Multiple personality disorder

Dissociative pathology, when the patient feels the separation of the previously integral self, manifests itself in many clinical variations. One of them, its extreme manifestation is multiple personality, that is, the division of the I into several subpersonalities (alter personalities, ego states), each of which thinks, feels and interacts with the world around them in its own way. These personalities regularly take turns monitoring the behavior of the individual. Unconscious dissociation is more common, patients do not notice the division of their I and do not control the activity of their unconscious subpersonalities, since their change is accompanied by complete amnesia. Each personality has its own memory. Even if some of the memories of the true personality are retained, the alternative ego state is perceived as alien, uncontrollable and related to some other person.

American psychiatry diagnoses this phenomenon as dissociative identity disorder. The current ICD-10 classification calls a similar condition "multiple personality disorder" and refers it to other dissociative (conversion) disorders, without separating it into a separate nosology. The diagnostic criteria are generally the same. They are most fully and clearly described in the new version of the International Classification of Diseases, 11th revision (ICD-11), where this mental disorder already has its own code. 

However, not all psychiatrists recognize the existence of the mental phenomenon of multiple personality. The disorder is rare, poorly understood, and difficult to diagnose. Patients usually do not notice the fact of dissociation of their personality, and therefore do not seek medical help. Basically, such cases are revealed when one of the subpersonalities of illegal actions is committed (usually this is not a real person). The diagnosis is made after a thorough forensic psychiatric examination designed to reveal the simulation. [1]

Epidemiology

The statistics of dissociative identity disorder (the most modern and correct name for the pathology) is based on a small sample, since it used to be very rare (until 1985, about 100 cases were registered and described). Such mental disorders are diagnosed for the first time, as a rule, at the age of about 30 years (the average age of patients was 28.5 years). In women, they are much more common than in men: for one representative of the stronger sex, according to various studies, there are from five to nine patients. The prevalence of pathology, according to various researchers, is estimated from the complete absence of such cases to 2.3-10% of the total population of the country. [2]The  [3]incidence is higher in English-speaking countries, but this may be due to the fact that multiple personality disorder is not universally recognized.

3% of psychiatrists indicated that at the time of the study they had treated or examined one or more patients who met the DSM-III criteria for multiple personality disorder, and 10% indicated that they had seen multiple personality disorder at least once in their professional career. Patients were not equally distributed among psychiatrists; three colleagues reported seeing a much larger number of patients with multiple personality disorder. The point prevalence of multiple personality disorder in psychiatric patients is 0.05-0.1%. [4]

In recent years, industrialized countries have experienced an inexplicable surge in "morbidity", already known about 40 thousand multiple personalities. However, most of them raise doubts about the correctness of the diagnosis. There are not so many psychiatrists in the world who have seriously studied multiple personality syndrome, and, as practice shows, it takes from six to eight years to establish a diagnosis.

Causes multiple personality

According to the American psychiatrist Frank W. Putnam and his other colleagues who have been closely involved in the study of the phenomenon of multiple personality, the division of the integral self into an alter personality is based on repeated violence experienced in childhood, most often sexual, the culprits of which are the closest people who are called to protect and protect the child. It can also be caused by physical abuse by parents or other family members - severe beatings and other cruel bullying towards the child. In many cases, these forms of violence, physical and sexual, were applied to the victim at the same time. [5]

Risk factors

Risk factors such as rejection, total indifference to the child on the part of parents or persons replacing them, significant, also, according to studies, led to the development of multiple personality syndrome, and even more often than purely cruel treatment (without a sexual component).

The likelihood of developing personality dissociation is higher in those cases when relatives living nearby, although they do not participate in the abuse, do not recognize it, pretending that nothing is happening. This makes the victim feel helpless in the face of the circumstances.

Also important is the regularity of the traumatic impact that depletes the internal reserves of the personality.

Experts suggest that war, destructive natural disasters, prolonged separation from the mother at the age of two, the death of parents and other critical situations can act as a stressor. [6]

Pathogenesis

The pathogenesis of personality separation, which is essentially a type of post-traumatic stress disorder, is triggered by regular severe mental trauma, which is superimposed on the characteristics of the victim, his ability to separate his identity from consciousness (to dissociation), the presence of personality disorders and more serious mental pathologies in the family. Which, in general, fits into the scheme of hereditary predisposition. Multiple Personality Disorder is seen as a defensive response that helps an individual who was abused during childhood to adapt and even survive. Research suggests that alter personalities usually appear in early childhood, because under conditions of intolerable stress, child development does not proceed as it should, and instead of a relatively unified identity, a segregated one appears.

A unified view of the pathogenesis of this disorder has not yet been developed. Not even all psychiatric schools agree with its existence. There are several theories of the origin of multiple personality. One of the hypotheses considers it as a type of psychogenic amnesia of exclusively psychological origin, through which the victim can displace from memory the traumatic events of a certain life span that go beyond normal human experience.

Another theory is iatrogenic. The emergence in recent years of a large number of multiple personalities is associated with the widespread use in the civilized world of various kinds of psychotherapeutic assistance, including hypnosis, as well as books and films, the hero of which suffers from this mental disorder. At least, most cases are considered iatrogenic when the patient remembers in whole or in part about the events that occurred with his other identities and seeks psychiatric help himself. The origin of multiple personality in this case is associated with suggestion or autosuggestion, and the factors contributing to the development of such a disorder are called the individual characteristics of a person. They are hypnotizable or hysterical individuals, self-centered and prone to fantasy.

Symptoms multiple personality

It is almost impossible to suspect that you have multiple personality syndrome, because basically the dissociation of the self into several alternative personalities is usually not realized. Switching personalities, as a rule, is accompanied by amnesia, of course, and the patient himself does not have complaints. The first signs that the patient can feel are, for example, the discreteness of time, when it seems to be torn apart and some time intervals "fall out" from memory, and those that are preserved are perceived as not connected with each other. In established and described cases of disorder, people noticed that they lost money (which they spent, as it later turned out, their subpersonalities), the level of gasoline in the car (it turned out that someone was driving it while the patient, as he thought, was asleep) and etc. Large temporary episodes are amnestied, which cannot be attributed to forgetfulness. Others may notice that a person's behavior and mood changes sharply, simply to the diametrically opposite, that he may not show up for a pre-arranged meeting, is sincerely surprised and denies that he knew about the meeting at all and promised to come. But various discrepancies in behavior and strangeness of a person do not at all mean that he has a separation of personality. To make a diagnosis, it is necessary to observe the patient for several years.

The specific manifestations of dissociative disorder are very diverse, there can be many alternative personalities - on average 14-15, there have been cases when the doctor counted up to 50 identities. They had different ages, gender, nationality, character, preferences, dressed differently and spoke in different voices, were not even always human beings.

Qualitatively, their existence is also very different: one patient may have both stable and complexly organized identities, and fragmentary ones, some may never “appear”, but others or some of the subpersonalities “know” about their existence.

In the clinical picture of multiple personality disorder, any manifestation of "minor" dissociative disorders may be present as symptoms. Phenomena of dissociative phenomena are observed, which, depending on the severity, can be either a variant of the norm or a symptom of pathology. These are absorption (a state of all-embracing absorption in something), absent-mindedness (daydreaming, an empty look - the individual is “not with us”), obsession, trance and hypnoid states, somnambulism (walking in a dream), dissociation of consciousness into the I-psychic and I- physical ("separation of the soul from the physical body") and near-death experiences.

And also undoubtedly pathological forms of dissociation: mental amnesia - a state when events that occurred during a certain period of time are amnestied, usually after a traumatic event (local mental amnesia). Sometimes, some events (traumatic) related to a certain period are selectively amnestized (displaced from memory), but others (neutral or pleasant) remain in the memory. Psychic amnesia is recognized by the patient, he knows that he has forgotten some important information about himself. It is observed in 98% of patients with multiple personality disorder. [7]

Psychogenic fugue - when a person suddenly leaves home, from work, while his personal identification completely or partially changes, and the original one disappears or the patient is very vaguely aware of it. The fugue, unlike the previous state, is not conscious. Fugue episodes occurred in more than half of the patients.

Every second patient has a deep depersonalization / derealization syndrome or some of its manifestations. A fifth of the patients walk in a dream.

Individuals with multiple identities may experience: pronounced mood lability; unstable behavior; discontinuity of time (loss of memory of whole time intervals); amnesia of the entire period of childhood or part of it; missing appointments, including with a doctor; conflicting information during the clarification of the medical history (depending on which identity came to the appointment at the moment).

The complex of symptoms known as Ross's "dissociative triad" includes the following:

• directly dissociation is manifested by a feeling of outside control of feelings and thoughts, their openness, the presence of voices commenting on the patient's actions, which is caused by the unconscious disintegration of mental functions;
• auditory pseudo-hallucinations are constantly present and do not lead to a disconnection from reality (unlike schizophrenia);
• the patient's history mentions intentions or attempts to commit suicide or inflict less significant harm on himself.

In addition, each ego state may have its own mental disorders, which significantly complicates the diagnosis. The most common (approximately 88%) depressive disorder occurs. Three-quarters of patients with dissociative identity disorder tried to commit suicide, and just over a third admitted to self-harm. Many suffer from insomnia, headaches, and have nightmares on a regular basis. Anxiety disorders and phobias often preceded the “switching” of identities, but could also be independent disorders. Such people are prone to addictive behavior, transsexualism and transvestism, since identities can be of different sexes. They often have hallucinations, catatonic manifestations, and disturbances in thinking associated with a crisis in the identity system, since none of them is able to completely control the behavior of an individual, while maintaining his authenticity. On this basis, one of the identities, imagining itself to be dominant, may develop a delusion of independence. [8]

Multiple personality disorder is rare and poorly understood, requiring a long time to be diagnosed (approximately six to eight years from the moment it enters the psychiatrist's field of vision). Psychiatrists, on the other hand, had the opportunity to observe individuals with advanced disorder. Nevertheless, its belonging to the adaptation syndromes is not objectionable, and the stages of development of the adaptation syndrome are known.

The first stage of anxiety caused by a traumatic event, when at first the victim experiences shock and the equilibrium state of all body functions is disturbed. In our case, people were subjected to regular bullying in childhood, feeling completely defenseless and unable to change anything, the stress was chronic and caused a feeling of hopelessness. Nevertheless, our body is designed in such a way that it seeks to restore balance, albeit at some other level, in new conditions. The second stage begins - the adaptation stage, at which the body turns on protective mechanisms and tries to resist stressors. Again, in our case, it is not possible to suspend their action, the body is exhausted in an unequal struggle, and the third stage has come - exhaustion, delimitation of vital functions, both mental and physical, since the protective mechanisms of an integrated personality have not justified themselves. A system of ego states appears with its own functions. At this stage, you cannot get out on your own; outside help is needed.

In the new international classifier ICD-11, dissociative identity disorder is singled out as a separate nosological unit among other dissociation, and is not included in other specified ones as in ICD-10. The name "multiple personality disorder" was abandoned, since the recognition of the existence of several subpersonalities casts doubt on the basic philosophical concept of the unity of personality and consciousness. Therefore, the concept of "alternative personalities" was replaced by the concept of "system of identities", embodying independent entities with fairly stable emotional and cognitive parameters. [9] The true (original) personality, outwardly normal, is called the master. He may not be aware of the existence of his other ego states, but there are cases when all identities knew each other and formed a cohesive collective. A change in ego states is manifested by such symptoms as nystagmus, rolling eyes, tremors, convulsions, absences. [10]

If one any personality is dominant, that is, controls the patient's behavior most of the time, and other ego states take possession of him periodically, but not for long, then such a pathology is spoken of as a complex dissociative invasion disorder.

Multiple personality is one of the most mysterious and controversial mental disorders. This is a chronic disease that can remain with the patient for life, and its specific manifestations are largely determined by the individual characteristics of the patient and the duration of dissociative experiences. All kinds of dissociation phenomena can be present as symptoms of a multiple personality located at the extreme point of this spectrum. [11]

Complications and consequences

Despite the fact that dissociative identity disorder is recognized as a mental pathology, not everything is clear with it. Not only that not all psychiatrists agree with its existence, many consider it a variant of the norm - a kind of existential state. Therefore, if the multiplicity of ego states does not cause discomfort for the individual himself and does not lead to the commission of illegal actions, then there is nothing to heal.

At the same time, most of the known multiple personalities were discovered and came to the attention of psychiatrists in connection with the fact that they committed a serious crime. Forensic psychiatrists, the subsequent study of these phenomena and their treatment, consider this disorder to be a pathology, moreover, very severe and difficult to treat. In the end, a multiple personality begins to have problems with integration in society, which, as practice shows, can lead to extreme manifestations of maladjustment - suicide or a crime against an outsider. [12]

Diagnostics multiple personality

Currently, the diagnosis of multiple personality is carried out according to the ICD-10 and DSM-V criteria, where, with minor differences, it is required that the patient regularly and alternately feel like different personalities (identities) with different individual characteristics, memories, and value systems. This is not easy to establish, in addition, each alter-identity has its own mental disorders, and in order to understand this "bouquet" of pathologies, it is required to observe the patient for a number of years.

Various psychological testing methods are used. The patient is interviewed according to a rigidly structured interview scheme for the diagnosis of dissociative disorders, proposed by the American Psychiatric Association. Questionnaires are used: dissociative experiences, peritraumatic dissociation. The results are assessed on the dissociation scale. [13]

Differential diagnosis

Differential diagnosis is carried out with mental illness, in particular, schizophrenia. In this case, they rely on specific symptoms, which are not characteristic of dissociative disorders. In schizophrenics, a splitting of mental functions is observed, perception, thinking and emotional reactions are impaired, in addition, they perceive the ongoing disintegration of the personality as a result of external influences. With multiple personality disorder, independent and rather complex identities are formed, each of which, in a different way, but completely draws its own picture of the world. [14]

Also excluded are organic pathologies of cerebral structures, abuse of psychoactive substances, severe somatic diseases, for which the general health of the patient is examined.

Multiple personality disorder is differentiated from religious practices and childhood fantasies that are within the normal range.

Treatment multiple personality

People with this disorder are treated at will, with the exception of cases when one of the identities (usually not the owner) has committed a crime. Various methods of psychotherapeutic influence are used - cognitive-behavioral, insight-oriented psychodynamic, family therapy. Clinical hypnosis techniques can also be used with extreme caution. [15]

Psychiatrists with experience in treating such patients around the world can be counted on one hand. Many of them summarized their experience with such patients and shared their treatment methods in books. For example, Richard Klaft and Frank W. Putnam describe very similar models and techniques of working in the treatment of multiple personality, which boils down to uniting (integrating) all ego states and merging them with the personality-master. Basically, however, it is possible to achieve a significant weakening of the influence of alternative personalities. This makes it possible to alleviate the patient's condition, to provide him and those around him with a safe existence. The mentioned psychiatrists propose to establish contact with all individuals, referring to the system of identities simultaneously as a whole. Then, by fragments, since each identity often includes separate episodes of memories, a holistic picture of the trauma experienced is restored, the events are spoken out, and the connections with the actual personal disconnection are analyzed. Conversation takes place with each alter identity, with which (in the presence of others) their and its own merits and demerits are spoken to. This allows one to realize that alte identities complement each other, the disadvantages of one are compensated by the advantages of the other. This technique allows you to effectively combine ego states into one personality. Working with dreams, keeping diaries is also used.

Some identities are easier to contact the therapist (Putnam calls them inner helpers). The sooner such an assistant is identified, the more effective psychotherapy is. Others, on the contrary, are hostile to the host personality, to the treatment, and to other ego states (internal persecutors). It is also advisable to identify them as quickly as possible and start working with them.

The treatment is long-term, full integration is not guaranteed. After unification, continuous post-integration therapy is carried out. A possible satisfactory effect is considered the result when the psychiatrist achieves a fruitful conflict-free coexistence and cooperation of all identities.

Drug therapy is used exclusively symptomatically, (for example, antidepressants in severe depression) to alleviate the patient's condition and more fruitful cooperation with him.

Prevention

The origin of this disorder is not entirely clear. It was found that most of the known multiple personalities were distinguished by increased self-hypnosis. They were born that way, and there's nothing you can do about it. However, most people with this trait do not suffer from multiple personality disorder.

Chronic psychotrauma received in childhood led to the development of the most severe form of dissociation - in most cases it was sexual and / or physical violence by one of the parents (less often, other family members). Such "skeletons in the closet" are usually carefully hidden, and it is not easy to warn them. All officially registered persons with this disorder (there are currently about 350 of them) have a history of severe traumatic situations associated with violence.

Psychiatrists who recognize dissociative identity disorder believe that it is theoretically possible to develop it in the absence of severe psychotrauma in childhood. This is also evidenced by the growth in recent years of calls for psychiatric help of various kinds of "multiple personalities". In this case, the main role is played by personal predisposition (a tendency to theatricality, fantasizing, self-hypnosis, narcissism), and the provoking factor is the information circulating this topic - books and films about multiple personalities. Such a plot is usually a win-win, many authors, both classics and our contemporaries (R.L. Stevenson, A. Hitchcock, K. Mooney), have turned to it, works always arouse increased interest and become bestsellers. It is impossible to eliminate their influence on predisposed persons.

The cases of complaints, which have become more frequent in recent years, raise doubts about the validity of the diagnosis among serious clinicians - experts in the field of this pathology. In addition, there is a widespread belief in the West that multiple personality is not a disease. This is an existential state that does not need to be prevented or treated, at least as long as it does not cause discomfort in the host personality and is not socially dangerous.

Based on the above, prevention of the development of multiple personality disorder is a socio-psychological problem of eliminating child abuse that has not yet been resolved in any country in the world.

Forecast

First, the diagnosis and then the treatment of dissociative identity disorder lasts for years, often consultations with a psychotherapist are necessary for the patient for life. The goal of psychotherapy is the reintegration of different identities into a single normally functioning personality is not always achieved, the absence of conflict between ego states and cooperation between them is considered a satisfactory result, that is, a stable and normally functioning multiple personality that does not experience psychological discomfort.