Dissociative identity disorder: causes, symptoms, diagnosis, treatment

Dissociative identity disorder, formerly called multiple personality disorder, is characterized by the presence of two or more alternating personalities and the inability to remember important personal information associated with one of the personalities. The cause is usually severe childhood trauma. Diagnosis is based on history, sometimes combined with hypnosis or interviews using medication. Treatment consists of psychotherapy, sometimes combined with medication.

What is unknown to one personality may be known to another. Some personalities may know about others and interact with them in a special inner world.

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Causes of Dissociative Identity Disorder

Dissociative identity disorder is associated with exposure to extreme stress (usually abuse), lack of attention and empathy during periods of extremely harmful life experiences in childhood, and a tendency to exhibit dissociative behavior (the ability to separate one's memory, sensations, identity from awareness).

Children are not born with a sense of a coherent personality; it develops under the influence of many factors. In children who have experienced extreme stress, the parts of the personality that should be integrated remain disjointed. Patients with dissociative disorder often had a history of chronic and severe abuse (physical, sexual, or emotional) in childhood. Some patients did not experience abuse but experienced early loss (such as the death of a parent), severe illness, or extreme stress.

Unlike most children, who develop a holistic, integrated assessment of themselves and others, children who grow up in adverse circumstances tend to keep their various feelings and emotions disconnected. Such children may develop the ability to withdraw from harsh circumstances by “withdrawing” or “retreating” into their own world. Each phase of development may result in the development of different personalities.

Symptoms of Dissociative Identity Disorder

A number of symptoms are characteristic: a fluctuating clinical picture; changing activity levels, from high to inactive; severe headaches or other painful sensations in the body; time distortions, memory lapses and amnesia; depersonalization and derealization. Depersonalization is a feeling of unreality, distance from oneself, detachment from one's physical and mental processes. The patient feels like an outside observer of his own life, as if he were watching himself in a movie. The patient may even have transient feelings that his body does not belong to him. Derealization is manifested by the perception of familiar people and environments as unfamiliar, strange or unreal.

Patients may find objects, items, handwriting samples that they are unable to recognize. They may refer to themselves in the plural (we) or in the third person (he, she, they).

Personality switching and amnestic barriers between them often lead to chaos in life. Since personalities often interact with each other, the patient usually claims to hear an internal conversation with other personalities that discusses or addresses the patient. Therefore, the patient may be misdiagnosed as psychotic. Although these voices are perceived as hallucinations, they are qualitatively different from the hallucinations typical of psychotic disorders such as schizophrenia.

Patients often have symptoms similar to those of anxiety disorders, mood disorders, post-traumatic stress disorder, personality disorders, eating disorders, schizophrenia, epilepsy. Suicidal intentions and attempts, as well as episodes of self-harm, are quite common in such patients. Many patients abuse psychoactive substances.

Diagnosis of Dissociative Identity Disorder

Patients usually have a history of 3 or more mental disorders with previous treatment resistance. The skepticism of some doctors about the validity of isolating dissociative identity disorder also plays a role in diagnostic errors.

Diagnosis requires specific questioning about dissociative phenomena. Sometimes long interviews, hypnosis or drug-assisted interviews (methohexital) are used, and the patient may be encouraged to keep a diary between visits. All these measures facilitate personality change during the assessment process. Specially designed questionnaires may be helpful.

The psychiatrist may also attempt to directly contact other personalities by inviting the part of the mind responsible for the behavior for which the patient developed amnesia or for which depersonalization and derealization were observed to speak.

Treatment for Dissociative Identity Disorder

Integration of the personality is the most desirable outcome. Medications can help treat symptoms of depression, anxiety, impulsivity, and substance abuse, but treatment to achieve integration is based on psychotherapy. For patients who cannot or do not want to integrate, the goal of treatment is to facilitate cooperation and collaboration between the personalities and to reduce symptoms.

The first step in psychotherapy is to provide the patient with a sense of safety before assessing traumatic experiences and exploring problematic personalities. Some patients benefit from hospitalization, where ongoing support and monitoring can help with painful memories. Hypnosis is often used to explore traumatic memories and reduce their impact. Hypnosis can also help to access personalities, facilitate communication between them, stabilize them, and interpret them. When the causes of dissociation are worked through, therapy can reach a point where the patient's personalities, relationships, and social functioning can be reunited, integrated, and restored. Some integration may occur spontaneously. Integration may be facilitated by negotiation and a fusion mindset, or integration may be facilitated by the technique of "image superposition" and hypnotic suggestion.

Prognosis of dissociative identity disorder

Symptoms wax and wane spontaneously, but dissociative identity disorder does not resolve spontaneously. Patients can be divided into three groups. Patients in Group 1 have predominantly dissociative symptoms and posttraumatic features, generally function well, and recover fully with treatment. Patients in Group 2 have dissociative symptoms combined with symptoms of other disorders, such as personality disorders, mood disorders, eating disorders, and substance use disorders. These patients recover more slowly, and treatment is less successful or longer lasting and difficult for the patient. Patients in Group 3 not only have significant symptoms of other mental disorders, but may also remain emotionally attached to their alleged abusers. These patients often require long-term treatment, the goal of which is primarily to help control symptoms rather than to achieve integration.