Dissociative Identity Disorder: December 2006

Description DID

This page is devoted to a description of causes and symptoms for DID and PTSD. If the content is too "medical", simpler explanations can be found in For Survivors.

SITE MAP DID : Different DSM-IV Diagnoses : For Survivors : Q & A : Survivors’ Stories :

Dissociative Identity Disorder

Despite being both common and reversible, Dissociative Identity Disorder frequently goes undiagnosed and untreated.

Unfortunately, people are often frightened of this condition because they they identify this diagnosis with those cases that exist on the extreme end of the spectrum of dissociative symptoms and behaviours.

In the simplest analysis, people have one identity or more than one identity. However, this simple dichotomy, which is too often denied by health and mental health professionals, is too narrow to describe the spectrum of manifestations of dissociative identity systems. This site will attempt to clarify the range of manifestations of DID.

prevalence

Reported prevalence (frequency) varies from one study to another. Most studies report prevalence of 1 to 4% of the population. Several studies uncovered previously undiagnosed dissociative identity disorder in 3 to 4% of acute psychiatric inpatients. With increased awareness amongst mental health professionals, the reported prevalence is rising.

DID is diagnosed four times more frequently in women, probably because females seek therapy. Males with DID are more likely to commit violent crimes and to be incarcerated within the penal system.

PTSD

Like DID, PTSD develops in response to the experience of traumatic events. Unlike DID, which results from trauma in early childhood, PTSD may develop at any age.

The characteristic symptoms (physiological arousal, avoidance, flashbacks) of PTSD may be present at presentation with DID, or may develop subsequently. While emotionally disturbing, PTSD represents a phase of healing within DID.

etiology

Etiology is the medical term for cause, those factors that predispose a person to develop a condition. In the case of DID and PTSD, the cause is trauma. DID develops when repeated, severe trauma occurs during early childhood. PTSD can develop at any age in response to trauma.

THE MERCK MANUAL, Sec. 15, Ch. 188, Dissociative Disorders: "North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of dissociative disorder."

diagnosis

The official diagnostic criteria according to the “The Diagnostic and Statistical Manual, 4 th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000a)” are:

A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

B. At least two of these identities or personality states 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 (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

However, few patients with DID display distinct identities early within therapy, and many deny, or are unaware of, amnesic episodes (time loss).

Because this condition is frequently missed or misdiagnosed, the interviewing clinician must have a high index of suspicion when patients complain of symptoms that are frequently encountered in DID/PTSD.

Useful questions cover the following areas:

Sense of gaps within childhood memories – many patients have extensive periods without memories, and are initially acquainted with little of their personal history.
Having been told often that he/she has done or said something that is not recalled within a reasonable timeframe.
Awareness of losing periods of time – most often noticed in relation to watching television programs. Vague complaints of “difficulty with time” are common.
Sense of saying or doing something outside volitional control.
Sense of having feelings or thoughts that do not belong to his/herself.
Sense of buzzing or ringing in the ears, often accompanied by headache, or hearing voices.

These questions ought to be repeated from time to time as patients may initially deny symptoms out of lack of trust, or may not yet be aware of the symptoms as being unusual.

The clinician’s awareness of the ways in which patients describe their symptoms usually quickly unmasks the rare case of factitious “DID”.

dissociation

Dissociation is a mental process in which the main, host identity is no longer fully aware of the contents of consciousness. This is different than sleep and unconsciousness in that a different segment of the consciousness, an alter identity or personality, is awake and conscious during dissociation.

Dissociative symptoms exist on a spectrum. Dissociation can be partial and result in not feeling fully conscious and in control of thoughts, feelings, and actions. Depersonalization, a sense of not being oneself, is a mild form of dissociation. Highway hypnosis, drifting off into thought during lectures, performing on 'automatic pilot', daydreaming, and deep absorption in a book, or the internet, are all mild forms of dissociation from externals. In essence, the object of consciousness has moved inward and narrowed in such examples.

At other times, dissociation is complete and results in amnesia for events that happened during the dissociative event. This is experienced as a disruption in the continuity of time, resembling the cut from one scene to another that we observe in motion pictures and television dramas. Episodes where the person is unaware of actions, particularly of movement from one locale to another, are often called dissociative fugues, or fugue states.

Dissociative episodes are most often brief, a matter of minutes to hours. However, some survivors with DID experience protracted episodes that may last months.

symptoms

alter system

voices

healing

treatment

hypnosis

neural basis for DID and PTSD

The limbic system is the emotion and emotional memory area, and is part of the primitive unconscious brain. It comprises paired structures nestled deep to the cerebral hemispheres, the lobes of the neocortex.

For more information see inside "Brain"

missed and misdiagnosed

Why is DID misdiagnosed?

common misdiagnoses

In childhood, the commonest misdiagnosis for DID is ADHD. Childhood Adjustment Disorder is probably the second most frequent misdiagnosis.

Thirty years ago, paranoid schizophrenia appears to have been the most common misdiagnosis for adult patients with DID.

Currently, bipolar affective disorder (formerly called manic-depression) is the commonest misdiagnosis for patients with DID. Obsessive-compulsive disorder, borderline personality disorder, panic disorder, anxiety disorder, temporal lobe epilepsy, and dysthymia (depression lasting more than six months) are other examples of misdiagnoses. All of these conditions, and others, may be co-morbid, coexist with DID, but represent misdiagnoses in the presence of DID. Adult ADHD is becoming increasingly popular as a misdiagnosis.

PTSD is an accurate diagnosis in so far as PTSD is often a component of DID, yet the main diagnostic and therapeutic point has been missed if DID is not also recognized when present.