Dissociative identity disorder
Encyclopedia
Dissociative identity disorder (DID) is a psychiatric diagnosis
and describes a condition in which a person displays multiple distinct identities
(known as alters or parts), each with its own pattern of perceiving and interacting with the environment.
In the International Statistical Classification of Diseases and Related Health Problems the name for this diagnosis is multiple personality disorder. In both systems of terminology, the diagnosis requires that at least two personalities (one may be the host) routinely take control of the individual's behavior with an associated memory loss
that goes beyond normal forgetfulness; in addition, symptoms cannot be the temporary effects of drug use
or a general medical condition. DID is less common than other dissociative disorders, occurring in approximately 1% of dissociative cases, and is often comorbid
with other disorders.
There is a great deal of controversy surrounding the topic of DID. The validity of DID as a medical diagnosis has been questioned, and some researchers have suggested that DID may exist primarily as an iatrogenic adverse effect of therapy. DID is diagnosed significantly more frequently in North America than in the rest of the world.
Patients may experience an extremely broad array of other symptoms such as pseudoseizures that may appear to resemble epilepsy
, schizophrenia
, anxiety disorder
s, mood disorder
s, post traumatic stress disorder, personality disorder
s, and eating disorder
s.
investigations of DID. Many of the investigations include testing and observation in a single person with different alters. Different alter states have shown distinct physiological
markers and some EEG
studies have shown distinct differences between alters in some subjects, while other subjects' patterns were consistent across alters.
Neuroimaging studies of individuals with dissociative disorders have found higher than normal levels of memory encoding
and a smaller than normal parietal lobe
.
Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of people diagnosed with DID. Brain imaging studies have corroborated the transitions of identity in some DID sufferers. A link between epilepsy
and DID has been postulated but this is disputed. Some brain imaging
studies have shown differing cerebral blood flow
with different alters, and distinct differences overall between subjects with DID and a healthy control group.
A different imaging study showed that findings of smaller hippocampal
volumes in patients with a history of exposure to traumatic stress and an accompanying stress-related psychiatric disorder were also demonstrated in DID. This study also found smaller amygdala
volumes. Studies have demonstrated various changes in visual parameters between alters. One twin study
showed heritable factors were present in DID.
memories or experiences from consciousness
. A high percentage of patients report child abuse
. People diagnosed with DID often report that they have experienced severe physical and sexual abuse
, especially during early to mid childhood. Several psychiatric rating scales of DID sufferers suggested that DID is strongly related to childhood trauma rather than to an underlying electrophysiological
dysfunction.
Others believe that the symptoms of DID are created iatrogenically
by therapists using certain treatment techniques with suggestible patients, but this idea is not universally accepted. Skeptics have observed that a small number of US therapists were responsible for diagnosing the majority of individuals with DID there, that patients did not report sexual abuse or manifest alters until after treatment had begun, and that the "alters" tended to be rule-governed social role
s rather than separate personalities which is consistent with replacing the personalities-focused MPD term with the identities-focused DID term. Additionally in China with "virtually no popular or professional knowledge of DID (...)" where "contamination cannot exist" it has been concluded that "the findings are not consistent with (...) iatrogenic models (...)".
's Diagnostic and Statistical Manual of Mental Disorders
(DSM). The DSM-II used the term multiple personality disorder, the DSM-III grouped the diagnosis with the other four major dissociative disorders
, and the DSM-IV-TR
categorizes it as dissociative identity disorder. The ICD-10
continues to list the condition as multiple personality disorder.
The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV require that an adult, for non-physiological reasons, be recurrently controlled by multiple discrete identity
or personality
states while also suffering extensive memory lapses
. While otherwise similar, the diagnostic criteria for children requires also ruling out fantasy.
Diagnosis should be performed by a therapist, psychiatrist
or psychologist
clinically trained in the specific material who may use specially designed interviews (such as the SCID-D) and personality assessment tools to evaluate a person for a dissociative disorder
.
The psychiatric history
of individuals diagnosed with DID frequently but not always contains multiple previous diagnoses of various mental disorders and treatment
failures.
The proposed diagnostic criteria for DID in the DSM-5
is:
a) With pseudoseizures or other conversion symptoms
b) With somatic symptoms that vary across identities
The proposed Criterion C is intended to "help differentiate normative cultural experiences from psychopathology." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, and not have to diagnose those who report it as having a mental disorder.
The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.
The Dissociative Experiences Scale (DES) is a simple, quick, and validated questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20 and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D diagnoses and a cutoff of 20 missed 25%. The reliability of the DES in non-clinical samples has been questioned. There is also a DES scale for children and DES scale for adolescents. One study argued that old and new trauma may interact, causing higher DID item test scores.
, and the dissociative conditions of dissociative amnesia and dissociative fugue. The clearest distinction is the lack of discrete formed personalities in these conditions. Malingering
may also be considered, and schizophrenia, although those with this last condition will have some form of delusions, hallucinations or thought disorder.
and medication
s for comorbid
disorders. Some behavior therapists
initially use behavioral treatments such as only responding to a single identity, and using more traditional therapy once a consistent response is established. It has been stated that treatment recommendations that follow from models that do not believe in the traumatic
origins of DID might be harmful due to the fact that they ignore the posttraumatic symptomatology of people with DID.
symptoms and features of post traumatic stress disorder normally recover with treatment. Those with comorbid
addictions
, personality
, mood
, or eating disorder
s face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of symptom
relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives. Individuals with the condition commonly attempt suicide
.
and prevalence of DID over time is that the condition was misdiagnosed as schizophrenia
, bipolar disorder
, or other such disorders in the past; another explanation is that an increase in awareness of DID and child sexual abuse
has led to earlier, more accurate diagnosis. Other clinicians believe that DID is an iatrogenic
condition over diagnosed in highly suggestive individuals, though there is disagreement over the ability of the condition to be induced by hypnosis. Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:
Figures from the general population show less diversity:
Dissociative identity disorder is diagnosed in a sizable minority of patients in drug abuse
treatment facilities.
with other psychiatric diagnoses, such as anxiety disorders (especially post-traumatic stress disorder-PTSD), mood disorders, somatoform disorders, eating disorders, as well as sleep problems and sexual dysfunction. Dissociative identity disorder has been found to more commonly occur with particular personality disorders including Avoidant Personality Disorder
(76% co-morbidity), Self-defeating Personality Disorder
(68% co-morbidity), Borderline Personality Disorder
(53% co-morbidity) and Passive-Aggressive Personality Disorder (45% co-morbidity). Schizotypal Personality Disorder
also had a 58% crossover with dissociative tendencies.
An intense interest in spiritualism
, parapsychology
, and hypnosis
continued throughout the 19th and early 20th centuries, running in parallel with John Locke
's views that there was an association of ideas
requiring the coexistence of feelings with awareness of the feelings. Hypnosis
, which was pioneered in the late 18th century by Franz Mesmer
and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.
The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100. Epilepsy
was seen as a factor in some cases, and discussion of this connection continues into the present era.
By the late 19th century there was a general acceptance that emotionally traumatic experiences could cause long-term disorders which might display a variety of symptoms. These conversion disorder
s were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivé (1863-?) who suffered a traumatic experience as a 13 year-old when he encountered a viper. Vivé was the subject of countless medical papers and became the most studied case of dissociation in the 19th century.
Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. It was in this climate that Jean-Martin Charcot
introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet
, took these ideas and went on to develop his own theories of dissociation. One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym
Christine Beauchamp; American neurologist
Morton Prince
studied Fowler between 1898 and 1904, describing her case study
in his 1906 monograph
, Dissociation of a Personality. Fowler went on to marry one of her analyst's colleagues.
In the early 20th century interest in dissociation and multiple personalities waned for a number of reasons. After Charcot's death in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet's association with Charcot tarnished his theories of dissociation. Sigmund Freud
recanted his earlier emphasis on dissociation and childhood trauma.
In 1910, Eugen Bleuler
introduced the term schizophrenia to replace dementia praecox
. A review of the Index medicus
from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States. A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.
Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports. Bleuler also included multiple personality in his category of schizophrenia. It was concluded in the 1980s that DID patients are often misdiagnosed as suffering from schizophrenia.
The public, however, was exposed to psychological ideas which took their interest. Mary Shelley
's Frankenstein
, Robert Louis Stevenson
's Strange Case of Dr Jekyll and Mr Hyde, and many short stories
by Edgar Allan Poe
had a formidable impact. In 1957, with the publication of the book The Three Faces of Eve
and the popular movie which followed it, the American public's interest in multiple personality was revived. During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.
Between 1968 and 1980 the term that was used for dissociative identity disorder was "Hysterical neurosis, dissociative type". The APA wrote: "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."
The highly influential book Sybil
(which was purported to be true, but has since been identified as likely heavily fictionalized) was published in 1974, which popularized the diagnosis through a detailed discussion of the problems and treatment of the pseudonymous Sybil
. An October, 2011 report on NPR included discussions with Debbie Nathan, author of the book "Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case", and other psychology professionals, about the allegations that the "Sybil" story was, if not a fraud, then a case that involved questionable or duplicitous behavior by the patient, as well as by her doctor, who was interested in the theory and who wanted to believe this was an actual case and who may have been intent on making sure it would be seen as such, and also by the original "Sybil" book's author, who had a large amount of money involved in the book contract.
Six years following the publication of the book "Sybil", the diagnosis of multiple personality disorder appeared in the DSM III. Controversy over the iconic case has since arisen, with some calling Sybil's diagnosis the result of iatrogenic therapeutic methods while others have defended the treatment and reputation of Sybil's therapist, Cornelia B. Wilbur
. As media coverage spiked, diagnoses climbed. There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990. Joan Acocella
reports that 40,000 cases were diagnosed from 1985 to 1995. The majority of diagnoses are made in North America, particularly the United States
, and in English
-speaking countries more generally with reports recently emerging from other countries.
and often iatrogenic
condition which they believe is in decline. In China with "virtually no popular or professional knowledge of DID (...)" where "contamination cannot exist" it has been concluded that "the findings are not consistent with (...) iatrogenic models (...)".
There is considerable controversy over the validity of the multiple personality profile as a diagnosis. Unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient and the treatment provider. The relationship between dissociation and multiple personality creates conflict regarding the DID diagnosis. While other disorders require a certain amount of subjective interpretation, those disorders more readily present generally accepted, objective symptoms. The controversial nature of the dissociation hypothesis is shown quite clearly by the manner in which the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
(DSM) has addressed, and re-addressed, the categorization over the years.
The second edition of the DSM referred to this diagnostic profile as multiple personality disorder. The third edition grouped MPD in with the other four major dissociative disorders
. The current edition, the DSM-IV-TR
, categorizes the disorder as dissociative identity disorder (DID). The ICD-10
(International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as multiple personality disorder.
Psychiatrist Colin A. Ross
has stated that based on documents obtained through freedom of information legislation
, psychiatrists linked to Project MKULTRA
claimed to be able to deliberately induce dissociative identity disorder using a variety of aversive techniques.
Paris believes that the first possible cause is the most likely.
The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable. There are several main points of disagreement over the diagnosis.
Skeptics claim that people who present with the appearance of alleged multiple personality may have learned to exhibit the symptoms in return for social reinforcement. One case cited as an example for this viewpoint is the "Sybil
" case, popularized by the news media. Psychiatrist Herbert Spiegel
stated that "Sybil" had been provided with the idea of multiple personalities by her treating psychiatrist, Cornelia Wilbur
, to describe states of feeling with which she was unfamiliar.
One of the primary reasons for the ongoing recategorization of this condition is that there were once so few documented cases (research in 1944 showed only 76) of what was once referred to as multiple personality. Dissociation is recognized as a symptomatic presentation in response to trauma
, extreme emotional stress, and, as noted, in association with emotional dysregulation
and borderline personality disorder
.
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
and describes a condition in which a person displays multiple distinct identities
Identity (social science)
Identity is a term used to describe a person's conception and expression of their individuality or group affiliations . The term is used more specifically in psychology and sociology, and is given a great deal of attention in social psychology...
(known as alters or parts), each with its own pattern of perceiving and interacting with the environment.
In the International Statistical Classification of Diseases and Related Health Problems the name for this diagnosis is multiple personality disorder. In both systems of terminology, the diagnosis requires that at least two personalities (one may be the host) routinely take control of the individual's behavior with an associated memory loss
Memory loss
Memory loss can be partial or total and it is normal when it comes with aging. Sudden memory loss is usually a result of brain trauma and it may be permanent or temporary. When it is caused by medical conditions such as Alzheimers, the memory loss is gradual and tends to be permanent.Brain trauma...
that goes beyond normal forgetfulness; in addition, symptoms cannot be the temporary effects of drug use
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
or a general medical condition. DID is less common than other dissociative disorders, occurring in approximately 1% of dissociative cases, and is often comorbid
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
with other disorders.
There is a great deal of controversy surrounding the topic of DID. The validity of DID as a medical diagnosis has been questioned, and some researchers have suggested that DID may exist primarily as an iatrogenic adverse effect of therapy. DID is diagnosed significantly more frequently in North America than in the rest of the world.
Signs and symptoms
Individuals diagnosed with DID demonstrate a variety of symptoms with wide fluctuations across time; functioning can vary from severe impairment in daily functioning to normal or high abilities. Symptoms can include:- Multiple mannerisms, attitudes and beliefs which are not similar to each other
- Unexplainable headaches and other body pains
- Distortion or loss of subjective time ( a long time)
- DepersonalizationDepersonalizationDepersonalization is an anomaly of the mechanism by which an individual has self-awareness. It is a feeling of watching oneself act, while having no control over a situation. Sufferers feel they have changed, and the world has become less real, vague, dreamlike, or lacking in significance...
- DerealizationDerealizationDerealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...
- Severe memory lossMemory lossMemory loss can be partial or total and it is normal when it comes with aging. Sudden memory loss is usually a result of brain trauma and it may be permanent or temporary. When it is caused by medical conditions such as Alzheimers, the memory loss is gradual and tends to be permanent.Brain trauma...
- DepressionDepression (mood)Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
- Flashbacks of abuse/trauma
- Sudden anger without a justified cause
- Frequent panic/anxiety attacks
- Unexplainable phobiaPhobiaA phobia is a type of anxiety disorder, usually defined as a persistent fear of an object or situation in which the sufferer commits to great lengths in avoiding, typically disproportional to the actual danger posed, often being recognized as irrational...
s
Patients may experience an extremely broad array of other symptoms such as pseudoseizures that may appear to resemble epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
, schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
s, mood disorder
Mood disorder
Mood disorder is the term designating a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders classification system where a disturbance in the person's mood is hypothesized to be the main underlying feature...
s, post traumatic stress disorder, personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
s, and eating disorder
Eating disorder
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
s.
Physiological findings
Reviews of the literature have discussed the findings of various psychophysiologicPathophysiology
Pathophysiology is the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome...
investigations of DID. Many of the investigations include testing and observation in a single person with different alters. Different alter states have shown distinct physiological
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...
markers and some EEG
Electroencephalography
Electroencephalography is the recording of electrical activity along the scalp. EEG measures voltage fluctuations resulting from ionic current flows within the neurons of the brain...
studies have shown distinct differences between alters in some subjects, while other subjects' patterns were consistent across alters.
Neuroimaging studies of individuals with dissociative disorders have found higher than normal levels of memory encoding
Encoding (Memory)
Memory has the ability to encode, store and recall information. Memories give an organism the capability to learn and adapt from previous experiences as well as build relationships. Encoding allows the perceived item of use or interest to be converted into a construct that can be stored within the...
and a smaller than normal parietal lobe
Parietal lobe
The parietal lobe is a part of the Brain positioned above the occipital lobe and behind the frontal lobe.The parietal lobe integrates sensory information from different modalities, particularly determining spatial sense and navigation. For example, it comprises somatosensory cortex and the...
.
Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of people diagnosed with DID. Brain imaging studies have corroborated the transitions of identity in some DID sufferers. A link between epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
and DID has been postulated but this is disputed. Some brain imaging
Neuroimaging
Neuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/pharmacology of the brain...
studies have shown differing cerebral blood flow
Cerebral blood flow
Cerebral blood flow, or CBF, is the blood supply to the brain in a given time. In an adult, CBF is typically 750 millitres per minute or 15% of the cardiac output. This equates to 50 to 54 millilitres of blood per 100 grams of brain tissue per minute. CBF is tightly regulated to meet the brain's...
with different alters, and distinct differences overall between subjects with DID and a healthy control group.
A different imaging study showed that findings of smaller hippocampal
Hippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...
volumes in patients with a history of exposure to traumatic stress and an accompanying stress-related psychiatric disorder were also demonstrated in DID. This study also found smaller amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
volumes. Studies have demonstrated various changes in visual parameters between alters. One twin study
Twin study
Twin studies help disentangle the relative importance of environmental and genetic influences on individual traits and behaviors. Twin research is considered a key tool in behavioral genetics and related fields...
showed heritable factors were present in DID.
Causes
This disorder is theoretically linked with the interaction of overwhelming stress, traumatic antecedents, insufficient childhood nurturing, and an innate ability to dissociateDissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
memories or experiences from consciousness
Consciousness
Consciousness is a term that refers to the relationship between the mind and the world with which it interacts. It has been defined as: subjectivity, awareness, the ability to experience or to feel, wakefulness, having a sense of selfhood, and the executive control system of the mind...
. A high percentage of patients report child abuse
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
. People diagnosed with DID often report that they have experienced severe physical and sexual abuse
Sexual abuse
Sexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...
, especially during early to mid childhood. Several psychiatric rating scales of DID sufferers suggested that DID is strongly related to childhood trauma rather than to an underlying electrophysiological
Electrophysiology
Electrophysiology is the study of the electrical properties of biological cells and tissues. It involves measurements of voltage change or electric current on a wide variety of scales from single ion channel proteins to whole organs like the heart...
dysfunction.
Others believe that the symptoms of DID are created iatrogenically
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
by therapists using certain treatment techniques with suggestible patients, but this idea is not universally accepted. Skeptics have observed that a small number of US therapists were responsible for diagnosing the majority of individuals with DID there, that patients did not report sexual abuse or manifest alters until after treatment had begun, and that the "alters" tended to be rule-governed social role
Role
A role or a social role is a set of connected behaviours, rights and obligations as conceptualised by actors in a social situation. It is an expected or free or continuously changing behaviour and may have a given individual social status or social position...
s rather than separate personalities which is consistent with replacing the personalities-focused MPD term with the identities-focused DID term. Additionally in China with "virtually no popular or professional knowledge of DID (...)" where "contamination cannot exist" it has been concluded that "the findings are not consistent with (...) iatrogenic models (...)".
Development theory
It has been theorized that severe sexual, physical, and/or psychological trauma in childhood by a primary caregiver predisposes an individual to the development of DID. The steps in the development of a dissociative identity disorder are theorized to be as follows:- The child is harmed by a trusted caregiverCaregiverCaregiver may refer to:* Caregiver or carer - an unpaid person who cares for someone requiring support due to a disability, frailty, mental health problem, learning disability or old age...
and splits off the awarenessAwarenessAwareness is the state or ability to perceive, to feel, or to be conscious of events, objects or sensory patterns. In this level of consciousness, sense data can be confirmed by an observer without necessarily implying understanding. More broadly, it is the state or quality of being aware of...
and memoryMemoryIn psychology, memory is an organism's ability to store, retain, and recall information and experiences. Traditional studies of memory began in the fields of philosophy, including techniques of artificially enhancing memory....
of the traumatic event to survive in the relationship. - The memories and feelings go into the subconsciousSubconsciousThe term subconscious is used in many different contexts and has no single or precise definition. This greatly limits its significance as a definition-bearing concept, and in consequence the word tends to be avoided in academic and scientific settings....
and are experienced later in the form of a separate part of the self. - The process reoccurs at future traumatic events resulting in more parts of the self to develop, each containing different memories and performing different functions that are meant to keep the child safe and to allow them to form an attachment to the caregiver. Sometimes abusers attempt to do this deliberately, as in the case of the more morbid abusive group practices of various sects, or torture variations.
- DissociationDissociationDissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
becomes a coping mechanism for the individual when faced with further stressful situations.
Diagnosis
The diagnosis of dissociative identity disorder is defined by criteria in the American Psychiatric AssociationAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
's Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM). The DSM-II used the term multiple personality disorder, the DSM-III grouped the diagnosis with the other four major dissociative disorders
Dissociative disorders
Dissociative disorders are defined as conditions that involve disruptions or breakdowns of memory, awareness, identity and/or perception. See also dissociation. People with dissociative disorders are able to escape from reality involuntarily...
, and the DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
categorizes it as dissociative identity disorder. The ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
continues to list the condition as multiple personality disorder.
The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV require that an adult, for non-physiological reasons, be recurrently controlled by multiple discrete identity
Identity (social science)
Identity is a term used to describe a person's conception and expression of their individuality or group affiliations . The term is used more specifically in psychology and sociology, and is given a great deal of attention in social psychology...
or personality
Personality psychology
Personality psychology is a branch of psychology that studies personality and individual differences. Its areas of focus include:* Constructing a coherent picture of the individual and his or her major psychological processes...
states while also suffering extensive memory lapses
Amnesia
Amnesia is a condition in which one's memory is lost. The causes of amnesia have traditionally been divided into categories. Memory appears to be stored in several parts of the limbic system of the brain, and any condition that interferes with the function of this system can cause amnesia...
. While otherwise similar, the diagnostic criteria for children requires also ruling out fantasy.
Diagnosis should be performed by a therapist, psychiatrist
Psychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
or psychologist
Psychologist
Psychologist is a professional or academic title used by individuals who are either:* Clinical professionals who work with patients in a variety of therapeutic contexts .* Scientists conducting psychological research or teaching psychology in a college...
clinically trained in the specific material who may use specially designed interviews (such as the SCID-D) and personality assessment tools to evaluate a person for a dissociative disorder
Dissociative disorders
Dissociative disorders are defined as conditions that involve disruptions or breakdowns of memory, awareness, identity and/or perception. See also dissociation. People with dissociative disorders are able to escape from reality involuntarily...
.
The psychiatric history
Psychiatric history
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient...
of individuals diagnosed with DID frequently but not always contains multiple previous diagnoses of various mental disorders and treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
failures.
The proposed diagnostic criteria for DID in the DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
is:
- Disruption of identity characterized by two or more distinct personality states (one can be the host) or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others, or reported by the patient.
- Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.
- Causes clinically significant distress and impairment in social, occupational, or other important areas of functioning.
- The disturbance is not a normal part of a broadly accepted cultural or religious practice and 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.
-
- These specifiers are under consideration.
a) With pseudoseizures or other conversion symptoms
b) With somatic symptoms that vary across identities
The proposed Criterion C is intended to "help differentiate normative cultural experiences from psychopathology." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, and not have to diagnose those who report it as having a mental disorder.
Screening
The SCID-D may be used to make a diagnosis. This interview takes about 30 to 90 minutes depending on the subject's experiences.The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.
The Dissociative Experiences Scale (DES) is a simple, quick, and validated questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20 and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D diagnoses and a cutoff of 20 missed 25%. The reliability of the DES in non-clinical samples has been questioned. There is also a DES scale for children and DES scale for adolescents. One study argued that old and new trauma may interact, causing higher DID item test scores.
Differential diagnoses
Conditions which may be present with similar symptoms include borderline personality disorderBorderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
, and the dissociative conditions of dissociative amnesia and dissociative fugue. The clearest distinction is the lack of discrete formed personalities in these conditions. Malingering
Malingering
Malingering is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation ; avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences;...
may also be considered, and schizophrenia, although those with this last condition will have some form of delusions, hallucinations or thought disorder.
Treatment
Treatment of DID may attempt to reconnect the identities of disparate alters into a single functioning identity with all its memories and experiences intact - functioning much like the normal brain. In addition or instead, treatment may focus on symptoms, to relieve the distressing aspects of the condition and ensure the safety of the individual. Treatment methods may include psychotherapyPsychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
and medication
Psychiatric medication
A psychiatric medication is a licensed psychoactive drug taken to exert an effect on the mental state and used to treat mental disorders. Usually prescribed in psychiatric settings, these medications are typically made of synthetic chemical compounds, although some are naturally occurring, or at...
s for comorbid
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
disorders. Some behavior therapists
Behaviour therapy
Behaviour therapy, or behavior therapy is an approach to psychotherapy based on learning theory which aims to treat psychopathology through techniques designed to reinforce desired and eliminate undesired behaviours.-History:...
initially use behavioral treatments such as only responding to a single identity, and using more traditional therapy once a consistent response is established. It has been stated that treatment recommendations that follow from models that do not believe in the traumatic
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
origins of DID might be harmful due to the fact that they ignore the posttraumatic symptomatology of people with DID.
Prognosis
DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociativeDissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
symptoms and features of post traumatic stress disorder normally recover with treatment. Those with comorbid
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
addictions
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
, personality
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
, mood
Mood disorder
Mood disorder is the term designating a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders classification system where a disturbance in the person's mood is hypothesized to be the main underlying feature...
, or eating disorder
Eating disorder
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
s face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives. Individuals with the condition commonly attempt suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
.
Epidemiology
The DSM does not provide an estimate of incidence; however the number of diagnoses of this condition has risen sharply. A possible explanation for the increase in incidenceIncidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
and prevalence of DID over time is that the condition was misdiagnosed as schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
, or other such disorders in the past; another explanation is that an increase in awareness of DID and child sexual abuse
Child sexual abuse
Child sexual abuse is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation. Forms of child sexual abuse include asking or pressuring a child to engage in sexual activities , indecent exposure with intent to gratify their own sexual desires or to...
has led to earlier, more accurate diagnosis. Other clinicians believe that DID is an iatrogenic
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
condition over diagnosed in highly suggestive individuals, though there is disagreement over the ability of the condition to be induced by hypnosis. Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:
| Country | Prevalence in mentally ill populations | Source study |
|---|---|---|
| India India India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world... |
0.015% | Chiku et al. (1989) |
| Switzerland Switzerland Switzerland name of one of the Swiss cantons. ; ; ; or ), in its full name the Swiss Confederation , is a federal republic consisting of 26 cantons, with Bern as the seat of the federal authorities. The country is situated in Western Europe,Or Central Europe depending on the definition.... |
0.05 - 0.1% | Modestin (1992) |
| China China Chinese civilization may refer to:* China for more general discussion of the country.* Chinese culture* Greater China, the transnational community of ethnic Chinese.* History of China* Sinosphere, the area historically affected by Chinese culture... |
0.4% | Xiao et al. (2006) |
| Germany Germany Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate... |
0.9% | Gast et al. (2001) |
| Netherlands Netherlands The Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders... |
2% | Friedl & Draijer (2000) |
| United States United States The United States of America is a federal constitutional republic comprising fifty states and a federal district... |
10% | Bliss & Jeppsen (1985) |
| United States | 6 - 8% | Ross et al. (1992) |
| United States | 6 - 10% | Foote et al. (2006) |
| Turkey Turkey Turkey , known officially as the Republic of Turkey , is a Eurasian country located in Western Asia and in East Thrace in Southeastern Europe... |
14% | Sar et al. (2007) |
Figures from the general population show less diversity:
| Country | Prevalence | Source study |
|---|---|---|
| Canada Canada Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean... |
1% | Ross (1991) |
| Turkey (male) | 0.4% | Akyuz et al. (1999) |
| Turkey (female) | 1.1% | Sar et al. (2007) |
Dissociative identity disorder is diagnosed in a sizable minority of patients in drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
treatment facilities.
Comorbidity
Dissociative identity disorder frequently co-occursComorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
with other psychiatric diagnoses, such as anxiety disorders (especially post-traumatic stress disorder-PTSD), mood disorders, somatoform disorders, eating disorders, as well as sleep problems and sexual dysfunction. Dissociative identity disorder has been found to more commonly occur with particular personality disorders including Avoidant Personality Disorder
Avoidant personality disorder
Avoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
(76% co-morbidity), Self-defeating Personality Disorder
Self-defeating personality disorder
Self-defeating personality disorder is a personality disorder that was never formally admitted into the Diagnostic and Statistical Manual of Mental Disorders . It was discussed in an appendix of the manual's revised third edition...
(68% co-morbidity), Borderline Personality Disorder
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
(53% co-morbidity) and Passive-Aggressive Personality Disorder (45% co-morbidity). Schizotypal Personality Disorder
Schizotypal personality disorder
Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and often unconventional beliefs.-Genetic:...
also had a 58% crossover with dissociative tendencies.
History
Before the 19th century, people exhibiting symptoms similar to those were believed to be possessed.An intense interest in spiritualism
Spiritualism
Spiritualism is a belief system or religion, postulating the belief that spirits of the dead residing in the spirit world have both the ability and the inclination to communicate with the living...
, parapsychology
Parapsychology
The term parapsychology was coined in or around 1889 by philosopher Max Dessoir, and originates from para meaning "alongside", and psychology. The term was adopted by J.B. Rhine in the 1930s as a replacement for the term psychical research...
, and hypnosis
Hypnosis
Hypnosis is "a trance state characterized by extreme suggestibility, relaxation and heightened imagination."It is a mental state or imaginative role-enactment . It is usually induced by a procedure known as a hypnotic induction, which is commonly composed of a long series of preliminary...
continued throughout the 19th and early 20th centuries, running in parallel with John Locke
John Locke
John Locke FRS , widely known as the Father of Liberalism, was an English philosopher and physician regarded as one of the most influential of Enlightenment thinkers. Considered one of the first of the British empiricists, following the tradition of Francis Bacon, he is equally important to social...
's views that there was an association of ideas
Association of Ideas
Association of Ideas, or Mental association, is a term used principally in the history of philosophy and of psychology to refer to explanations about the conditions under which representations arise in consciousness, and also for a principle put forward by an important historical school of thinkers...
requiring the coexistence of feelings with awareness of the feelings. Hypnosis
Hypnosis
Hypnosis is "a trance state characterized by extreme suggestibility, relaxation and heightened imagination."It is a mental state or imaginative role-enactment . It is usually induced by a procedure known as a hypnotic induction, which is commonly composed of a long series of preliminary...
, which was pioneered in the late 18th century by Franz Mesmer
Franz Mesmer
Franz Anton Mesmer , sometimes, albeit incorrectly, referred to as Friedrich Anton Mesmer, was a German physician with an interest in astronomy, who theorised that there was a natural energetic transference that occurred between all animated and inanimate objects that he called magnétisme animal ...
and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.
The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100. Epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
was seen as a factor in some cases, and discussion of this connection continues into the present era.
By the late 19th century there was a general acceptance that emotionally traumatic experiences could cause long-term disorders which might display a variety of symptoms. These conversion disorder
Conversion disorder
Conversion disorder is a condition in which patients present with neurological symptoms such as numbness, blindness, paralysis, or fits without a neurological cause. It is thought that these problems arise in response to difficulties in the patient's life, and conversion is considered a psychiatric...
s were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivé (1863-?) who suffered a traumatic experience as a 13 year-old when he encountered a viper. Vivé was the subject of countless medical papers and became the most studied case of dissociation in the 19th century.
Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. It was in this climate that Jean-Martin Charcot
Jean-Martin Charcot
Jean-Martin Charcot was a French neurologist and professor of anatomical pathology. He is known as "the founder of modern neurology" and is "associated with at least 15 medical eponyms", including Charcot-Marie-Tooth disease and amyotrophic lateral sclerosis...
introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet
Pierre Janet
Pierre Marie Félix Janet was a pioneering French psychologist, philosopher and psychotherapist in the field of dissociation and traumatic memory....
, took these ideas and went on to develop his own theories of dissociation. One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym
Pseudonym
A pseudonym is a name that a person assumes for a particular purpose and that differs from his or her original orthonym...
Christine Beauchamp; American neurologist
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
Morton Prince
Morton Prince
Morton Henry Prince was an American physician who specialized in neurology and abnormal psychology, and was a leading force in establishing psychology as a clinical and academic discipline. He was part of a handful of men who disseminated European ideas about psychopathology, especially in...
studied Fowler between 1898 and 1904, describing her case study
Case study
A case study is an intensive analysis of an individual unit stressing developmental factors in relation to context. The case study is common in social sciences and life sciences. Case studies may be descriptive or explanatory. The latter type is used to explore causation in order to find...
in his 1906 monograph
Monograph
A monograph is a work of writing upon a single subject, usually by a single author.It is often a scholarly essay or learned treatise, and may be released in the manner of a book or journal article. It is by definition a single document that forms a complete text in itself...
, Dissociation of a Personality. Fowler went on to marry one of her analyst's colleagues.
In the early 20th century interest in dissociation and multiple personalities waned for a number of reasons. After Charcot's death in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet's association with Charcot tarnished his theories of dissociation. Sigmund Freud
Sigmund Freud
Sigmund Freud , born Sigismund Schlomo Freud , was an Austrian neurologist who founded the discipline of psychoanalysis...
recanted his earlier emphasis on dissociation and childhood trauma.
In 1910, Eugen Bleuler
Eugen Bleuler
Paul Eugen Bleuler was a Swiss psychiatrist most notable for his contributions to the understanding of mental illness and for coining the term "schizophrenia."-Biography:...
introduced the term schizophrenia to replace dementia praecox
Dementia praecox
Dementia praecox refers to a chronic, deteriorating psychotic disorder characterized by rapid cognitive disintegration, usually beginning in the late teens or early adulthood. It is a term first used in 1891 in this Latin form by Arnold Pick , a professor of psychiatry at the German branch of...
. A review of the Index medicus
Index medicus
Index Medicus is a comprehensive index of medical scientific journal articles, published since 1879. It was initiated by John Shaw Billings, head of the Library of the Surgeon General's Office, United States Army...
from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States. A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.
Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports. Bleuler also included multiple personality in his category of schizophrenia. It was concluded in the 1980s that DID patients are often misdiagnosed as suffering from schizophrenia.
The public, however, was exposed to psychological ideas which took their interest. Mary Shelley
Mary Shelley
Mary Shelley was a British novelist, short story writer, dramatist, essayist, biographer, and travel writer, best known for her Gothic novel Frankenstein: or, The Modern Prometheus . She also edited and promoted the works of her husband, the Romantic poet and philosopher Percy Bysshe Shelley...
's Frankenstein
Frankenstein
Frankenstein; or, The Modern Prometheus is a novel about a failed experiment that produced a monster, written by Mary Shelley, with inserts of poems by Percy Bysshe Shelley. Shelley started writing the story when she was eighteen, and the novel was published when she was twenty-one. The first...
, Robert Louis Stevenson
Robert Louis Stevenson
Robert Louis Balfour Stevenson was a Scottish novelist, poet, essayist and travel writer. His best-known books include Treasure Island, Kidnapped, and Strange Case of Dr Jekyll and Mr Hyde....
's Strange Case of Dr Jekyll and Mr Hyde, and many short stories
Short story
A short story is a work of fiction that is usually written in prose, often in narrative format. This format tends to be more pointed than longer works of fiction, such as novellas and novels. Short story definitions based on length differ somewhat, even among professional writers, in part because...
by Edgar Allan Poe
Edgar Allan Poe
Edgar Allan Poe was an American author, poet, editor and literary critic, considered part of the American Romantic Movement. Best known for his tales of mystery and the macabre, Poe was one of the earliest American practitioners of the short story and is considered the inventor of the detective...
had a formidable impact. In 1957, with the publication of the book The Three Faces of Eve
The Three Faces of Eve
The Three Faces of Eve is a 1957 American film adaptation of a case study by Corbett H. Thigpen and Hervey M. Cleckley. It was based on the true story of Chris Costner Sizemore, also known as Eve White, a woman who suffered from Dissociative Identity Disorder formerly known as multiple personality...
and the popular movie which followed it, the American public's interest in multiple personality was revived. During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.
Between 1968 and 1980 the term that was used for dissociative identity disorder was "Hysterical neurosis, dissociative type". The APA wrote: "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."
The highly influential book Sybil
Sybil (book)
Sybil is a 1973 book by Flora Rheta Schreiber about the treatment of Sybil Dorsett for dissociative identity disorder by her psychoanalyst, Cornelia B...
(which was purported to be true, but has since been identified as likely heavily fictionalized) was published in 1974, which popularized the diagnosis through a detailed discussion of the problems and treatment of the pseudonymous Sybil
Shirley Ardell Mason
Shirley Ardell Mason was an American psychiatric patient and commercial artist who was reputed to have multiple personality disorder. Her life was fictionalized in 1973 in the book Sybil, and two films of the same name were made in 1976 and 2007...
. An October, 2011 report on NPR included discussions with Debbie Nathan, author of the book "Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case", and other psychology professionals, about the allegations that the "Sybil" story was, if not a fraud, then a case that involved questionable or duplicitous behavior by the patient, as well as by her doctor, who was interested in the theory and who wanted to believe this was an actual case and who may have been intent on making sure it would be seen as such, and also by the original "Sybil" book's author, who had a large amount of money involved in the book contract.
Six years following the publication of the book "Sybil", the diagnosis of multiple personality disorder appeared in the DSM III. Controversy over the iconic case has since arisen, with some calling Sybil's diagnosis the result of iatrogenic therapeutic methods while others have defended the treatment and reputation of Sybil's therapist, Cornelia B. Wilbur
Cornelia B. Wilbur
Cornelia B. Wilbur was an American psychiatrist. She graduated from the University of Michigan in 1930 and was one of eight women medical college graduates in 1939...
. As media coverage spiked, diagnoses climbed. There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990. Joan Acocella
Joan Acocella
Joan B. Acocella is an American journalist who is the dance and book critic for The New Yorker. She has written several books on dance, literature, and psychology....
reports that 40,000 cases were diagnosed from 1985 to 1995. The majority of diagnoses are made in North America, particularly the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, and in English
English language
English is a West Germanic language that arose in the Anglo-Saxon kingdoms of England and spread into what was to become south-east Scotland under the influence of the Anglian medieval kingdom of Northumbria...
-speaking countries more generally with reports recently emerging from other countries.
Controversy
DID is a controversial diagnosis and condition, with much of the literature on DID still being generated and published in North America, to the extent that it was once regarded as a phenomenon confined to that continent. Even among North American psychiatrists there is a lack of consensus regarding the validity of DID. Practitioners who do accept DID as a valid disorder have produced an extensive literature with some of the more recent papers originating outside North America. Criticism of the diagnosis continues, with Piper and Merskey describing it as a culture-boundCulture-bound syndrome
In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture...
and often iatrogenic
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
condition which they believe is in decline. In China with "virtually no popular or professional knowledge of DID (...)" where "contamination cannot exist" it has been concluded that "the findings are not consistent with (...) iatrogenic models (...)".
There is considerable controversy over the validity of the multiple personality profile as a diagnosis. Unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient and the treatment provider. The relationship between dissociation and multiple personality creates conflict regarding the DID diagnosis. While other disorders require a certain amount of subjective interpretation, those disorders more readily present generally accepted, objective symptoms. The controversial nature of the dissociation hypothesis is shown quite clearly by the manner in which the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM) has addressed, and re-addressed, the categorization over the years.
The second edition of the DSM referred to this diagnostic profile as multiple personality disorder. The third edition grouped MPD in with the other four major dissociative disorders
Dissociative disorders
Dissociative disorders are defined as conditions that involve disruptions or breakdowns of memory, awareness, identity and/or perception. See also dissociation. People with dissociative disorders are able to escape from reality involuntarily...
. The current edition, the DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
, categorizes the disorder as dissociative identity disorder (DID). The ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
(International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as multiple personality disorder.
Psychiatrist Colin A. Ross
Colin A. Ross
Colin A. Ross is a psychiatrist of Canadian origin and professional training. Ross attended medical school at the University of Alberta, Edmonton, Canada and completed his training in psychiatry at the University of Manitoba, Winnipeg, Canada...
has stated that based on documents obtained through freedom of information legislation
Freedom of information legislation
Freedom of information legislation comprises laws that guarantee access to data held by the state. They establish a "right-to-know" legal process by which requests may be made for government-held information, to be received freely or at minimal cost, barring standard exceptions...
, psychiatrists linked to Project MKULTRA
Project MKULTRA
Project MKULTRA, or MK-ULTRA, was the code name for a covert, illegal CIA human experimentation program, run by the CIA's Office of Scientific Intelligence. This official U.S. government program began in the early 1950s, continued at least through the late 1960s, and used U.S...
claimed to be able to deliberately induce dissociative identity disorder using a variety of aversive techniques.
Over-representation in North America
In a review, Joel Paris offered three possible causes for the sudden increase in people diagnosed with DID:- The result of therapist suggestions to suggestible people, much as CharcotJean-Martin CharcotJean-Martin Charcot was a French neurologist and professor of anatomical pathology. He is known as "the founder of modern neurology" and is "associated with at least 15 medical eponyms", including Charcot-Marie-Tooth disease and amyotrophic lateral sclerosis...
's hysterics acted in accordance with his expectations. - Psychiatrists' past failure to recognize dissociation being redressed by new training and knowledge.
- Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: "hysteria".
Paris believes that the first possible cause is the most likely.
The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable. There are several main points of disagreement over the diagnosis.
Skeptics claim that people who present with the appearance of alleged multiple personality may have learned to exhibit the symptoms in return for social reinforcement. One case cited as an example for this viewpoint is the "Sybil
Shirley Ardell Mason
Shirley Ardell Mason was an American psychiatric patient and commercial artist who was reputed to have multiple personality disorder. Her life was fictionalized in 1973 in the book Sybil, and two films of the same name were made in 1976 and 2007...
" case, popularized by the news media. Psychiatrist Herbert Spiegel
Herbert Spiegel
Herbert Spiegel was an American psychiatrist who popularized therapeutic hypnosis as a mainstream medical treatment for patients suffering from pain, anxiety and addictions...
stated that "Sybil" had been provided with the idea of multiple personalities by her treating psychiatrist, Cornelia Wilbur
Cornelia B. Wilbur
Cornelia B. Wilbur was an American psychiatrist. She graduated from the University of Michigan in 1930 and was one of eight women medical college graduates in 1939...
, to describe states of feeling with which she was unfamiliar.
One of the primary reasons for the ongoing recategorization of this condition is that there were once so few documented cases (research in 1944 showed only 76) of what was once referred to as multiple personality. Dissociation is recognized as a symptomatic presentation in response to trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
, extreme emotional stress, and, as noted, in association with emotional dysregulation
Emotional dysregulation
Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...
and borderline personality disorder
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
.
See also
- DissociationDissociationDissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
- Dissociative identity disorder in popular culture
- Fugue stateFugue stateA fugue state, formally dissociative fugue or psychogenic fugue , is a rare psychiatric disorder characterized by reversible amnesia for personal identity, including the memories, personality and other identifying characteristics of individuality...
- Identity formationIdentity formationIdentity formation is the development of the distinct personality of an individual regarded as a persisting entity in a particular stage of life in which individual characteristics are possessed and by which a person is recognised or known . This process defines individuals to others and themselves...
- Psychogenic amnesiaPsychogenic amnesiaPsychogenic amnesia, also known as functional amnesia or dissociative amnesia, is a memory disorder characterized by extreme memory loss that is caused by extensive psychological stress and that cannot be attributed to a known neurobiological cause...
- Splitting (psychology)Splitting (psychology)Splitting may mean two things: splitting of the mind, and splitting of mental concepts . The latter is thinking purely in extremes Splitting (also called all-or-nothing thinking in cognitive distortion) may mean two things: splitting of the mind, and splitting of mental concepts (or black and...