociative disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings.
Possession states are another form of dissociation. Primitive cultures and some fundamentalist religious groups have strong beliefs in possession states. The classic psychiatric review of possession states was done by Oesterreich (1966) who felt there were two main forms of possession: a “somnambulistic” or hysterical form and a lucid or obsessional form. In the lucid form the person is aware of him or herself but feels invaded and engaged in a struggle for control over his or her behavior. In the somnambulistic form the individual has lost all consciousness of the self and speaks with the voice of the “intruder”.
The DSM-5 (2013) states that identity disorder possession form identities typically manifest as behaviors that appear as if a spirit, supernatural being, or outside person has taken control, such that the individual begin speaking or acting in a distinctly different manner. DSM-5 also notes that the majority of possession states around the world are normal, part of spiritual practice and do not meet the criteria for DID. The identities that arise during possession form dissociative identity disorder present recurrently, are unwanted and involuntary, cause clinically significant distress or impairment and are not a normal part of a broadly accepted cultural or religious practice.
For more extensive review of the history of possession and treatment by exorcism the reader is directed to Oesterreich (1966) and Pattison and Wintrob (1981).
Near death and out of body experiences may also be seen as a form of dissociation. Finally, a few other unusual psychiatric syndromes are seen as forms of dissociation. Folie a deux or folie a plusieurs have a core feature of the transfer of mental symptoms, particularly paranoid delusions, from one person to another. Le Delire de negation or Cotard syndrome involves, in its extreme form, a complete denial of the existence of self. In milder forms, this may be seen as a sense of depersonalization-like change in the self or a feeling of despair or self-loathing (Enoch and Trethowan, 1979).
Factors that Influence the Form of Dissociation
Age
Dissociative reactions seem to have their origin as an adaptive response to overwhelming trauma. Age at the time of trauma appears very significant. DID generally develops only when sustained and very severe trauma occurs before the age of 11 or 12. After that, when trauma occurs, the individual generally has enough ego strength to avoid the more serious development of alters. Although, dissociation for a particular traumatic event or series of events (such as war trauma) may occur.
There is a remarkable degree of agreement among various sources of information as to the average age of the DID patient at time of diagnosis. Putnam and Post (1988) reviewed the literature and found a mean age of 28.5 years. Kluft (1985) suggested that the clinical presentation of DID varies with age but that “the most floridly multiple clinical presentations typically occur within the third and fourth decades”.
Gender
The role of gender has been a bit more difficult to assess. Initially, far more women were reported to have DID. Ratios went from 2:1 to as high as 8:1. (Allison, 1974; Putnam et al, 1986). The DSM-IV-TR states that DID is diagnosed three to nine times more frequently in adult females than adult males. In childhood, the female to male ratio may be more even (American Psychiatric Association, 2002), but is more difficult to diagnose DID in children and more data is needed. DSM-5 notes that females with DID predominate in adult clinical settings but not in child clinical settings. Women with DID, as do women in general, have a higher tendency to direct their anger at themselves through suicidal behaviors or self-mutilation and therefore may be more likely to come into contact with the mental health system. Men, in general, tend to direct feelings of anger outward and therefore get caught in the criminal justice system. A study by Bliss and Larson in 1985 found a relatively high incidence of DID among rapists and sex offenders. A word of caution here: whenever one is working with a criminal population, one must be very cautious to assess for malingering.
Ethnic and Socio-economic Status
The data on ethnic and socioeconomic status are scanty but from what is available, one can conclude that DID occurs across all major racial groups and socio-economic settings (Putnam et al., 1989).
Attachment Issues
Courtois, (2012) points out that emotional abuse, including neglect and failure to respond and soothe a child is also implicated in the development of dissociative disorders. This understanding allows us to make a shift back toward the interpersonal patterns started early in life and away from solely working with the trauma.
Culture
A cross-cultural perspective is particularly important in the evaluation of Dissociative Disorders because dissociative states are a common and accepted expression of cultural activities or religious experience in many societies. In most instances, the dissociative states are not pathological and do not lead to significant distress, impairment or help-seeking behavior. However, a number of culturally defined syndromes characterized by dissociation do cause distress and impairment and are recognized indigenously as manifestations of pathology. The symptomatology may take different forms in different cultures, such as recurrent brief episodes of dissociative stupor or spirit possession in India (American Psychiatric Association, 2000).
Section II: Assessment and diagnosis of DID
Symptom Profile
Most patients who are diagnosed with DID have had a long history of psychiatric or neurologic symptoms. They may have received numerous other diagnoses by several different clinicians before the correct diagnosis is made. Patients in the NIMH study (1986) averaged 6.8 years from initial presentation in the mental health system to correct diagnosis. Typical diagnoses include: depression, schizoaffective disorder, bipolar disorder, borderline personality disorder and temporal lobe epilepsy. Patients may show co-existing signs of obsessive compulsive disorder, eating disorders, substance abuse problems and impulse control problems. Clearly it is essential to take a very careful and extensive history with these patients to look for possible dissociative dynamics of an underlying process. The single most common presenting symptom is depression. Though, vegetative symptoms can be short lived or even absent in patients with DID. About ¾ describe mood swings. Family members may have told them they have frequent mood swings-sometimes several times a day or even multiple times in an hour. They may even have been told that at times they act like a different person.
Many have a history of suicide attempts or gestures as well as self-destructive ideation and behaviors such as cutting and eating disorders. It is important to ask about where cutting is occurring. Many victims of severe sexual abuse will report self-mutilation of genitals and breasts. They often have low self-esteem and are anhedonic. Difficulty concentrating is often reported as are feelings of fatigue, sexual difficulties and crying spells.
Rarely do patients enter treatment volunteering information about dissociation. It may take many months of contact for patients to talk about these systems. Because of the lost time, unexplained voices in their heads, confusion about where they have been or what they have done, they often think they are “crazy”. About 98% of DID patients report loss of time. One NIMH study (Putnam, 1986) indicated that about 55% report fugue states and 53% report feelings of depersonalition. About 20% report episodes of sleepwalking. Most patients have come up with explanations for these behaviors, in particular the use of drugs and/ or alcohol. The presence of substance abuse can certainly confound the picture and does complicate treatment. Alcohol and stimulants are commonly abused. Drug abuse often begins with the prescription of narcotics for treatment of severe headaches, commonly seen in DID and often present when “switching” between alters occurs. Patients rarely seem to abuse hallucinogens. They are struggling to stay in contact with reality and avoid any additional “really weird experiences”. They often feel they are already hallucinating. Therapists often refuse to treat patients that are actively abusing substances. However, sometimes it is important to provide some treatment before the patient is completely clean or sober. One of my patients so hated herself that the idea that she was worthy enough to stop drinking was impossible for her to accept. We worked for about a year trying to get to a place where she was willing to accept that it was okay for her to accept treatment and to get a couple of alters to help in this process. She then was able to enter and successfully complete an in-patient substance abuse program for women. Treatment for the DID issues resumed after she had attained sobriety and was well connected with support groups.
As noted above, these patients do report what seem to be hallucinations. They hear voices in their heads that berate them or command them to hurt themselves or others. They may hear screaming, laughing, the crying voice of a child or children in distress. They may also hear some voices that offer consolation, comfort or advice. Unlike schizophrenics who report voices outside commanding them, these patients generally describe the voices as in their heads and often as “loud thoughts”. They may hear lengthy and coherent conversations unlike the more primary process voices heard by schizophrenics. Since these experiences occur long before the diagnosis of DID is made, they are often terrifying for patients.
Many patients may report seeing changes in their body image. When an alter is out, that is who they see in the mirror. As a result, they may develop an aversion to mirrors. They also describe “autoscopic” hallucinations. They report seeing themselves from up above, or as if watching a movie of themselves. These out of body experiences are usually accompanied by profound depersonalization, similar to the near death experiences reported by others. During therapy sessions they may report disembodied faces floating in the air, blood or hideous scenes. When this occurs, it is typically associated with the emergence of material related to past trauma.
Around 5-12% of DID patients report the presence of olfactory and tactile hallucinations (Putnam, 1989). However, olfactory hallucinations are more common in patients with temporal lobe abnormalities as documented on EEG’s. Somatic memories (especially pain in the vaginal area or pressure on the chest and feelings of being unable to breathe) which are quite common can be confused with tactile memories.
At times, especially during early parts of treatment, alters switch so rapidly that a “revolving door crisis” occurs. Basically, this is a series of alters whizzing in and out in an attempt to gain control. It may look to the clinician and feel to the patient like a thought disorder, but it is usually transient and can be related to a specific crisis.
Delusions also can occur. Many alters believe they can physically harm another personality, a fixed belief that they can separate, without harm to themselves. Often what appears to be a delusion turns out to have a basis in fact when the therapist begins to understand the dynamics of the patient’s dissociative pathology. Although some DID patients may have ideas that qualify as truly delusional, one rarely finds that these delusions are of the type generally seen in paranoid disorders where the patient believes that some external agency (e.g. the FBI, men from Mars, etc) is sending them messages through the media or in some other way (Putnam,1989) The delusions of DID are often those of passive influence experiences, which have a basis in fact, or delusions of separateness secondary to the excessive narcissistic investments of some alters in their individuality.
About 1/3 of DID patients report self-mutilation, though this number is probably much higher (Putnam et al., 1986). They may engage in more typical types of burning or cutting. However many develop more bizarre habits which include insertion of foreign objects such as broken glass or other foreign objects into the vagina or anus.
One NIMH study (Putnam, 1989) reported that around 14% of patients with DID have become catatonic. This may occur when the individual is overwhelmed by outside stimuli that trigger a massive recall of traumatic experiences. It may also be used as a healing experience that filters out or slows down overwhelming stimuli to a tolerable level. Ellen, a 34 year old DID patient ran into an uncle who repeatedly raped her throughout her childhood and adolescence. He had also attempted to sexually assault her on two occasions when she was pregnant. In an attempt to get away from him she tried to flee. Overwhelmed, younger alters came and went. The uncle found her and again assaulted her. Ellen began to decompensate. She thought bugs were crawling under her skin and that she was spreading them to her husband and child. She began digging at her skin, repeatedly disinfected all surfaces in her home and kept changing bed linens. Hospitalization was utilized in an attempt to reassess her medications and stabilize her. Although she agreed to this treatment initially, once hospitalized she was flooded with memories of past hospitalizations after suicide attempts. I received a frantic call from the family that she was now catatonic. This lasted for a relatively brief time but was very frightening for the family and hospital staff who felt she was having seizures. Although it was critical to follow up with an EEG, I felt this was probably a defensive dissociative response. The EEG was negative and a seizure disorder was ruled out.
As noted previously, headaches are very common. They often represent conflicts and struggles for control of the body, forced switching or punishment by an alter. They often do not respond to typical pain medications. Although use of hypnosis is not recommended for “search and find missions” to uncover unidentified abuse, it can be an excellent technique for relief of chronic pain, headaches associated with “switching” of alters and general calming of the system. After having practiced this type of relaxation/calming technique in therapy sessions, I have utilized this very successfully over the phone when a patient has called in crisis.
Sensory disturbances
Numbness
Tingling sensations
Parasthesias
Visual disturbances including some reports of blindness
Psychogenic deafness
Motor disturbances
Limb paralysis
Aphonia (inability to produce sounds)
Deafness
Symptoms resembling tardive dyskinesia (often associated with rapid switching)Cardio-respiratory symptoms including: dyspnea, palpitations, chest pain and choking or a sense of smothering
Gastro-intestinal symptoms, especially irritable bowel syndrome, are quite common in patients with DID. They often report episodes of nausea, vomiting or diarrhea. Gastric pain often occurs with viscerally remembered trauma. These patients also report pain in the reproductive system and, in particular, the vagina.
In addition, unusual dermatological reactions, unexplained fevers, changes in blood sugar or unusual responses to anesthesia have been reported. Although medications may be taken by the host (usually the presenting patient) individual and presumed to affect the entire body, this may not actually be the case. One person may take the sleeping medicine but others wake up and wander about the house or actually go out during the night. It can be important therapeutically to remind the patient that all parts, inside and out, must take the medicine.
Some patients also have significant negative reactions at certain times of year, such as Halloween, religious holidays or to certain things or events. This is because the abuse may have taken place during these specific times or in certain locations (such as a church when cult abuse is reported).
Many patients with DID have and continue to hold very responsible jobs. These individuals seem to have at least one or more very strong alters that keep younger and more troublesome alters away from work. I have worked with several nurses with DID. It really isn’t surprising that some part of them would be in a helping profession. Other patients, however, have a history of frequent job changes. Others appear to lead itinerant lives traveling the country in prolonged fugue states. There is often a periodicity to their wanderings and we may begin to expect when we will hear from them again. Because of their long histories of abuse and cycles of self-abusive behaviors, they often have histories of re-victimization as adults. Unfortunately, this is part of the legacy of childhood abuse.
Diagnosis
Diagnosis of DID is not always easy. The key is knowing how and where to look for evidence. Often your first clue is that in consecutive sessions you begin to hear information that is confusing, time lines are unclear and the patient may seem confused when you refer to something said in a previous session. You may notice slightly different styles of dress or manners of speech. Pay attention to your own sense of confusion. It is probably an important sign of what your patient is feeling. It is also important to watch for defensive or compensatory maneuvers by the patients who seek to evade questions or divert parts of the inquiry. Ask about loss of time, amnesias for periods of childhood or important life events. You might hear about a suicide attempt or hospitalization during one session and then get a confused look from the same client during the next session when you bring up the same topic. Ask about out of body experiences and feelings of depersonalization. Inquire whether others have called them a liar for attempts to cover up the fact that they can’t recall being places, talking to people, buying certain things or rearranging things at home or work. Ask if they have a history of being late. Alters, wanting time “out”, often interfere with getting places on time. Many patients have diaries that can fill in gaps in history. But not all the alters know about the diaries or want to know what is in them.
It is important to rule out any organic causes for symptoms, so communication with their primary care doctor is important. You also may be a critical link to their physician in explaining certain behaviors and/ or lack of apparent “cooperation” by the patient in medication management.
Traditional psychological tests are not terribly useful in the diagnosis of DID. The MMPI, MCMI or other traditional psychological tests may actually be invalid or inconclusive as different parts are triggered to answer different questions. However, tests to assess level of dissociation including the Structured Clinical Interview for the DSM-IV Dissociative Disorders (SCID-D) can be very helpful (Steinberg, 1994).
These include:
In the end, the only real confirmation of the presence of DID is when the clinician is able to meet alter personalities directly. This can be a fascinating experience. Early in my career over 20 years ago, I was treating a nurse who drove nearly an hour to see me. She acknowledged a history of sexual abuse and often would begin to cry when talking about the atrocities she had experienced. She asked if she could hold a teddy bear in my office and often seemed to let her nose run on the bear, a behavior that seemed a bit unusual for a nurse. I had never knowingly treated anyone with multiple personalities, though I saw many individuals who had been abused, and frankly, if asked then, I probably would have said I wasn’t sure they existed. One day, shortly after she arrived, she said she had a very bad headache. I asked her if she wanted to lie down on the couch for a few minutes. She did and shut her eyes. She lay there for what I felt was a long time and I began to think she had fallen asleep. I sat quietly and was therefore surprised when she opened her eyes, looked confused and began talking to me. Her voice and mannerisms were that of a young child, around 3 or 4. It was very difficult to deny the existence of the diagnosis at that point. I then learned about a previous hospitalization and spoke to the attending psychiatrist. Although he had been suspicious of the presence of alters, he had never met any and therefore could not make the diagnosis. Treatment with this woman went quite well. She had no substance abuse issues, was actually the primary bread winner in her family and attended treatment regularly. When we completed treatment, she had integrated all the alters but one adolescent whom she chose to keep available “for safety”. Adolescent alters often offer a strong voice and protection against abusers and can be extremely helpful in treatment when helped to mature and not act out inappropriately.
It is important to be gentle but direct when giving the patient the diagnosis. Although it can be scary for them to hear, it is often a relief that there is a logical explanation for their symptoms and recognition that they are not “crazy”. Again, I want to add a word of caution. It is critical to avoid searching for the presence of alters through hypnosis. We do not want to create iatrogenic outcomes. If alters are present, they will make themselves known. You will meet them or another part may tell you about them. On the other hand, it is important to recognize that hypnotic phenomena occur commonly in most dissociative populations and play a significant role in their psychopathology. (Kluft, 2012) High hypnotizability is commonly encountered in traumatized individuals whose conditions become the most chronic. Kluft goes on to point out that highly hypnotizable people are vulnerable to slipping into alert trances in which, with eyes wide open, they manifest many of the qualities of the more formally and traditionally hypnotized individuals. They may demonstrate a reduction in their alertness and activity of their critical intellect, a toleration of mutually incompatible perceptions without reacting to their incompatibility, the intensification of affect, rapid mobilization of transference phenomena and an increased responsiveness to suggestions. As a result, it is critical for those treating dissociative disorders to be well aware of these phenomena and trained in understanding and the use of hypnosis. We will discuss this further is the section on treatment.
Mental Status Evaluation
The following summary of what you might observe in a mental status evaluation of a patient with DID has been adapted from Putnam (1989). Remember that the changes noted below can occur within a single session or during separate sessions separated by days, weeks, months and in some cases years. Generally, little switching occurs during a first session. However, different alters may appear for complete sessions. Most patients with DID have spent a great deal of time and effort hiding what is actually happening to them and they may try hard to hide this from a therapist until they feel safe in treatment.
Appearance: Style of dress, grooming, general appearance and mannerisms may change dramatically from session to session. Note changes in facial appearance, expressions, posture and mannerisms which may occur within a single session. Handedness and habits such as needing eyeglasses may change within a short period of time.
Speech: Watch for changes in rate, pitch, accent, loudness and vocabulary. Note the use of idiosyncratic expressions and the use of profanity within single and across several sessions.
Motor processes: Rapid blinking, eyelid fluttering, marked eye rolls, tics, twitches, startle reactions, shudders and facial grimaces often accompany the switching between alter personalities. Sometimes dramatic full body “struggles” are noticed as individual alters fight to come out and/or the host tries to prevent this from occurring.
Thought Processes: Thought processes may appear to be non-sequential and illogical at times. Associations may appear to be loose and patients may appear to block or lose their train of thought. This is most prominent with rapid switching or “revolving door crises”. The thought disorder does not seem to persist beyond the crisis. They may report lying to cover up the fact that they have no memory of being somewhere or doing something.
Hallucinations and Delusions: Auditory and/or visual hallucinations and delusions may seem to be present. The patient may report voices arguing about the patient or what the patient should do. The voices are generally within the head. Voices may be both positive and negative. After the correct diagnosis is made, they may tell you that they have always felt that because of the voices in their head they felt they were “crazy”.
Intellectual functioning: Short- term memory, orientation, calculations and fund of knowledge are generally intact. In fact many patients with DID are quite intelligent. Long term memory may show spotty deficits.
Judgment: Patients may display rapid fluctuations in appropriateness of behavior and judgment. These shifts often occur along an age dimension (i.e. from adult to childlike behavior).
Insight: The personality presenting for treatment most of the time may not be aware of the existence of alternate personalities.
Suicide Risk: DSM-5 (2013) notes that over 70% of outpatients with DID have attempted suicide. Multiple attempts are common and other self-injurious behavior is frequent. Assessment of suicide risk may be complicated when there is amnesia for past suicidal behavior or when the presenting identity does not feel suicidal and was unaware that other dissociated identities do.
Section III: Alters seen in DID
Alters
Putnam (1989) describes alters as “discrete states of consciousness organized around a prevailing affect, sense of self (including body image) with a limited repertoire of behaviors and a set of state dependent memories”. Kluft (1984) describes an alter as “an entity with a firm, persistent and well-founded sense of self and a characteristic and consistent pattern of behavior and feelings in response to given stimuli. It must have a range of functions, a range of emotional responses and a significant history of its own existence”.
Some authors emphasize the importance of personality and personality fragments. This can be difficult to distinguish and I truly have found it appears to make little difference during treatment. I also have found that while it is clearly important to know what alters exist, I rarely spend time counting numbers of personalities as if somehow the more the merrier or the more the “sicker”. For example, one patient spoke of the scary Indians that kept her from doing things. She talked about them as if they were an army. As treatment progressed, I learned that although there were a lot of them (I never knew how many), they were 11 years old and served to make noise to sabotage her treatment. We dealt with them as a single group of scared kids and they disappeared. They were never formally integrated but have never returned in many years. However, it is important to identify the key players and typical types of alters.
It is also critical to recall that alter personalities generally arise as a defensive response to what is perceived as overwhelming trauma (Kluft, 1984). Over time, alters may come to acquire a significant degree of autonomy and investment in their separateness (Kluft, 1984). They may change from performing psychologically defensive tasks, such as screening out or absorbing unbearable experiences, to having their own independent objectives which conflict with those of the individual as a whole. They may acquire new functions or relinquish old ones. It is critical for the therapist to learn what they perceive to be their current role in the system. Often, for the individual to heal, the alters have to accept a new job description which utilizes their particular skills. For example, the mouthy teen who may have acted out by drinking, may be encouraged to help the others speak up for themselves. As they begin to feel they are heard, they may voluntarily give up some of their anger which is destructive to the system and help the system process appropriate anger towards the actual abusers.
Types of alter personalities
The literature is quite consistent about the types of alters frequently present in patients with DID. There is always the host, the one who has executive control over the greatest percentage of time. This may not be the birth individual. It is the host who usually present initially for treatment. Sometimes, the host is actually a social facade as several agree to pass as one. There are often a number of child personalities, each holding specific memories of traumatic events. These children often appeared for the first time during some horrific event that the birth child could not have tolerated. Sometimes, one child was present for a part of a particular event and another child appeared to handle the rest of it. These memories will eventually be told bit by bit with the different children contributing to the whole history. These children are generally frozen at that age and point of development until late in treatment when they may blend or grow into the adult prior to integration. Some of the children may be non-verbal, some may just cry and some may initially see the therapist as an abuser. One patient of mine had an alter that didn’t communicate verbally but used sign language. Unfortunately the child was pretty young and couldn’t spell very well, so communication was often quite a challenge. There may be quite a few child alters, more than adult. They can cause problems as they usually are lacking the judgment or skills to handle certain situations into which they emerge. However, for the most part, adult alters keep young alters from driving cars or showing up at work. At least ½ of patients with DID have alters who see themselves in diametric conflict with the host. These are called persecutors. Sometimes they represent introjects of the original abuser. Others may have evolved from the original helper person into current persecutors. They may actively try to undermine treatment. A natural tendency for therapists is to try to avoid the persecutors or silence them in some way. This can be a major clinical error. They are an important part of the DID system and must be dealt with. Otherwise, they have power over you and the other alters will remain terrorized. They can be won over and once they know that you are not afraid of them they may actually help in treatment. Remember, all the alters were created by the system to help them survive in some way. In their anger, they often contain much of the energy and strength that the DID patient needs to survive and improve. Many patients who have been abused have incorporated some of the abuser into themselves, just as many perpetrators of abuse may have some victim behaviors/emotions in them.
One of my female patients had a male alter she described as an “entity”. It “was” the grandfather who had been her primary abuser. She could not accept that he could actually be a part of her. He would threaten to kill the patient and harm the other alters. At times, he would take control and do things like go out on her porch and smoke a cigar. After a difficult session during which my patient talked about her anger towards her grandfather, I received a phone call from this alter threatening me to leave my patient alone and telling me he was in charge. The voice was deep and intimidating. I finally was able to convince him to not hurt anyone at least until he met with me in the next session. When he arrived I really was a bit taken aback and somewhat intimidated. He walked and spoke in a very masculine style. He promptly sat in my chair and made a lewd comment about a picture of a little girl on my wall. No wonder the host was afraid of him. After a while I was able to talk to him about his relationship with the host. He insisted he had never hurt her as a child and that he actually loved her. But he was tired of being bad-mouthed. He bought her clothes and ice cream when she was little. He had been the one to teach her about sex and often took control of the body when she had sex with her husband. He decided he really didn’t want to do that anymore since he was an old man and would give that job back to her. He also was able to contract not to hurt the host or any other part, inside or out. We discussed his strengths and ways he could help the host. The patient said she felt much more present and relaxed during sex with her husband after that session. This alter showed up a few times after that, but generally for very brief periods and never actually hurt anyone.
Frequently there are one or more suicidal personalities. Fortunately, there is generally what is called the internal self- helper. They are present in approximately 50-80 % of DID patients and often are very helpful. They may be rather passive and emotionless but often provide information and insights. There are often teenagers who can be mouthy and at times are responsible for drinking, drugging or sexually acting out. But, once you gain their trust and they see you understand that their behavior was to numb out the host so he or she could survive, they can be very helpful. They often can hold the younger parts, read them stories or play with them. They also can stand up to people who continue to try to hurt the others. Another interesting phenomenon is the presence of cross gender alters in around 50% of patients with DID. They may be introjects of the abuser or may be attempts at finding someone “stronger’ to handle things. But, it may also be an explanation for the unisex look of many patients with DID. Male patients often have a female alter that represents the good mother.
There are often alters that are promiscuous or ones that handle the sexual relationship with a spouse. It is not unusual to hear that a woman with DID was very outgoing and sexually available before the marriage, however, after the wedding avoids sexual behavior. It is as if the sex, now, back in the family, represents the trauma of incest again. Also commonly present are alters identified as administrators, wage earners, autistic or handicapped, those with special talents or those speaking a foreign language unknown to the other alters and those who deny the presence of any pain, sometimes referred to as anesthetic or analgesics. There may be some imitations and imposters just to confuse the therapist. Sometimes alters will be identified as demons or spirits, more often seen in patients from rural areas or those with more fundamentalist religious beliefs. The original person or birth person is often not seen until much later in therapy. This person is sometimes described as sleeping or even dead. These alters have differing awareness of the others. One of the major tasks of treatment is to make available to the entire system of personalities the knowledge and secrets held by the others. This generalization of knowledge gradually erodes the need for separateness and begins the movement toward resolution and integration.
Manifestations of Switching
The manifestations of switching vary. Some are quite dramatic and involve a strong physical response as the alters literally struggle to take over the body. Other times the change will be observed with eyes rolling back, blank stares, staring at the rug or ceiling or complaints of severe headache followed by closing of the eyes. I have seen changes occur when the patient removed her glasses and could now see perfectly well, though other alters could not. Be aware that different alters may have different physiologic sensitivities, different allergic reactions or responses to alcohol. For example, one might do the drinking and the other wakes up with a hangover. One of my colleagues had a patient whose blood sugar dropped dramatically when a child alter was present. This never occurred when an adult was “out”. Other patients report that they have been “put to sleep” during surgery and in the middle of the operation another alter awoke completely unaffected by the anesthesia! Clearly it is a good idea that physicians and surgeons are aware of the presence of this disorder before any surgical procedure. Although I previously noted that it is inappropriate to use hypnosis for a “search and find” of alters, be aware that patients frequently go through a self-hypnosis as alters go in and out.
Treatment with DID patients in some ways is not much different than good treatment with most other patients, especially those who have experienced severe trauma. There are, however, some differences and some “tricks of the trade” which are extremely important.
The 2005 guidelines for the treatment of DID from the International Society for the Study of Dissociation state the importance of not creating countertherapeutic and iatrogenic outcomes. These guidelines recommend that therapists not treat any alternate identity as more important than any other, not create additional alternate identities by asking the client to name them when there may be none, not suggest that alternate identities function more elaborately or autonomously than they are already, not ask the client to ignore or get rid of alternate identities and not play favorites with any of the alternate identities. Instead, the therapist must help to foster the idea that alternate identities represent adaptive attempts to cope with of master problems that the DID client experiences. Hence, the alternate identities can be helped to find more adaptive ways to solve problems rather than using solutions that are dysfunctional, unsafe or problematic.
In a survey of practices and recommended treatment interventions of DID (Brand, Loewenstein et al, 2011) it was found that highly experienced therapists recommended a carefully staged treatment consisting of three phases. In the initial phase, they advocated emphasizing skill building in development and maintenance of safety from dangerousness to self and others and other high risk behaviors such as emotion regulation, impulse control, interpersonal effectiveness, grounding and containment of material. In addition, they recommended specific trauma-focused cognitive therapy to address trauma-based cognitive distortions. They uniformly recommended identifying and working with dissociated self states beginning early in treatment. They advised the use of exposure or controlled abreaction techniques, modified not to overwhelm these patients balanced with core, foundational interventions for the middle stage. The last stage of treatment was less clearly delineated and more individualized. Unification of the self states (formal integration) appears to occur in only a minority of patients with DID.
Courtois (2012) also identifies three stages which are measured in mastery of skills and healing tasks, not time. They are:
Principles of Treatment
The following are 12 basic principles for treatment.
Contraindications for Intense Memory Work
It is extremely important to know when to avoid memory work and to make stabilization the primary goal. Be very cautious or avoid memory work altogether under the following conditions:
Guidelines
When it has been determined that a particular individual cannot tolerate intensive memory work the following guidelines for supportive or short-term treatment are recommended (Steele, 1991):
Techniques for Management of Traumatic Memories
Most patients will be a bit leery of talking about the trauma they experienced. After all, they developed alters so they wouldn’t have to think about or remember the bad experiences. Alters often feel they are stuck in the abuse. They believe that it is actually happening again. They need constant reminders that this is now and the abuse was then. Abreaction, an emotional release or discharge after recalling a painful experience that has been repressed because it was intolerable, is a routine part of trauma work. However, some therapists encourage this emotional release to be processed as if the original trauma was actually occurring and feel they had to provide extra long sessions to allow the patient to process all their feelings. I believe this is unduly painful and unnecessary. By using techniques to help the patient process what happened, while at the same time, understanding they do not have to re-live every moment of every emotion, I believe patients can achieve appropriate release while remaining safe and less traumatized. The emotion can be processed and contained. Steele , 1991, in a workshop presentation, identified a number of excellent techniques discussed below to help minimize the pain involved when revisiting the trauma. Patients are generally in a state of autohypnosis when they are recalling memories. Although, as I discussed above, hypnosis is not used to go on a “search and find mission” to look for abuse, hypnotic induction techniques can be used to give the patient safety suggestions.
Permissive amnesia- Tell them, “You can remember only what you need and what is useful”. This gives the patient permission rather than prohibiting them from doing something. It allows them to have the control.
Affect modulation/desensitization- It is helpful to teach patients early in therapy how to rate their feelings on a scale from 1-10. 1 is no unpleasant feelings and 10 is intolerable. Ask the patient what number is intolerable to them. Then, you can let them know that if they reach that level of discomfort while discussing memories, they can give you a signal you both agree on or simply say stop. It is important that you ask someone in the system to make sure everyone inside gets this message.
Anchors and bridges between now and then- It is often helpful to have the patient hold a familiar object in their hand to ground them in the present. Although some patients with poor boundaries may ask to hold your hand, do not do this! With DID patients it is extremely important to keep physical boundaries clear and firm.
Containment Imagery- Having the patient visualize placing the memories into an area of containment, such as boxes, vaults, safes or in files that are put into a cabinet is extremely helpful. They are instructed that the memories can stay in these containers until the patient chooses to retrieve them. Some patients like to imagine special locks added to these containers. You can encourage them to let alters that are inside facilitate containment.
Safe spaces- Help the client move from the memory to a safe space that you have identified prior to intense memory work. Sometimes a child alter can go inside the system and sit with an older and supportive alter. Some alters like to go inside to a beach, a quiet room, a nice field, etc. One of my clients felt extremely safe floating in a boat with her feet dangling in the water as she looked at surrounding cliffs. We utilized this imagery very successfully after difficult sessions as well as over the phone when she called in a crisis mode.
Distancing and the use of artificial dissociation- Using the past tense and the third person gives added safety. Say, “What was happening back then?” or “Tell me what the little girl noticed then.”
Cognitive rather than feeling lines of questioning- “What is she thinking now?”
Movie screens, television or DVD techniques- Have the patient put the memory on a movie screen, TV or DVD. Instruct them that they are sitting in front of a control panel. They have control and can start, stop, re-wind, freeze or blur the frame. They can eject the DVD at any time. They can even change the channel.
Positional change in the memory- You might say: “Let yourself move off the bed from under the abuser and float to any place that feels safer in the room. Now you can watch what is happening. You can move behind or above the abuser.” This allows another perspective and encourages distancing so that the memory can be experienced with diminished physicality.
Time distortion- You can let the patient know that although the experience lasted a long time, the memory can be short. Tell them that they can remember all they need to know.
Recovering from the memory- If they get overwhelmed they can be put into a deeper trance to rest and relax.
Additional Comments on Treatment
I often find it helpful to have sessions twice a week. Very occasionally I will see a patient three times per week, especially if we are dealing with a particular crisis or avoiding a hospitalization. Most patients do fine with a 50 minute hour. But, sometimes 1 1/2 hour sessions are helpful in making sure the patient has settled down and an adult alter is present before the patient leaves. Some between-session calls are inevitable with these patients. But I really try to keep these to a minimum. If the patient is calling too often between sessions it probably means you are going too fast or there are not enough safeguards in place. Remember, it is up to you to establish clear boundaries. Be careful that you are not getting abused. Don’t let these patients intrude on your private life. Some may try to stalk you or call constantly.
One patient who became angry at me about some issue (inevitable in treatment) left a nasty note on my car. We had a very long discussion about boundaries and that my car was my private property. She was welcome to say whatever she wanted to me or leave a note in my office. But she could not touch my car. She got the point and it never happened again.
Be very careful of setting up meetings with patients outside of the office. They rarely work out and give the patient the idea that you are their friend, not their therapist. This is important with all patients. But patients with DID may be more likely to push for this. Or you may be pulled to try to extend yourself for them.
Transference and Countertransference
It is critical that therapists treating patients with DID are very aware of issues related to transference and counter-transference. Therapists working with multiples will quickly discover that these patients are extremely capable of generating very complex transference and countertransference issues. Transference, defined as responses to a therapist that are primarily based on and displaced from significant childhood figures, especially parents and siblings. Transference reactions are generally archaic, infantile and primary-process responses. The displacement may involve a single traumatic event or repeated traumatic episodes. The reactions range on a continuum ranging from appropriate responses to reality-based stimuli to very inappropriate or psychotic responses. With the DID patient, the therapist may have to deal with different transference issues among the alters. Transference reactions can be precipitated by a variety of stimuli. DID patients are extraordinarily perceptive. They may pick up on when the therapist is not feeling well and seems a bit distant. They may have a very strong reaction when normal therapeutic issues have to be dealt with such as billing, vacations or unexpected interruptions during sessions. They may react to the color of the therapist’s hair or clothing. I had one patient become very upset when I wore a scarf one day. After much discussion she was able to recognize that her mother often wore scarves when disciplining her. The transference issues involved in treatment of patients with DID are generally not as well organized as in the typical patient undergoing psychoanalysis. They may be dealt with in a more piecemeal fashion, as necessary. One area, however, requires special mention. This is the act of touching the patient. If a therapist touches a patient with DID, some alters might have the transference experience of the therapist as an important childhood figure who was nurturing and comforting. Simultaneously, other alters may experience the therapist as the abuser and become terrified. This is why I am so specific about avoiding physical contact with these patients. Much later in therapy, as trauma is resolved there are times it may be appropriate to shake hands or even give a supportive hug. However, this is not frequent and should never be done without specific permission from all the alters.
As I mentioned above, DID patients often elicit strong countertransference reactions in therapists. Countertransference is the response on the part of the therapist toward the patient that, although evoked by some event within the therapy, is primarily directed at gratifying the therapist’s needs rather than advancing the patient’s treatment. The emotions being elicited in the therapist may also derive from the important figures in therapist’s past, such as parents and siblings. Therapists living with their own teenagers may have very strong unconscious reactions to the teen alters. Similarly, a very hostile or sad reaction may be evoked by an alcoholic or suicidal alter if these issues were a part of the therapist’s past.
Countertransference feelings include many feelings such as anger and hostility, sexual attraction, confusion, desire to distance oneself or hold and nurture the patient. Different alters in the DID patient may actually evoke several of these feelings at one time, causing further confusion. Again, I cannot emphasize enough the importance of the therapist being aware of these issues and getting supervision and their own therapy, especially if their countertransference issues cannot be understood and dealt with appropriately.
Adjunctive Therapies
At times it is very helpful to have sessions with the spouse or children of the patient with DID. Understanding the effects of DID on the outside family system and providing support can be critical. Referral of family members to other therapists can be made as appropriate. It is generally helpful to discuss the dynamics of DID with the spouse. As they begin to understand the DID process they will often feel validated about their own observations and report that now “things makes sense”. Periodic meetings with the husband and wife can be very helpful in building and sustaining the marriage during the difficult time. Healthy spouses can be encouraged to work out a relationship with some of the more hostile alters, can be used to support child alters and can be reassured that with resolution of the trauma many of the characteristics of their favorite alters will emerge and remain.
It is important to be aware of a spouse who seeks to use the patient’s illness for self-gratification. It is not surprising that patients with DID tend to marry people with a fair amount of their own pathology. Thus, the spouse may try to elicit certain alters for certain types of sexual behavior, thereby repeating the trauma. Many survivors of abuse marry abusers in an unconscious attempt to resolve their early trauma. Alcoholism, character pathology/ personality disorders and sexual/gender identification issues are not uncommon in spouses of these patients.
Therapists can help children of patients with DID understand their perceptions of changes in their parent. Children are often very aware of minor differences/changes in their parent. They need to be helped to understand that their parent’s behavior is part of an illness and not something to be imitated or manipulated for their own benefit. During crisis situations the therapist can help provide stability with reality-oriented discussions, emphasizing realistic attitudes and behavior. Their fears about what is happening can be addressed as well their feelings of guilt if they wish their parent were to be removed or die.
The literature gives no evidence that the utilization of group therapy with multiples is effective. Meetings with family of origin members should only be done when it is clear they are supportive of the patient and validate their experiences. This is generally a very rare occurrence since the trauma that caused the DID generally occurred within the family of origin with the participation of family members. Their participation may have been that of the active abuser or the more passive but non-protector (generally a parent or parent figure).
Internal group therapy or conversations among the alters, are often a helpful part of treatment. Individual patients are encouraged to figure out how the internal parts communicate with each other. One patient described a large conference table where alters sat and communicated about important issues as well as how to respond to a variety of situations. Early in treatment some of the figures were described to me as looking ghost-like. As they emerged in therapy they became more prominent at the table. Another patient said her alters communicated by cell phones. Modern technology can’t be escaped! In any case, once you have identified how internal communication is handled, messages can be given to everyone, consultations about treatment are facilitated and treatment is generally a bit easier.
Some therapists trained in EMDR (Eye Movement Desensitization and Reprocessing) find this to be a helpful technique for memory processing.
Cult Abuse
This was a topic of considerable discussion in the 1980’s and many of the allegations of cult abuse remain unproven. Spanos (1996) was clear in his statement that “there is no good evidence to support belief in the existence of a conspiracy of murdering, child-abusing satanic cultists”. I have worked with several patients who have described very ritualistic and cult-like activities often within a church. One patient, early in her treatment, contacted an attorney to possibly file criminal charges. The attorney refused to take the case because he felt her accounts of the abuse were too disjointed. This was not surprising since the history was being given by different parts. When treatment was complete the patient decided that she did not want to pursue the legal issues. She had found a sense of peace and wanted to keep it. It is important to listen carefully to the patient and remember that you (or the legal system) may never be able to prove what actually happened. Going through legal proceedings can be extremely stressful and even traumatic. Most patients with DID are not able to tolerate such procedures, especially before integration has occurred.
Section V: Models of Treatment
Although many models of treatment have been used with DID patients, most of the literature advocates a modified form of Psychodynamic Psychotherapy (Braun, 1986; Greaves, 1980; Kluft, 1985, 1987). The information in the presentation is based this type of treatment. Patients with DID generally cannot tolerate the traditional unresponsive neutral response advocated by standard Psychoanalysis. They will push the therapist to break boundaries and can make the therapist uncomfortable as they push the therapist to be more “real” with them. Experienced therapists generally find an equilibrium between the reality-based needs of the patient to be responded to in an active and direct manner and the therapist’s need to maintain a therapeutic stance toward the patient. Putnam (1989) points out that “one must be flexible in order to be effective with patients with DID and yet one must be rigid with regard to certain treatment boundaries or the therapy degenerates into chaos”. Such paradoxes permeate the treatment of DID.
Pais (2009) proposes a family approach to conceptualize the treatment of DID. Her use of addressing the family system both within the patient (among alters) and with the patient’s spouse and/or children appears quite useful. Just as it is important to promote effective communication with all families, it is important to improve communication with the patient’s internal family. Encouraging the patient to utilize group talks with all family members present is helpful in both these situations.
Many clinicians recognize that some Cognitive techniques may also be helpful, especially when dealing with substance abuse issues and confronting cognitive distortions. Some clinicians have reported success with Eye Movement Desensitization and Reprocessing (EMDR) with trauma patients (Wiley, 2004). But there is little research using EMDR in treatment of DID. There is also a relatively new treatment called Target therapy that is being used. Target (Trauma Affect Regulation: Guide for Education and Therapy) was developed at the University of Connecticut by Julian Ford, Ph.D. Target teaches skills for managing psychological, relational and work/school problems that result when a person experiences a high level of stress. When utilized with DID patients, the therapy essentially denies the existence of alters and forces the individual to stay focused in the present and on what is happening now. I have had one patient who was introduced to Target therapy during a hospital stay and was extremely traumatized by the experience. Target therapy may be more helpful with other types of trauma victims, especially veterans returning from war zones. However, Target therapy is still quite new and further research is needed to determine its effectiveness in patients with DID.
Hospitalization
Unfortunately, most hospitals offer little to no treatment today. Insurance companies simply won’t pay. So unless your patient has a lot of private funds and can go to a specialized treatment program, hospitalization is best used for safety issues when all other techniques have failed or if the risk is too high to take a chance on more intensive out-patient work.
Section VI: Common Themes in Treatment
The following issues tend to occur regularly with patients having DID:
Section VII: Integration of the Personalities
Although therapy may be long and arduous, patients with DID can achieve integration and lead very meaningful lives. Integration is often more of a process completed over several months or even years, rather than a single event and must always be done with full cooperation of the system. There is a tendency for therapists, and sometimes patients, to want to rush this process. Integration should never be attempted to simply get rid of a troublesome part. The integration process should only be initiated when there is no longer a need for certain parts, most often young children. Several child alters may be blended into one child in a healing ceremony conducted during a voluntarily induced hypnotic trance. Corydon Hammond, Ph.D., in his book on hypnotic trances, (1990), has several excellent examples. After a few such ceremonies have occurred with several alters, integration may spontaneously occur among other alters as treatment winds down. When done prematurely integration generally fails and the patient and therapist become frustrated when alters return. Some patients are wary of integration. They are afraid of the loss of parts of themselves. I explain to patients that when parts integrate, in spite of the loss of their physical being, the desired essence of their particular personality generally remains. Integration ceremonies generally describe “all that is the essence of one flowing into the other, so there is nothing really lost. But only one body and name can exist.” In spite of this, some patients choose to keep an awareness of and the essence of all the parts. But all the parts know about everyone else and there are no secrets. Essentially, they function as a well-run corporation.
Most experienced therapists agree that integration, while an important milestone, does not signal the end of treatment. The patient must work on developing a strong sense of integrated self. They have to adjust to dealing with difficulties without the use of dissociation. Sometimes, significant others will have difficulty adjusting to the patient’s new behaviors and this may be an important time to work on marital and other family issues.
A complete review of all medications used with patients having DID is beyond the scope of this presentation. However, information on typical types of drugs prescribed as well as some newer and more experimental drugs will be discussed. Medication can often be an essential part of treatment for patients with DID. The key here is being cognizant of what symptoms are being treated. All patients are different and there is no single medication for treatment of DID. Medications are primarily used to ameliorate non-dissociative symptoms such as depression and anxiety. Other symptoms, such as OCD, panic and agoraphobia can respond well to antidepressants and anxiolytics.
It is very important to remember that many patients with DID have a disordered sense of time. As a result, medication compliance can be difficult and at times it may be necessary to have a partner or spouse administer the medications. However, because of control issues, this should only be done when absolutely necessary and with permission of the system. It is far better to find an alter that takes charge of medication management. It is critical to be aware of the potential abuse of any medication by a particular alter. Communication between the therapist and prescribing physician is extremely important.
It is a very interesting phenomenon that not all alters respond in the same way to medications. In particular, adequate surgical and dental anesthesia appears to be difficult to achieve in patients with DID (Barkin et al., 1986.) As mentioned previously, there are anecdotal reports (Putnam, 1985) that suggest some alters may go under but others may wake up on the table during the surgery, causing problems and dismay by the surgical team. If a patient is having surgery, it may be very helpful to advise the surgeon and recovery room personnel that a child alter or an alter other than the original patient may be the first to wake up. I have seen a similar behavior occur in patients with the use of sleeping pills. Although the host takes her medications at night and should be “knocked out,” other alters get up and engage in a variety of tasks throughout the night.
Sleep difficulties are frequent in patients with DID. Patients certainly function better when they are well rested. They are likely to seek medications for this problem. It is imperative to remember that these medications can be used for suicide attempts and must be used with extreme caution in patients with suicidal ideation or a past history of suicide attempts.
Recently, a medication called Prazosin, a centrally active alpha adrenergic antagonist used for treating hypertension and benign prostatic hypertrophy, has been found to substantially reduce trauma-related nightmares and other symptoms of PTSD in combat veterans. I currently have one patient with DID for whom Prazosin has been very helpful in significantly reducing nightmares and nighttime flashbacks. More research is needed on the effects of Prazosin in the DID population.
As noted above, substance abuse is not uncommon in patients with DID. Opioids, prescribed for treatment of chronic pain, can lead to addiction. Suboxone (buprenorphine and naloxone) has recently been found to be helpful in treatment of opioid addiction. Buprenorphine is an opioid medication similar to morphine, codeine and heroin. However, it produces less euphoric effects and therefore may be easier to stop taking. Naloxone blocks the effects of opioids. This drug is administered sublingually. Although antipsychotics are not commonly used in treatment of DID, they have been utilized at very low doses to treat acute symptoms of anxiety.
Section IX: Critical Review of DID as a Diagnosis
As I mentioned previously, there are still those that deny the existence of DID. Most critics of DID seem to agree that the behavior named by this diagnosis is a socially learned behavior. Nicholas Spanos, Ph.D, was particularly vocal about this issue. Dr. Spanos was Professor of Psychology and Director of the Laboratory of Experimental Hypnosis at Carlton University. His last book, written just before his death in 1994, Multiple Identities and False Memories and published after his death in 1996, provides what he describes as a “sociocognitive” perspective on the subject of multiple identities. He conducted many experiments in his own laboratory at Carlton University which he later utilized to draw his conclusions. Spanos argued that the idea that MPD (DID) is a naturally occurring mental disorder is fundamentally flawed. He proposed that multiple identities can be understood as rule-governed social constructions established, legitimized and maintained through social instruction. He believed that neither a history of abuse nor severe psychopathology was necessary for the maintenance of multiple identities.
Spanos saw hypnotic behavior, including hypnotic amnesia, to be strategic behavior enacted to fulfill the subject’s beliefs and expectations about hypnosis. He went on to point out that theories of MPD (DID) that are based on the premise that hypnotic behaviors occur during some altered state or that hypnotic and non-hypnotic behaviors are processed or stored in different ways, are completely invalid.
Spanos (1996) and others (Brownville, 1975) believed that the regular co-occurrence of sexual abuse memories and DID resulted from the confluence of several sociohistorical trends. The first involved a reawakening of interest in DID during a period of intense societal interest in the topic of child abuse. In the 1970’s, largely as a result of the feminist movement, public attention focused on sexual aggression against women and on the complicity of existing social institutions in fostering, or at least tolerating, such aggression. These two issues came together to produce a growing concern about the sexual abuse of children and the prevalence and consequences of such abuse.
Merskey (1992) reviewed a large number of cases from the 20th century and earlier that provided information about treatment procedures and symptomatology of DID. He believes that the rise in DID diagnosis can be traced to the influence of the books and other films including The Three Faces of Eve (Thigpen and Cleckly, 1957) and Sybil (Schreiber, 1973). Merskey (1992) went on to report that he had found highly leading and suggestive procedures utilized in the diagnosis of MPD (DID) He has referred to DID as the “manufacture of madness”. Sybil (Schreiber, 1973) was reported as having suffered horrendous physical and sexual abuse during early childhood. Spanos (1996) felt this book encouraged therapists to look for and find evidence of severe child abuse in cases of DID. Spanos (1996) also points out that a number of highly experienced clinicians report never having seen a case of MPD
McHugh (1992) argues that hysteria, what he sees as the DID patient’s “more or less unconscious effort to appear more significant to others and to be more entitled to their interest and support, along with the current social canonization of the victim, accounts for the fanciful behavior of those who claim to have multiple identities and personalities”. He calls the diagnosis a “psychiatric misadventure” (Muller, 1998).
More recently, Traub (2009) focused on whether or not DID can be reliably identified and validly categorized. In assessing four factors, childhood trauma, prevalence ratings, media influences and psycho-physiological perspectives, he ultimately concludes that evidence either supporting or opposing the validity of current categorization of this disorder seems unconvincing and inconclusive. He points out that it is difficult to assess intensity, duration and kind of abuse which lead to this disorder. He notes that the prevalence ratings highlight the dramatic increase of the diagnosis in the 1980’s, with perspectives supporting both the under-diagnosis and over-diagnosis of DID. He then points out that with the growth of popular books about patients with DID, such as Sybil, Michelle remembers, and The Three Faces of Eve, there was not only an increase in the number of reported cases, but the number of alternate personalities increased from a typical two or three to an approximate 15 alters. He suggests the possibility that the expectations of the mental health professional may have unwittingly encouraged the development of additional alters, thereby diminishing the validity of DID as a diagnosis. Finally he notes that although some EEG studies showed differences in the brain activity of each personality, other studies did not support these results. On the other hand, Birnbaum & Thompson (1996) reported a difference in visual capacities between alters and a twin study done by Jang, Paris, Zweig-Frank & Liversly in 1998) demonstrated that genetic influences played a role in DID development. Traub (2009) feels psycho-physiological perspectives remain shrouded in doubt.
Shaffer and Oakley (2005) argue that dissociative identity disorder is best interpreted as a causal model of a possible post-traumatic process, a mechanical model of an abnormal psychological condition. The feel that there is no good reason to demonstrate that anyone has every suffered from DID because the proponents of DID violate the basic methodological principles of good causal modeling. In their discussion of memory, they point out that they believe that many of the “memories” that are brought up regarding the past of DID patients are quite plausibly the result of iatrogenic suggestion and that the practice of recovering repressed memories is fundamentally misguided based on a highly dubious account of how memory works.
Piper and Mersky, in an article entitled, The Persistence of Folly: Critical Examination of Dissociative Identity Disorder, (2004) argue that the concept of DID is illogical. They feel that DID proponents diagnostic and treatment methods encourage patients to behave as if they have multiple selves. They also feel that the vague and elastic definition of “alter personality” makes a reliable diagnosis of DID impossible. They point out that most patients show no signs of multiplicity before being diagnosed with DID. I would like to point out that every patient of mine that I ultimately diagnosed with DID either reported symptoms of loss of time, being told of behaviors they didn’t recall or presented an alter, very different from the initial patient presentation to me, well before the diagnosis.
It is also important to be aware that many who argue against the existence of DID insist that these patients are really suffering from severe borderline personality disorder. But, even borderline patients who are very labile do not have emotions and behaviors that coalesce around strikingly different identities to the extent of many patients diagnosed with DID (Muller, 1998).
I would agree that it is difficult, if not impossible to remove all cultural influence from the diagnosis of DID and many other mental illnesses. However, it is equally as important to understand why a patient’s life is being lived as it is. In other words, what do their specific symptoms mean? In 25 years of practice working with thousands of patients who have been physically and sexually abused, I have diagnosed DID in approximately 10 individuals. As I described earlier in this course, I was not looking for the diagnosis and was rather skeptical of its existence when I first discovered behaviors consistent with DID in my patient. I had not tried to hypnotize the woman or tried to elicit the appearance of any alters. A highly functioning nurse, whom I had been seeing in psychotherapy for several months, arrived at my office complaining of a headache. She laid down on the couch and shut her eyes. I thought she had fallen asleep when her eyes opened and a very young child who didn’t seem to know me appeared to be present in both voice and mannerisms. Only one of my patients seemed comfortable with the diagnosis. And with this individual I remained skeptical of her true diagnosis. The rest of my DID patients found the diagnosis disturbing on the one hand, but, on the other hand, an explanation for many of the difficulties they had been dealing with throughout their lives. They reported they had always just assumed they must be crazy because of the “black holes” in time and voices in their heads. At some level, the diagnosis came as a relief. Traditional psychoanalytic theory stresses the need for symptoms to be understood. It is in this frame of reference that I believe DID, as well as many other illnesses must be treated. If dissociation has helped a person survive a history of severe trauma, the therapist must respect these behaviors and work with them. I have experienced the challenges and rewards of helping individuals learn to accept their past history and develop new non-dissociative coping skills. Although I would always be very skeptical of an individual therapist who claimed to have a lot of DID patients in their practice at any given time, in part because it is not that common and in part because it would be too taxing on an individual therapist, I remain firm in my belief that DID does indeed exist and is an example of the extraordinary coping mechanisms that human beings utilize for survival.
Conclusion
Work with these patients is quite challenging but very rewarding. They are often extremely insightful and can pick up on your moods and changes in behaviors. I have had the privilege of working with hundreds of trauma patients and many patients with DID. I have learned so much about the strength of the human spirit and ability to survive from each one. A word of advice: Maintain a sense of humor. One patient who had a child alter that liked to play Tic Tac Toe with me after difficult sessions always won. When I “complained” to her that I couldn’t understand why I always lost, she promptly laughed and said: “You are looking at the board with one set of eyes. I have at least nine watching all the time!” I never did win no matter how hard I tried.
Finally, anyone treating patients with DID must recognize the stress they are under when they listen to the horrific details that can lead to the development of DID. Make sure you have a good support system and take time for your own self-care. Schedule time with friends, exercise and take care of your own physical and mental health. We are more authentic and believable as therapists if we live and model healthy behaviors.
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