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Dissociative Identity Disorder
Amanda Manelski
PSYC 3145/20/2009 |

Paula is 38 years old, divorced, and a mother of two children. She is constantly having memory problems, emotional difficulties, and severe headaches. Her behavior in class is sometimes odd because she participated in discussions but did not seem familiar with the material. Her relationships with other people are unpredictable. Sometimes she would threaten to kill other people like her mother and an older man Cal. She does not spend time with her father, but can sometimes recall some parts of the incestuous relationship they had when she was younger. Paula often complains of feeling like she lost parts of her days, and had unexplained experiences that were extremely frustrating. Sherry is in her 30’s and has expressed in different ways of her unfavorable feelings towards Paula’s children. She often expresses how boring Paula can be. Sherry explains Paula’s relationship with her father as always leaving Sherry behind to experience the pain and humiliation of rape by her father. Sherry said that she and Janet were the ones responsible for many of the unexplained events that occurred for Paula. Janet is an angry 15 year old who is often fidgety and somewhat flirty. Janet occasionally watches Caroline. Caroline is a 5 year old girl who cannot sleep without her stuffed puppy. Heather is 23 years old and in love with the older man Cal, whom which everyone else hates. Paula, Sherry, Janet, Caroline and Heather all have different personalities and behaviors. Paula cannot recall knowing any of those girls, and Sherry can acknowledge all of them except Heather. One would think that these were the different characters in a soap opera series, but in reality they are all just one person. This would be the effects of Dissociative Identity Disorder (DID) or previously known as Multiple Personality Disorder (MPD). Dissociative Identity Disorder is a mental illness that affects one in every hundred people (Haddock, 2001). The DSM IV-TR, which was created by the American Psychiatric Association (APA, 2000), classifies an individual as having DID if they meet the following criteria: (a) the presence of two or more distinct identities or personality states; (b) at least two of theses identities or personality state recurrently take control of the person’s behavior; (c) inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness; (d) the disturbance is not due to the direct physiological effects of a substance or a general medical condition and in children the symptoms are not attributable to imaginary playmates (APA, 2000). The underlying characteristic of DID is dissociation, and when people dissociate they may feel disconnected from the world surrounding them and/or even from themselves. The disconnection can become so intense that the person may not be able to remember or recall anything that happened during the dissociated state (Haddock, 2001). When one is faced with overwhelming stress they will use defense mechanisms to help them, and dissociation is an example of defense to protect one’s stressful experience. When there is no longer threat after the trauma but dissociation continues to interfere with life functioning, one may then develop DID (Haddock, 2001). Dissociative identity disorder is the most severe of the four (dissociative amnesia, dissociative fugue, dissociative identity, and depersonalization) main categories of dissociation disorders. Symptoms of dissociation correlate with highly aversive or traumatic events especially repeated childhood emotional, physical and/or sexual abuse (Putnam, 1984). Dissociation can be seen as adaptive because it reduces overwhelming stressors that one experiences. Continued use of dissociation into adulthood could become maladaptive, and one may automatically disconnect from situations that they may see as dangerous or threatening. Dissociative identity allows a person to be separated from reality and develop different identities to cope with stressful situations. People with DID have one dominant personality that is most present and identifies with the patients real name, which is called the Host. The different identities are called “alters” and at least two personalities control the individual’s behavior. Alters may serve distinct roles in coping with problem areas. The host personality is usually unaware of the existence of other personalities within the body and it is usually unconscious when another personality is in control of the body. Length and duration of time loss of the unconscious host varies from each personality and individual (Allison, 1980). Alters are usually aware of the host personality and other altered personalities. The active alters can differ in their attitudes, dispositions, self-image, body-image, age, and gender. Alters have their own set of memories, but when they have common memories they will be from different perspectives. When alters are not in control of the body they often describe themselves as inhibiting another world, or sit in another alternative world and watch the events as they happen in the ‘real’world (Allison, 1980). The average number of alters is about 10 but not limited to that. The history of DID is as complex as the illness itself. There has been and still is many controversies to whether DID should be considered a real disorder, because opinions about DID range from accepting the validity of the diagnosis to believing that the diagnosis are created by therapists as a result of suggestion at which they do not actually exist (Hacking, 1992). The American Psychiatric Association identifies DID as a real mental illness, and continuous revision of the DSM show developments in diagnosis’s of the disorder. In the past DID has been linked to hysteria, somnambulism, demonie possession (Flora, 1988) and trance states (Ross 1996). Hysteria has been the most important and direct link to DID, which involves physical symptoms or psychological symptoms or both when there is no clear natural cause (Acocella, 1999). Hysteria comes from the hystera which means “uterus” and was first identified as a disease of women. It was believed that DID only affected women and was caused by changes in the womb. The association between the illness and a womb expressed that disordered sexual activity could have an effect on emotional stability (Veith, 1965). Thomas Willis introduced the idea that hysteria came from the brain, mainly the nervous system instead of in the womb during the seventeenth century. Willis did not believe that hysteria was only a disorder for women (Veith, 1965). In the eighteenth century Franz Anto Mesmer introduced his theory of “animal magnetism”, and he began treating his patients by applying magnets to their bodies (Gillispie, 1974). He made ‘induced somnambulism’ popular and extended mesmeric rapport into mesmeric induced hypnosis (Gillispie, 1974), which was then the beginning of medical and public methods of getting people into altered consciousness, and the possibility of subconscious life. Eberhardt Gmelin wrote the first account in 1791 of DID in much detail in “exchange personality”, and claimed that he could change the personalities to alter with the movement of his hand (Putnam, 1992). Around the same time of Gmelin, Benjamin Rush wrote the first American text of psychiatry, “Medical Inquiries and Observations Upon Diseases of the Mind” in 1812. His theory concluded that the cause for the doubling of consciousness was a disconnection between the two hemispheres of the brain (Putnam, 1992). France 1875, the term consciousness had changed and was referred to as ‘personality’ (Hacking, 1992). The first classification of DID was called “double consciousness” (Hacking, 1992).A physician Robert Carter came up with the theory of repression as a cause of hysteria, and believed that sexual passion was most frequent and important determinant causing hysteria (Veith, 1965). Carter created three main factors as the cause of hysteria: “(1) the temperament of the individual, (2) the event or situations which trigger the initial attack, and (3) the degree to which the affected person is compelled to conceal or ‘repress’ the exciting causes” (Veith, 1965). Pierre Janet, 1889, is known as one of the first scientists to link dissociation to stress and psychological trauma (Hacking, 1995). He was also one of the first people to argue that people under hypnosis are not unconscious but actually have a divided consciousness. Much of the work done for dissociation theory was done by the early work of Janet. He can be credited for the idea that dissociation is a defensive function or coping mechanism that individuals invoke unconsciously to escape the impact of traumatic experiences. Janet referred to the divided states of consciousness as alternative personalities which could be produced through hypnosis. The divided consciousness functions under the level of consciousness and would still allow an individual to perform complex mental operations. Dissociation can become automatized by the individual learning how to use dissociation to cope with highly traumatic experiences, but in turn dissociation becomes automatic even in minor stressful events (van der Kold & van der Hart, 1989). During this time, the connection between childhood trauma and DID became a topic of speculation, but the theory of abuse in DID does not become a main topic for causality until 1975 (Hacking, 1992). Interest in DID was at its highest in the late nineteenth century, and then dropped to nearly no interest in the the early 20th century (Ross, 1996). There are many reasons to why dissociation was not being studied or treated. One explaination of the decrease of interest in DID would be Sigmund Freud’s seduction theory, which was a repression model of psychopathology that explained away any childhood abuse and no treatment of dissociative symptoms (Miller, 2000). Schizophrenia, which Bleuler had coined, is also an influence for the drop of interest in dissociation. Schizophrenia means Split mind in Greek, and the problem was that there are similar symptoms of both diseases (Ross, 1996). In the 1980’s interest of dissociation returned. The combined forces of child protection and feminism is said to have the most important influence on the return of DID (Acocelle, 1999). Another factor that may have caused an increase of interest in DID was the way the media displayed the disorder. There were two books, which were also made into movies, The Three Faces of Eve and Sybil, and both provided huge impacts on the public’s awareness and perceptions of DID (Ross, 1996). The first edition of the DSM in 1952 did not include hysteria as an illness, but there was a disorder that referred to hysteria which was dissociative reaction. Dissociative reaction included dissociated states like depersonalization, dissociated personalities, stupor, fugue, amnesia, dream states and somnambulism (Veith, 1965). DSM-II (1963) is when ‘multiple personality’ is first mentioned under the category of “Neuroses”, specifically “Hysterical Neuroses””Dissociative Type”. The DSM-II defines it as “In the dissociative type, alterations may occur in the patient’s state of consciousness or in his identity, to produce such symptoms as amnesia, somnambulism, fugue, and multiple personality”(APA, 1963, P. 40). The third edition of the DSM (DSM-III), dissociative disorders were recognized as a type of mental illness and specifics on diagnostic criteria for multiple personality disorder (MPD) were included. The DSM-III had three criteria that had to be present: which were (1) the existence within the individual of two or more distinct personalities, each of which is dominant at the particular time; (2) the personality that is dominant at any particular time determines the individual’s behavior; (3) and each individual personality is complex and integrated with its own unique behavioral patterns and social relationships (APA, 1980). A revised DSM-III came out in 1987, and the DSM-III-R consisted in changes in the multiple personality disorder classification. It contains a sub classification for “conversion type” and is described a lot like symptoms of hysteria in the past. Changes to the diagnostic criteria for MPD are: the existence within the person of two or more distinct personalities or personality state each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self; and at least two of these personalities or personality state recurrently take full control of the persons behavior (APA, 1987, P. 272). In the fourth edition of the DSM amnesia and memory loss is mentioned. DSM-IV was published in 1994 and re-labeling of multiple personality disorder to dissociative identity disorder in the diagnostic criteria section C. The history of DID can be seen through the progression of diagnoses in the DSM I to the most current DSM IV-TR. Not many studies have been conducted regarding brain activity in patients with DID, but studies have been done with people diagnosis with other disorders like PTSD (post traumatic stress disorder) and borderline personality disorder have a number of dissociative-like symptoms that could be compared to DID. Studies have provided that DID patients overall report of having high rates of experiencing stressful events that were repeated during their earlier lives (Ross et al., 1991). The hippocampus is an organ in the brain that releases glucocorticoids during stressful events, and hypothesized that extensive exposure to glucocorticoids could lead the hippocampus to decrease in volume. Ketamine is an antagonist of NMDA receptors, which have a high concentration in the hippocampus. Healthy patients given ketamine resulted in experiencing dissociative symptoms (Krystal et al., 1994). In a study by Eric Vermetten and Christian Schmahl (2003) showed that patients with DID, compared to healthy patients, have 19.2% smaller hippocampal volume and a 31.6% smaller amygdalar volume. They have also hypothesized that stress acting through NMDA receptors may mediate dissociation symptoms, and anterior and posterior parts of the brain were affected DID (Vermetten, 2003). Another study used a fMRI on PTSD patients in a dissociative state, and greater brain activity was found in the temporal, inferior, and medial frontal regions and also in occipital, parietal, anterior cingulated, and medial prefrontal cortical regions (Lanius et al., 2002). A study using single photon emission tomography showed bilateral orbitofrontal hyperperfusion and left lateral temporal, which is the dominant hemisphere, hyperfusion (Sar et al., 2001). A positron emission tomography in women with DID showed the presence of different patterns of regional cerebral blood flow in the different states of self, and also showed the role in conscious experience in the medial prefrontal cortex and the posterior associative cortices (Reinder et al., 2003). Forrest (2001) proposed an ‘orbitofrontal model’ for DID patients, which hypothesizes the critical role of the orbitofrontal cortex in the development of dissociated identities due to its inhibitory functions (Putnam, 1997). Vedat Sat hypothesized that an increased perfusion rates in the medial and superior frontal and occipital regions may be an inhibitory response to orbitofrontal perfusion change (Sar et al., 2001). This studies have given some of the contributions to the validity of DID as a diagnostic category, but more studies of brain imaging for DID patients must be conducted to advance research and improve future treatment. Before the 19th century DID and other mental illnesses were seen as magical witchcraft, and treatment included spells, rituals, herbs, ointments, prayers, beatings, exorcisms, bloodletting, purging, and even hole drilling in the skulls to let out demons. Hypnosis has been used since the early 19th century to help in the treatment for DID (Ellenberger, 1970). Common uses for hypnosis are calming, soothing, containment and ego strengthening. Electroconvulsive therapy has been use before but it is usually not recommended. Modern day treatment for DID includes a strong therapeutic relationship, a said therapeutic environment, appropriate boundaries, development of no self-or other- harm contracts and understanding of the personality structures, working through traumatic and dissociated material, the development of more mature psychological defenses, and the integration of states of self (Putnam & Loewenstein, 1993). Pharmacological approaches of using antianxiety, mood stabilizers and selective serotonin re-uptake inhibitor antidepressants aid in the co-morbid disorders (Putnam & Loewenstein, 1993). Hypnosis and continuous therapy are the most commonly use treatments for DID, but still today there is no cure for DID. Dissociative identity disorder is hard to diagnosis and currently not curable, but with more research the future of treatment may be promising to those with the disorder.

References
Allison, R. (1980). Minds in many pieces: The making of a very special doctor. New
York: Rawson, Wade.

Acocella, J. (1999). Creating hysteria: Women and Multiple Personality Disorder. San
Francisco: Jossey-Bass Publishers.

American Psychiatric Association. (1963). Diagnostic and statistical manual of mental disorders . Washington, DC: Author.

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

Ellenberger, H. (1970). The discovery of the unconscious: The history and evolution of dynamic psychology. New York: Basic Books.

Flora, E. W. (1988). Tracing the Historical Development Of The Diagnosis and
Treatment of Multiple Personality Disorder in 19th and 20th Century North America. Michigan:UMI Dissertation Services.

Gillispie, C. C. (1974). Dictionary of Scientific Biography IX: Macrobius to Naumann.
New York, NY: Charles Scribner’s Sons.

Hacking, I. (1992). Multiple personality disorder and its hosts. History of the Human
Sciences, 5(2), 3-31.

Haddock, D. B. (2001). The Dissociative Identity Disorder Sourcebook. Chicago:Contemporary Books.

Hornstein NL, Putnam FW: Clinical phenomenology of child and adolescent dissociative disorders. J Am Acad Child Adolesc Psychiatry 1992; 31:1077–1085
Krystal JH, Karper LP, Seibyl JP, Freeman GK, Delaney R, Bremner JD, Heninger GR, Bowers MB Jr, Charney DS: Subanesthetic effects of the noncompetitive NMDA antagonist, ketamine, in humans: psychotomimetic, perceptual, cognitive, and neuroendocrine responses. Arch Gen Psychiatry 1994; 51:199–214
Lanius RA, Williamson PC, Boksman K, Densmore M, Gupta M, Neufeld RW, Gati JS, Menon RS: Brain activation during script-driven imagery induced dissociative responses in PTSD: a functional magnetic resonance imaging investigation. Biol Psychiatry 2002; 52:305–311
Miller, N. K. (2000). The Seduction Theory: A Misunderstanding of Freud. US:
University Microfilms International.

Putnam, F.W. (1984). The psychophysiologic investigation of Multiple Personality
Disorder. Psychiatric Clinics of North America, 7, 31-39.

Putnam, F.W., & Loewenstein, R.J. (1993). Treatment of Multiple Personality Disorder:
A survey of current practices. American Journal of Psychiatry, 150, 1048-
1052.

Putnam, F.W. (1997). Dissociation in children and adolescents: A developmental perspective.
New York: Guilford Press.

Reinders, A.A.T.S., Nijenhuis, E.R.S., Quak, J., Korf, J., Haaksma, J., Paans, A.M.J., et al. (2006). Psychobiological characteristics of Dissociative Identity Disorder:
A symptom provocation study. Biological Psychiatry, 60, 730–740.

Ross, C. A. (1996). History, phenomenology, and epidemiology of dissociation. In L. K.
Michelson and W. J. Ray (Ed), Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives (3-24). New York: Plenum Press.

Ross CA, Miller SD, Bjornson L, Reagor P, Fraser GA, Anderson G: Abuse histories in 102 cases of multiple personality disorder. Can J Psychiatry 1991; 36:97–101

Sar, V., Unal, S.N., Kiziltan, E., Kundakci, T., Ozturk, E., (2001). HMPAO SPECTS study of regional cerebral blood flow in Dissociative Identity Disorder. Journal of Trauma & Dissociation, 2(2), 5-25.

Van der Hart, O., Brown, P., & Van der Kolk, B.A. (1989). Pierre Janet’s treatment of
-traumatic stress. Journal of Traumatic Stress, 2, 379-395.

Veith, I. (1970). Hysteria: The History of a Disease. Chicago: University of Chicago
Press.

Vermetten, E., Schmahl, C., Linder, S., Loewenstein, R.J., & Bremner, J.D. (2006).
Hippocampal and amygdalar volumes in Dissociative Identity Disorder. The
American Journal of Psychiatry, 163, 630–636.