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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 (Sar V, Tutkun H, Alyanak B, Bakim B, Baral IM: Frequency of dissociative disorders among psychiatric outpatients in Turkey. Compr Psychiatry 2000; 41:216–222)


 * 6% of poor inner-city, hospital-based psychiatric outpatients were diagnosed as having DID


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

88.6% of the [DID] patients were women


 * The [DID] 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 (BPD) criteria, and 4.1 extrasensory experiences.


 * Similarly, all of the DID subjects in the Vermetten et al. study also met diagnostic criteria for PTSD.


 * Participants with a DD had BPD, somatization disorder, major depression, PTSD, and history of suicide attempt more frequently than did participants without a DD.


 * A majority of them had comorbid major depression, somatization disorder, and BPD. Most of the patients with DD reported auditory hallucinations, symptoms associated with psychogenic amnesia, flashback experiences, and childhood abuse and/or neglect.


 * 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.

Childhood sexual abuse, physical neglect, and emotional abuse were significant predictors of a DD diagnosis. Only 28.7% of the dissociative participants had received psychiatric treatment previously. Because DDs are trauma-related, significant part of the adult clinical consequences of childhood trauma remains obscure in the minds of mental health professionals and of the overall community. Childhood physical or sexual abuse was reported by 77.1% of the [DID] patients.


 * Our findings add to the growing amount of data concerning both the association between childhood trauma [or childhood physical or sexual abuse] and adult dissociative psychopathology.


 * Logistic regression analysis indicated that the patients who met the criteria for a DD diagnosis were much more likely to have reported childhood physical or sexual abuse (odds ratio=5.86, 95% CI=2.06–16.67, p<0.001 / odds ratio=7.88, 95% CI=2.65–23.39, p<0.001)


 * The histories of the patients who met the DD criteria were also marked by significantly more prolonged and more severe childhood physical or sexual abuse, compared with the patients who did not meet the DD criteria.

Finally, this study focused solely on specific acts of childhood physical abuse and sexual abuse; we did not measure other childhood trauma, such as emotional abuse or neglect, or adult traumatic experiences, which have been shown to influence adult psychiatric and dissociative symptoms (Herman JL, Perry JC, van der Kolk BA: Childhood trauma in borderline personality disorder. Am J Psychiatry 1989; 146:490–495) (Briere J, Runtz M: Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl 1990; 14:357–364) (Lipschitz DS, Winegar RK, Nicolaou AL, Hartnick E, Wolfson M, Southwick SM: Perceived abuse and neglect as risk factors for suicidal behavior in adolescent inpatients. J Nerv Ment Dis 1999; 187:32–39) (Simeon D, Guralnik O, Schmeidler J, Sirof B, Knutelska M: The role of childhood interpersonal trauma in depersonalization disorder. Am J Psychiatry 2001; 158:1027–1033).


 * Memory processing depends on the creation of associations (...) storage, and retrieval. (...) Traumatic [or childhood physical or sexual abuse] experiences (...) can create, especially in children, [discontinuities and] [contradictory memory encoding and storage]. (...) Processing traumatic (...) [or childhood physical or sexual abuse] [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).


 * DID patients function as two or more identities or DIS, categorized as ‘neutral identity states’ (NIS) and ‘traumatic identity states’ (TIS). NIS inhibit access to traumatic memories thereby enabling daily life functioning. TIS have access and responses to these memories. We tested whether these DIS show different psychobiological reactions to trauma-related memory.

DID 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 [adjust to expectations] ward off further anticipated abuse. Thus, they will tend to hide rather than reveal their [conscious] symptoms, expecting (and often experiencing) disbelief when their [unconscious] 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.

Do clinicians "remember" to make the diagnosis when it occurs? (...) In another study featured in this issue, Foote and colleagues... This is a surprisingly high figure, and it suggests that DDs may be underdiagnosed and undertreated. Indeed, only 5% of this group had previously been correctly diagnosed. As the authors note, there is no definitive psychopharmacological treatment for these disorders, and some 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. Furthermore, Foote and colleagues provide more evidence linking both physical and sexual abuse to dissociative symptoms, with odds ratios of 5.86 for physical abuse and 7.87 for sexual abuse. Similarly, all of the DID subjects in the Vermetten et al. study also met diagnostic criteria for PTSD. These strong but not absolute associations between trauma and dissociation suggest that a stress-diathesis model linking traumatic experience with vulnerability to dissociation may account for an even greater amount of the psychopathology associated with traumatic dissociation (Butler LD, Duran REF, Jasiukaitus P, Koopman C, Spiegel D: Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology. Am J Psychiatry 1996; 153(July suppl):42-63). DD were highly prevalent in this clinical population and typically had not been previously diagnosed clinically. (...) These results confirmed both the high prevalence and the extensive underdiagnosis of DDs in an outpatient psychiatric population. The 29% prevalence of DDs in this population was surprisingly high, Why, then, do DD continue to remain underdiagnosed, undertreated, and, frankly, insufficiently respected?


 * Chart review revealed that only 5% [of] patients in whom a DD was identified during the study had previously received a DD diagnosis.


 * Only 28.7% of the dissociative participants had received psychiatric treatment previously.

Several epidemiological studies over the past 15 years have shown that DD may have been previously underdiagnosed and that with proper screening and diagnostic instrumentation, a much higher prevalence is encountered. (...) In most of these studies, a DD had been correctly diagnosed in only a small percentage of the patients before their inclusion in the study. Given that the population receiving outpatient psychiatric treatment is much larger than the psychiatric inpatient population, it is plausible that many patients with dissociative pathological features are receiving outpatient treatment without the benefit of a correct diagnosis. (...) Their data indicated that a substantial number of patients with DDs would have been missed if the DES screening method had been used. (Latz TT, Kramer SI, Hughes DL: Multiple personality disorder among female inpatients in a state hospital. Am J Psychiatry 1995; 152:1343–1348)


 * because most other comorbid conditions are treated pharmacologically, the dissociative symptoms of patients with undiagnosed DDs (...) may be masked (...) by the medications given, while ending the search for other [DD] treatment.


 * treatments, such as antipsychotics, may worsen rather than improve symptoms by reducing cognitive control, increasing depersonalization, and blunting affective response


 * no definitive pharmacological treatments are available for DDs

Patients with DDs are notoriously difficult to treat; this difficulty is of course greatly amplified when the condition goes undiagnosed. (...) This study, like many others, highlights the importance of developing better methods of screening for these disorders, with the hope of delivering more effective and better targeted care.

The high prevalence of DD 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)


 * 1) [Dissociative Disorders Interview Schedule (DDIS)]
 * 2) * The DDIS is a 131-item structured interview used to assess DSM-IV diagnoses of somatization disorder, major depression, BPD, alcohol and drug abuse, and the five DSM-IV dissociative disorders. (Ross CA, Heber S, Norton GR, Anderson D, Anderson G, Barchet P: The Dissociative Disorders Interview Schedule: a structured interview. Dissociation 1989; 2:169–189)
 * 3) * It is also used to inquire about a wide range of other experiences, including trauma history, and about features thought to be associated with DID, such as Schneiderian symptoms.
 * 4) * It has been found to have good interrater reliability (kappa=0.68) and a false positive rate of less than 1% for the diagnosis of DID. With our population, we repeatedly had the impression that the DDIS questions (in which the DSM-IV diagnostic criteria are essentially incorporated verbatim) were poorly understood by our patients. To compensate for possible misunderstanding, we first asked each DDIS question exactly as worded, and then if the interviewer felt the patient might not have understood the question, the interviewer was permitted to ask the question again, with explanations as necessary. This procedure yielded two diagnostic impressions: a strict DDIS rating and a clinical impression. If either diagnostic impression was negative, the diagnosis was scored as negative.
 * 5) * Latz et al. (...) administered a structured interview for DD (the DDIS, described in the Method section) to every patient in their study and found that the Dissociative Experiences Scale (DES) scores of the patients who were found to have a DD according to the interview overlapped extensively with the DES scores of the patients without a DD diagnosis according to the interview. Their data indicated that a substantial number of patients with DDs would have been missed if the DES screening method had been used. (Latz TT, Kramer SI, Hughes DL: Multiple personality disorder among female inpatients in a state hospital. Am J Psychiatry 1995; 152:1343–1348)
 * 6) Structured Clinical Interview for DSM–IV Dissociative Disorders–Revised (SCID–D–R)
 * 7) * In addition, although we tried to improve on the diagnostic accuracy of the structured interview by giving the interviewer the option to ask clarifying questions after finishing the structured interview, this method is still not the same as the commonly accepted "gold standard" for ascertainment of a dissociative diagnosis, which is the administration of a structured interview (DDIS or SCID-D-R) followed by an open-ended clinical interview administered by an experienced diagnostician with expertise in DDs. A clinician using the most conservative diagnostic standard would need to witness alter personality states in the interview before making a definitive diagnosis of DID.
 * 8) [Traumatic Experiences Questionnaire (TEQ)]
 * 9) * The TEQ is a 49-item self-report measure used for assessing detailed, specific experiences in four domains: childhood physical abuse, childhood sexual abuse, witnessing of domestic violence, and adult retraumatization. (Kaplan ML, Asnis GM, Lipschitz DS, Chorney P: Suicidal behavior and abuse in psychiatric outpatients. Compr Psychiatry 1995; 36:229–235) (...)
 * 10) * For childhood physical abuse, the mean TEQ score of the patients who met the DD criteria was 5.1 (SD=3.3), compared to 2.8 (SD=2.9) for those who did not meet the criteria (t=15.22, df=80, p<0.001).
 * 11) * For childhood sexual abuse, the mean TEQ score of the patients who met the DD criteria was 3.7 (SD=4.0), compared with 1.0 (SD=2.1) for those who did not meet the criteria (t=9.88, df=80, p<0.002) . (...)
 * 12) * Also, in the assessment of trauma history, it should be noted that self-report of past traumatic experiences is subject to distortion and misremembering.
 * 13) * Finally, this study focused solely on specific acts of childhood physical abuse and sexual abuse; we did not measure other childhood trauma, such as emotional abuse or neglect, or adult traumatic experiences, which have been shown to influence adult psychiatric and dissociative symptoms (Herman JL, Perry JC, van der Kolk BA: Childhood trauma in borderline personality disorder. Am J Psychiatry 1989; 146:490–495) (Briere J, Runtz M: Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl 1990; 14:357–364) (Lipschitz DS, Winegar RK, Nicolaou AL, Hartnick E, Wolfson M, Southwick SM: Perceived abuse and neglect as risk factors for suicidal behavior in adolescent inpatients. J Nerv Ment Dis 1999; 187:32–39) (Simeon D, Guralnik O, Schmeidler J, Sirof B, Knutelska M: The role of childhood interpersonal trauma in depersonalization disorder. Am J Psychiatry 2001; 158:1027–1033)
 * 14) [Multidimensional Inventory of Dissociation (MID)]
 * 15) * The MID is a 218-item, self-administered, multiscale instrument that comprehensively assesses the phenomenological domain of pathological dissociation and diagnoses the DD.
 * 16) * 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 (...)
 * 17) * The MID demonstrated internal reliability, temporal stability, convergent validity, discriminant validity, and construct validity.
 * 18) * The MID also exhibited incremental validity over the DES by predicting an additional 18% of the variance in weighted abuse scores on the TEQ . (...)
 * 19) * Confirmatory factor analysis (CFA) of the MID's factor scales (Dell & Lawson, 2005) has strongly supported a one-factor model . (...)
 * 20) * both the MID's 168 dissociation items and the construct of pathological dissociation have a second-order, unifactorial structure.
 * 21) [Symptom Checklist–90 (SCL–90)]
 * 22) * Patients with DID reported significantly higher SCL–90 Global Severity Index (GSI) and individual subscale scores than those without DD. 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.
 * 23) [Dissociative Experiences Scale (DES)]
 * 24) * The DES is a widely used 28-item self-report measure for assessment of specific dissociative experiences . (Bernstein EM, Putnam FW: Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986; 174:727–735) (Carlson EB, Putnam FW: An update on the dissociative experiences scale. Dissociation 1993; 6:16–27) (...)
 * 25) * Specifically, if we had used a (...) [DES 30 as a cutoff, 46%] of the positive diagnoses we identified would have been missed (...) of the DD diagnoses (and a DES 20 as a cutoff would have been missed 25%).
 * 26) * The mean [DID] DES score was 49.1.
 * 27) * The subjects with DID and DID not otherwise specified in this study did not have significantly higher DES scores than the subjects with dissociative amnesia and depersonalization.


 * There are no quick fixes, although many patients do respond to long-term psychotherapy (...) to fragmented elements of her identity, working through traumatic [or childhood physical or sexual abuse] 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 DD in the DSM-IV are recommended.

Dissociative Disorder (DD)
Of these patients, 82 completed the DDIS. These 82 patients were compared with the 149 noncompleters (...) The overall group of 231 (...) [poor inner-city, hospital-based outpatient psychiatric] population (...) subjects
 * 1) The overall group of 231 subjects had a 59% prevalence of self-reported childhood physical abuse (N=103 of 175)
 * 2) * By our presumably most accurate trauma assessment measure—the face-to-face interview—this population had a prevalence of childhood physical abuse of 40%
 * 3) The overall group of 231 subjects had a (...) 34% prevalence of self-reported childhood sexual abuse (N=58 of 168).
 * 4) * By our presumably most accurate trauma assessment measure—the face-to-face interview—this population had a prevalence of (...) childhood sexual abuse of 42%