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2007 Q3

Changing the name of multiple personality disorder to dissociative identity disorder [was] to place the correct emphasis on the failure to integrate aspects of identity, memory, and consciousness rather than the apparent proliferation of "personalities." Indeed, the problem is not having more than one personality, it is having less than one.

In studies published since 2006


 * 1.1% of women in the general population were diagnosed as having DID


 * 4% of psychiatric outpatients were diagnosed as having DID


 * 6% of inner-city psychiatric outpatients were diagnosed as having DID


 * 14% of emergency psychiatric admissions were diagnosed as having DID.

88.6% of the patients were women (...) Childhood physical or sexual abuse was reported by 77.1% of the patients. The mean Dissociative Experiences Scale (DES) score was 49.1. The patients reported an average of 12.5 somatic symptoms, 6.2 Schneiderian symptoms, 10.0 secondary features of the disorder, 3.8 borderline personality disorder criteria, and 4.1 extrasensory experiences. Similarly, all of the dissociative identity disorder subjects in the Vermetten et al. study also met diagnostic criteria for PTSD.

Memory processing depends on the creation of associations (...) storage, and retrieval. (...) Traumatic experiences (...) can create, especially in children, [discontinuities and] [contradictory memory encoding and storage]. Processing traumatic (...) [conflicting] starkly different associations regarding experience, implications for the self, and emotional arousal—would be difficult under the best of circumstances. Just as in depression information is selectively retrieved (...) selective networks (/patterns) of association (/information) (...) preclude a more balanced view of the world (sometimes dangerous, sometimes safe) or of the self (good versus deserving of punishment).


 * 1) Dissociative identity states (DIS) have different psychobiological differences
 * 2) * regional cerebral blood flow data revealed different neural networks to be associated with different processing
 * 3) * psychobiological parameters tested were cardiovascular responses (heart rate, blood pressure, heart rate variability) and regional cerebral blood flow as determined with H215O positron emission tomography.
 * 4) [There is] a distinct pattern of hypothalamic-pituitary-adrenal (HPA)-axis dysregulation in dissociative disorders (DDs) (...) [Collecting] urine (...) and (...) blood sampling (...)
 * 5) * The DD group had significantly elevated urinary cortisol compared with the healthy comparison (HC) group (...)
 * 6) * The DD group demonstrated significantly greater resistance to, and faster escape from, dexamethasone suppression (...)
 * 7) * The psychiatric groups demonstrated a significant inverse correlation between dissociation severity and cortisol reactivity.

Dissociative disorders were highly prevalent in this clinical population and typically had not been previously diagnosed clinically. Why, then, do dissociative disorders continue to remain underdiagnosed, undertreated, and, frankly, insufficiently respected?
 * Chart review revealed that only four (5%) patients in whom a dissociative disorder was identified during the study had previously received a dissociative disorder diagnosis.
 * Only 28.7% of the dissociative participants had received psychiatric treatment previously.

Dissociative identity disorder has been called a "disease of hiddenness" (Kluft RP: Current issues in dissociative identity disorder. J Psych Pract 1999; 5:3–19). Patients try to put on a good appearance despite chaotic internal lives, in part to try to get by, in part to ward off further anticipated abuse. Thus, they will tend to hide rather than reveal their symptoms, expecting (and often experiencing) disbelief when their symptoms do emerge. Furthermore, sexual and physical abuse and its aftermath are disturbing; they arouse strong affect in observers as well as survivors, and sometimes necessitate legal action or protection from ongoing threat. The clinician is burdened with applying the integrative understanding to the situation that the patient is incapable of utilizing, which can be taxing.

Individuals with DID, may come to believe they are inhabited by a spirit (...) existence of such entities is mentioned in The Holy Quran, which allows them to be capable of creating such phenomenon themselves.

The high prevalence of dissociative disorders found in this study may be related to methodological factors (all patients were offered an interview rather than only those who had scored high on a screening self-report measure)


 * The Multidimensional Inventory of Dissociation (MID) is a 218-item, self-administered, multiscale instrument that comprehensively assesses the phenomenological domain of pathological dissociation and diagnoses the dissociative disorders. The MID measures 14 major facets of pathological dissociation; it has 23 dissociation diagnostic scales that simultaneously operationalize (1) the subjective/ phenomenological domain of pathological dissociation and (2) the hypothesized dissociative symptoms of DID (...) The MID demonstrated internal reliability, temporal stability, convergent validity, discriminant validity, and construct validity (...) both the MID's 168 dissociation items and the construct of pathological dissociation have a second-order, unifactorial structure.


 * Patients with DID reported significantly higher SCL–90 Global Severity Index (GSI) and individual subscale scores than those without dissociative disorders. It is recommended that patients who are polysymptomatic on the SCL–90 be considered for follow–up dissociative symptom assessment to aid differential diagnosis and to inform subsequent treatment.

treatments, such as antipsychotics, may worsen rather than improve symptoms by reducing cognitive control, increasing depersonalization, and blunting affective response while ending the search for other treatment.


 * There are no quick fixes, although many patients do respond to long-term psychotherapy (...) to fragmented elements of her identity, working through traumatic memories, helping the patient navigate current relationships with family and others, and avoiding further traumatization. The therapist needs to recognize that the patient is fragmented. Efforts to reify each fragment into a "personality" are not helpful.


 * Hypnosis can be useful in teaching patients about the dissociative nature of their symptoms by helping them to gain control over transitions among personality states, with the goal of improving internal communication and integrating disparate aspects of their identity.


 * Researchers in this area should design data collection procedures for maximum flexibility and participant comfort, while maintaining an acceptable level of scientific rigor.


 * Training is essential so that both principal investigators and assistants are able to deal sensitively with trauma survivors.


 * Psychology researchers have a unique ability to be aware of hierarchy and power in the experimental setting, and to consider these issues in order to convey respect for participants.

Revisions in diagnostic criteria of dissociative disorders in the DSM-IV are recommended.