Slogar, Sue-Mei - Dissociative Identity Disorder - Overview and Current Research

10/13/2014 Printable Version - Dissociative Identity Disorder: Overview and Current Research - Student Pulse

http://www.studentpulse.com/print?id=525 1/7

Print Page

Slogar, S. (2011). "Dissociative Identity Disorder: Overview and Current Research." Student Pulse,3(05). Retrieved from http://www.studentpulse.com/a?id=525

Dissociative Identity Disorder: Overview andCurrent ResearchBy Sue-Mei Slogar2011, Vol. 3 No. 05

Abstract

Show/Hide

This paper entails a description of factors related to diagnosis and treatment of Dissociative IdentityDisorder. Epidemiology, including risk factors and sociocultural aspects of the disorder are presented,along with recommendations for treatment. Highlights of current research focusing on neurobiologicaland psychobiological aspects of DID provide additional insight into providing accurate diagnosis andappropriate treatment. Recommendations for future research involve studies that will elaborate onresearch already completed, and provide a more detailed analysis of the characteristics of this unique andcomplex disorder.

Introduction to Dissociative Identity Disorder (DID)

Dissociative Identity Disorder (DID) is a fascinating disorder that is probably the least extensivelystudied and most debated psychiatric disorder in the history of diagnostic classification. There is alsonotable lack of a consensus among mental health professionals regarding views on diagnosis andtreatment. In one study involving 425 doctoral-level clinicians, nearly one-third believed that a diagnosisof Borderline Personality Disorder was more appropriate than DID. While most psychologistsdemonstrated belief that DID is a valid diagnosis, 38% believed that DID either likely or definitely couldbe created through the therapist’s influence, and 15% indicated that DID could likely or definitelydevelop as a result of exposure to various forms of media (Cormier & Thelen, 1998).

Description of DID

DiagnosisAccording to the diagnostic criteria outlined in the current edition of the DSM, diagnosis of DID requiresthe presence of at least two personalities, with a personality being identified as a entity having a uniquepattern of perception, thought, and relational style involving the both the self and the environment. Thesepersonalities must also display a pattern of exerting control on the individual’s behavior. Extensive andunusual loss of memory pertaining to personal information another feature of DID. Differential diagnosisgenerally involves ruling out the effects of chemical substances and medical (as opposed topsychological) conditions. When evaluating children, it is also important to ensure that symptoms aredistinguishable from imaginary play (American Psychiatric Association, 2000).

http://www.studentpulse.com/a?id=525



Prevalence & ComorbidityIn clinical populations, the estimated prevalence of DID ranges from 0.5 to 1.0% (Maldonado, Butler, &Spiegel, 2002). In the general population, estimates of prevalence are somewhat higher, ranging from 1-5% (Rubin & Zorumski, 2005). Females are more likely to receive a diagnosis of DID, at a ratio of 9:1(Lewis-Hall, 2002). This author also contends that the disproportionately high number of femalesdiagnosed with DID dispels the notion that incestual abuse is largely responsible for the development ofDID.

High percentages of individuals with DID have comorbid diagnoses of Post-Traumatic Stress Disorder orBorderline Personality Disorder (Gleaves, May, & Cardeña, 2001). In addition, individuals diagnosedwith DID commonly have a previous diagnosis of Schizophrenia. However, this most likely represents amisdiagnosis rather than comorbidity, due to the fact that both disorders involve experiencingSchneiderian symptoms (ibid.). Other possible comorbid disorders involve substance abuse, eatingdisorders, somatoform disorders, problems of anxiety and mood, personality disorders, psychoticdisorders, and organic mental disorders (ISSD, 2005), OCD, or some combination of conversion andsomatoform disorder (Kaplan & Sadock, 2008). While the symptoms of DID are complex in themselves,the presence of multiple additional symptoms further complicates diagnosis and treatment.

Client characteristics, course, & prognosisThe course and prognosis of untreated DID is uncertain, and for individuals with comorbid disorders,prognosis is less favorable. Other factors influencing a poor prognosis include remaining in abusivesituations, involvement with criminal activity, substance abuse, eating disorders, or antisocial personalityfeatures. Although DID occurs more frequently in the late adolescence or early adult age groups, theaverage age of diagnosis is thirty, with most diagnoses occurring 5-10 years after the onset of symptoms.A risk factor involves having first-degree relatives who have received diagnoses of DID (Kaplan &Sadock, 2008).

Risk factorsOne study found that the risk of developing a dissociative disorder (DD) increased seven times with achild’s exposure to trauma. A later diagnosis of DD was twice as likely when the child’s mother hadexperienced trauma within two years of the child’s birth (Pasquini, Liotti, Mazzotti, Fassone, & Picardi etal. 2002). Dissociative Identity Disorder is linked to childhood abuse in 95-98% of the cases (Korol,2008). However, other factors in addition to a history of abuse, such as disorganized or disorientedattachment style and a lack of social or familial support best predict that an individual will develop DID(ibid).

Studies on genetic factors contributing to DID present mixed findings. However, one study involvingdyzogotic and monozygotic twins found that considerable variance in experiences of pathologicaldissociation could be attributed to both shared and non-shared environmental experiences, but heritabilityappeared to have no effect (Waller & Ross, 1997). Another study utilizing objective ratings ofdissociative behavior found that shared environmental factors had little effect in both adopted siblingsand twin pairs (Becker-Blease, et al, 2004). However, dissociative behavioral correlations of r = 0.21 forfraternal twins and r = 0.60 for identical twins suggests the presence of a genetic effect. As this study didnot specifically investigate pathological dissociation, more research is needed to determine if the genetictendency to experience dissociation varies according to type of dissociation (pathological or non-pathological), and whether trauma influences the pathological development of a pre-existing tendency todissociate.

Multicultural considerationsSamples of participants from the United States, Canada, the Netherlands, Norway, and Turkey found asimilar prevalence estimates (Kluft & Foot, 1999). However, prevalence in India, Germany, and Japan is



much lower (Fujii, Suzuki, Sato, Muraka, & Takahashi, 1998). A study conducted with inpatient,outpatient, and the general population in China found prevalence rates of 0.5, 0.3, and 0.0%, respectively(Xiao, et al., 2006). Factors related to individualistic and collectivistic cultures may contribute to theprevalence and etiology of DID. According to Fujii et al., not only are reports of DID in Japan are farmore scarce than in North America, but other differences also exist. While most North Americansparticipants with DID were physically or sexually abused in childhood, Japanese participants diagnosedwith DID were far less likely to have experienced physical or sexual abuse. The North Americanparticipants in this study also had nearly three times as many alter personalities as Japanese participants.

Treatment of Dissociative Identity Disorder

PsychotherapyAlthough the ultimate goal of treatment is integrated functioning of the alter personalities (ISSD, 2005),the presence of multiple comorbid disorders, experiences of trauma, and safety concerns make acomprehensive treatment plan necessary. The International Society for the Study of Dissociation (ISSD)published some basic guidelines to aid clinicians in treating DID. Treatment most commonly follows aframework of “1) safety, stabilization and symptom reduction, 2) working directly and in depth withtraumatic memories, and 3) identity integration and rehabilitation” (p. 89).

A study involving 280 outpatient participants (98% DID diagnosis) from five different races (Caucasian,African American, Hispanic, Asian, and Other) demonstrated the effectiveness of a similar five-phasemodel in reducing symptoms of dissociation. As might be expected from successful treatment, clients inlater phases of treatment reported less self-harming behavior, symptom reduction, and more positivebehavior than clients in stage 1, as indicated by scores on the Dissociative Experiences Scale II, thePosttraumatic Stress Checklist-Civilian, and the Symptom Checklist-90-Revised (Brand, et al., 2009).

While elements of each phase occur throughout treatment, these phases describe the dominant concernsof therapy during the stages of treatment. Because of the intense feelings experienced as a result oftrauma, individuals with DID may behave in ways that facilitate exploitation or are dangerous tothemselves or others. Thus, a primary goal for treatment is to manage these behaviors and teach impulsecontrol with some form of cognitive or behavioral therapy. Even when amnesia exists between alters,therapists should hold the client responsible for behaviors of all alters. Therapists should also realize thatsome clients do not desire fusion or integration of their personalities. In this case, the goal of treatmentwould involve working towards cooperative functioning of alters. In working with alters, therapistsshould view alters not as problems to be removed, but as the client’s creative response to trauma.Identifying relationships between alters and communicating with alters directly are strategies useful intreating DID. Requesting that the client listen inwardly to alters may facilitate necessary discussionamong alters and between the therapist and client (ISSD, 2005).

MedicationNo randomized trials have been conducted to compare the effectiveness of various theoreticalorientations or medications in treating DID. However, a survey of psychiatrists treating DID found thatthe most favored treatment methods involved individual therapy, anxiolytics, and antidepressants (Sno &Schalken, 1999). In addition to these drugs, carbamazapine for use electroencephalograph abnormalities,prazosin for nightmares, and naltrexone for self-injurious behavior might be helpful (Kaplan & Sadock,2008). Although research involving pharmacotherapy for DID is scarce, two studies involving diazepamand perospirone seem promising.

Following unsuccessful treatment with antidepressants and tranquilizers, Okugawa, Nobuhara, Kitashiro,and Kinoshita (2005) examined the effects of treating DID with perospirone, a medication originallyintended for the treatment of schizophrenia. The clinical features of this case involve two alternate



personalities, who presented as a male (23 years) and a female (17 years). The client (host) was femaleand 30 years old, and had been diagnosed with DID for 13 years. During presentation of the youngfemale personality, the client reported hearing the male alter, which was her primary symptom, alongwith anxiety and identity dissociation. The client experienced remission of anxiety and hallucinatorysymptoms after a month of treatment with perospirone. Treatment was continued for 5 months, andmedication was gradually reduced over a period of 9 months. At the time of writing, the client hadexperienced remission of dissociative symptoms for 1 year. The results of this case study seemremarkable, especially because use of medication alone was responsible for drastic and sustainedimprovement in functioning, and continued use of medication was not required to maintain remission ofsymptoms.

Another case study conducted by Ballew, Morgan, and Lippmann (2003) suggests that diazepam’sanxiety-reducing properties may prove especially useful for assisting in memory retrieval in cases of DIDwhere memories contain traumatic materials. In this study, diazepam was used to successfully facilitatememory retrieval in an amnestic client who was unable to recall his location or identity. The authors ofthis study concluded that “Intravenous diazepam is aneffective, safe intervention to consider forfacilitation ofmemory retrieval in amnestic patients,” and DID can involve some degree of amnesia (p.347). However, because the efficacy and safety of diazepam has not been demonstrated in the treatmentof an adequate number of cases of dissociative disorders, it is difficult to generalize these findings orassess the appropriateness of this treatment. Medication is generally applicable to secondary features andcomorbid disorders, and not DID itself.

Integrative treatment planConsidering the complexity of DID and the lack of conclusive research on treatment methods, the besttreatment approach would involve an integrative style. The use of medication for anxiety and trauma-related symptoms and the phase approach allows for immediate treatment of distressing symptoms,flexibility, and a continual evaluation of progress. Depending on which theoretical orientation is moreappropriate, various psychotherapeutic modalities can be used to address specific problems as necessary.Inflexibly using one approach may hinder successful treatment, especially because DID often involvescomorbid disorders that may need to be considered separately. In addition to integrative individualtreatment, Kaplan and Sadock (2008) suggest that familiarity with systems theory and somatoformdisorders may be helpful to the therapist in understanding the client’s somatic symptoms andrelationships between alters.

Because research supports the importance of social support as a preventative factor, all efforts should bemade to discover sources of support for the client once stability is achieved. Group psychotherapy is oneway to achieve this goal. Advantages of group therapy include reducing isolation related to a diagnosis ofDID, the opportunity to interact with both genders in heterogeneous groups, and an accepting peer groupthat replaces the secrecy and isolation surrounding childhood abuse. Group therapy provides clients withthe opportunity observe others and learn the purpose of alters, and hope for their own recovery as othersin the group improve (Buchele, 1993 There are advantages and disadvantages to every treatment method,and it is the responsibility of the therapist to explore feasible options and empower clients in theirrecovery.

Research and Conclusions

Current researchResearch trends currently focus on neurobiological and psychobiological factors unique to this disorder.For example, one study investigated the differences between alters who have access to traumaticmemories and alters who suppress such information. The results indicate that different alters demonstrate



differences in emotional, sensori-motor, cardiovascular, and regional cerebral blood flow in response totraumatic memories (Reinders, et al., 2006).

Another study sought to apply known findings about related disorders to DID. Because individualsdiagnosed with disorders involving an etiology of stress (e.g., Post-Traumatic Sstress Disorder,Borderline Personality Disorder, Major Depressive Disorder with childhood trauma) have demonstrated areduction in hippocampal volume, the authors of this study used magnetic resonance imaging andvolumetric analyses to determine if any relationship also existed between DID and reduced hippocampalvolume. Results indicated that the volume of the hippocampus of participants with DID was 19.2%smaller and the amygdala was 31.6% smaller than normal controls (Vermetten, Schmahl, Lindner,Loewenstein, & Bremner, 2006).

Other studies have discovered findings that are relevant to the relationship between trauma and memoryin DID. A case study investigating the neural correlates of switching between alters used functionalmagnetic resonance imaging to study changes in the brain during switching. The results indicated thatduring switching to the alternate personality, the client’s bilateral hippocampus was inhibited, as well asthe right parahippocampal gyrus, right medial temporal lobe, globus pallidus, and substantia nigra.However, during transition to the host personality, the right hippocampus demonstrated evidence ofincreased activation, with no inhibition in any brain structures (Tsai, Condi, Wu, & Chang, 1999). Thesefindings contribute to an understanding of amnesia between alters, since regions of the brain involved inmemory are either inhibited or activated.

Other research supports the idea that alters develop to protect the host from unpleasant thoughts andmemories involving trauma and abuse. Autobiographical memories may differ between alterpersonalities, allowing the host to retain positive memories while alters contain negative traumaticmemories (Bryant, 2005). A study investigating directed forgetting found that “dissociative patientsshowed directed forgetting between states, but not within the same identity state” (p. 241). This studyclarifies the mechanism and function of memory in various dissociative states and helps explain whytrauma might result in the development of alters. Pushing threatening material out of consciousness canthen be facilitated by a switch from one state of consciousness to another (Elzinga, Phaf, Ardon, & vanDyck, 2003).

Future directionWhile clinicians now understand more about DID than in the past, additional research is needed to clarifyand further investigate the nature of DID. The research that has been completed on this disorder stillleaves many questions unanswered. For example, future research should further examine risk factors, andclarify how genetic and environmental factors contribute to this disorder. More studies should determinethe nature of the physical and psychological differences evident among alters, how they develop, andtheir significance. Psychopharmacological studies are needed to determine which medications work best,and why they are effective.

Multicultural research is necessary to determine how sociocultural factors affect the development andclinical presentation of DID. Additional research in this area will not only benefit individuals with DIDand their families, but also the research and clinical psychology community as a whole. Gaining animproved understanding of Dissociative Identity Disorder involves more than the categorization ofanother mental disorder. Increased knowledge in this area also contributes to an improved understandingof the nature of consciousness and the mind-brain relationship, as well.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (text



revision). Washington, DC: Author.

Ballew, L., Morgan, Y., & Lippmann, S. (2003). Intravenous diazepam for dissociative disorder:Memory lost and found. Psychosomatics, 44, 346-347.

Becker-Blease,K., Deater-Deckard, K., Thalia Eley, E., Freyd, J., Stevenson, J., & Plomin, R. (2004). Agenetic analysis of individual differences in dissociative behaviors in childhood and adolescence. Journalof Child Psychology and Psychiatry 45(3), 522–532.

Brand, R., Classen, C., Lanius, R., Loewenstein, R., McNary, S., Pain, C., & Putnam, F. (2009). Anaturalistic study of Dissociative Identity Disorder and Dissociative Disorder NotOtherwise Specifiedpatients treated by community clinicians.Psychological Trauma: Theory, Research, Practice, and Policy,1(2)153–171.

Bryant, R. (2005). Autobiographical memories across personalities in Dissociative Identity Disorder: Acase report. Journal of Abnormal Psychology, 104(4), 625-631.

Buchele, B. (1993). Group psychotherapy for persons with multiple personality and dissociativedisorders. Bulletin of the Menninger Clinic, 57(3), 362.

Cormier, J., & Thelen, M. (1998). Professional skepticism of Multiple Personality Disorder. ProfessionalPsychology: Research and Practice 29(2), 163-167.

Elzinga, B., Phaf, R., Ardon, A., & van Dyck, R. (2003). Directed forgetting between, but not within,dissociative personality states. Journal of Abnormal Psychology, 112(2), 237–243.

Fujii, Y., Suzuki, K., Sato, T., Muraka, Y., & Takahashi, T. (1998). Multiple Personality Disorder inJapan. Psychiatry and Clinical Neurosciences, 52, 299-302.

Gleaves, D., May, M., & Cardena, E. (2001). An examination of the diagnostic validity of dissociativeidentity disorder. Clinical Psychological Review, 21(4), 577-608.

International Society for the Study of Dissociation. (2005). [Chu, J., Loewenstein, R., Dell, P., Barach,P., Somer, E., Kluft, R., Gelinas, D., Van der Hart, O., Dalenberg, C., Nijenhuis, E., Bowman, E., Boon,S., Goodwin, J., Jacobson, M., Ross, C., Sar, V., Fine, C., Frankel, A., Coons, P., Courtois, C., Gold, S.,& Howell, E.]. Guidelines for treating Dissociative Identity Disorder in adults. Journal of Trauma &Dissociation, 6(4) pp. 69-149.

Kaplan, B., & Sadock, V. (2008). Kaplan and Sadock’s concise textbook of clinical psychiatry.Philadelphia, PA: Lippincott Williams & Wilkins.

Korol, S. (2008). Familial and Social Support as Protective Factors Against the Development ofDissociative Identity Disorder [Abstract].Journal of Trauma & Dissociation, 9(2), 249- 267.

Lewis-Hall, F., Williams, T., Panetta, J., & Herrera, J. (2002). Psychiatric illnesses in women: Emergingtreatments and research. Washington, DC: American Psychiatric Publishing.

Maldonado, J. R., Butler, L. D., & Spiegel, D. (2002). Treatments for dissociative disorders. In A Guideto Treatments That Work (2nd Ed.). New York: Oxford University Press.

Okugawa, G., Nobuhara, K., Kitashiro, M., Kinoshita, T. (2005). Perospirone for treatment ofDissociative Identity Disorder. Psychiatry and Clinical Neurosciences, 59, 624.



Pasquini, P., Liotti, G., Mazzotti, E., Fassone, G., Picardi, A., & The Italian Group forthe Study ofDissociation. (2002). Risk factors in the early family life of patients suffering from dissociative disorders.Acta Psychiatrica Scandinavica, 105, 110-116.

Reinders,A., Nijenhuis, E., Quak, J., Korf, J., Haaksma, J., Paans, A., Willemsen, A., & den Boer, J.(2006). PsychobiologicalcharacteristicsofDissociativeIdentityDisorder:A symptomprovocationstudy[Abstract]. Biological Psychiatry, 60(7), 730-740.

Rubin, E., & Zorumski, R. (Eds.). (2005). Adult psychiatry (2nd ed). Malden, MA: Blackwell Publishing.

Sno, H., & Schalken, H. (1999). Dissociative identity disorder: diagnosis and treatment in theNetherlands [Abstract]. European Psychiatry, 14(5), 270-277.

Tsai, G., Condie, D., Wu, M. T., & Chang, I. W. (1999). Functional magnetic resonance imaging ofpersonality switches in a woman with Dissociative Identity Disorder. Harvard Review of Psychiatry, 7,199-122.

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

Waller, N., & Ross, C. (1997).The prevalence and biometric structure of pathological dissociation in thegeneral population: Taxometric and behavior genetic findings. Journal of Abnormal Psychology, 106(4),499-510.

Xiao, Z., Yan, H., Wang, Z., Zou, Z., Xu, Y., Chen, J., Zhang, H., Ross, C., & Keyes, B. (2006). Traumaand dissociation in China. American Journal of Psychiatry, 163(8), 1388-1391.

Documents

Slogar, Sue-Mei - Dissociative Identity Disorder - Overview and Current Research