Dissociative Identity Disorder

Australasian Psychiatry 2016, Vol 24(1) 39 –41

© The Royal Australian and New Zealand College of Psychiatrists 2015

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DOI: 10.1177/1039856215604481 apy.sagepub.com

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AustrAlAsiAn Psychiatry

T he diagnosis of dissociative identity disorder (DID) is included in both DSM 5 and ICD 10. Content, criterion and construct validity for the

disorder are well established.1 It is not uncommon, with a community prevalence of between 0.4% and 1.1%. In clinical populations around 10% have dissociative dis- orders, of whom about half have DID.2 People with DID vary from high functioning professionals to severely impaired individuals. Diagnosis is often delayed for years because of complex presentations and lack of awareness and scepticism about the diagnosis.3 Despite a strong research base and evidence for brain changes associated with DID,1 the existence of the disorder is questioned by some psychiatrists. Some believe that people presenting with DID are invariably malingerers or that the disorder is an iatrogenic chimera induced by therapy,4,5 a view contradicted by other findings.6 Consequently, many people with DID present repeat- edly to treatment services without being diagnosed, have many costly and unnecessary investigations and unproductive treatment episodes and are at risk of self- harm and suicide.7 Outcomes can improve with diag- nosis and targeted treatment.1,8

Problems in diagnosis and management Lack of awareness and understanding about dissociative disorders

While there are a number of theories about the aetiology of the disorder, DID almost always arises on a back- ground of severe childhood trauma,6 a common prob- lem as the current Royal Commission into institutional abuse of children has shown.

The following model is useful for understanding most presentations. While in adults trauma often results in the familiar symptoms of PTSD, in children the trauma of child abuse often results in a profound disruption of the developing personality. Dissociation creates a number of separate identity states reflecting the time and the devel- opmental stage at which the trauma was experienced.

Dissociative identity disorder (DID) in clinical practice – what you don’t see may hurt you

David Leonard Psychiatrist, Albert Road Clinic, Melbourne, VIC, Australia John Tiller Emeritus Professor of Psychiatry, The University of Melbourne, Albert Road Clinic, Melbourne, VIC, Australia

Abstract Objectives: To identify problems that interfere with the recognition, diagnosis and management of people with dis- sociative identity disorder (DID) presenting to psychiatric outpatient and inpatient services and suggest solutions. Method: Problems and suggested solutions associated with clinical presentations and management of people with DID are outlined with references to relevant literature. Results: Problems in the recognition and management of DID are described. These lead to delays in diagnosis and costly, inappropriate management, destructive to services, staff and patients alike. Problems include lack of under- standing and experience and scepticism about the disorder, resulting in failure to provide appropriate treatment. Some suggestions to improve recognition and management are included. Conclusion: Better recognition, diagnosis and management of DID will lead to better and more cost effective outcomes.

Keywords: dissociative identity disorder, recognition, management

Corresponding author: David Leonard, Albert Road Clinic, 31 Albert Road, Melbourne, VIC 3004, Australia. Email: [email protected]

604481APY0010.1177/1039856215604481Australasian PsychiatryLeonard and Tiller research-article2015

Psychotherapy

Australasian Psychiatry 24(1)

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They may be termed ‘alter states’, i.e. alternative identity states. Each alter state has variable contact with the cur- rent time and place and variable awareness of other alter states. Although the distinction is not complete, these identity states may be divided into ‘apparently normal personalities’ and ‘emotional personalities’.9

Apparently normal personality alter states are largely cut off from trauma memories, are reasonably oriented and are often quite functional, e.g. working and acting as effective parents, partners and friends. They are often amnesic about memories of trauma and unaware of other alter states.

Emotional personality alter states are far less functional, are fixated on traumatic events and remain locked into the time of the trauma. They are constantly reliving epi- sodes of past trauma and re-experiencing such emotions as terror, impotent rage, self-hatred or despair.

Dissociation, by sequestering trauma memories, allows apparently normal personalities to function in the world.

Rejection by treatment services

When people with DID switch from one identity state to another, they are often disorientated and may present with complex, puzzling, dramatic pictures which cause diagnostic confusion. They may alienate treatment ser- vices with challenging and self-destructive behaviours and provoke antagonism and rejection.

Clinical example

All clinical cases discussed are actual cases presented with their consent.

A 25 year old woman suddenly becomes aware of her surroundings. There are police around her with drawn guns shouting at her to ‘drop the weapon’. She doesn’t know she is holding a weapon, or where she is, or how she got there. She is holding a blood-stained knife and bleeding profusely from a number of self-inflicted wounds. When she is taken to an emergency depart- ment she is not believed by the emergency personnel or psychiatric services when she says she has no memory of what happened. Her wounds sutured, she is scolded and sent on her way. Similar outcomes have accompanied her many similar episodes over the previous 10 years. When her dissociation was eventually recognised, she was able to talk of an ‘evil part’, a despairing teenage alter, taking over and trying to get herself killed. Her story of a lifetime of incestuous abuse was believed only when her father was arrested and convicted to a long jail term for other child sex offences. The episodes and asso- ciated self-harm ended with appropriate treatment.

Confusion about diagnosis

Most people with DID are mistrustful of others, embar- rassed, bewildered and secretive about their symptoms

and indeed may not be aware of many of their behav- iours. This creates diagnostic difficulties. Clues to diagnosis include atypical presentations, extensive co-morbidity, severity, chronicity and a history of poor response to treatment. A trauma history is almost always present but sometimes not easily obtained.3 The Dissociative Experiences Scale10 provides a useful list of probing questions to help elicit dissociative symptoms.

People with DID may be misdiagnosed with schizophre- nia due to perplexing, usually distressing, hallucinatory experiences affecting more than one sensory modality, perceived both in internal and external space.

People with DID may be co-morbid with borderline per- sonality disorder. Both disorders share some features, including a trauma background. DID may be differenti- ated by the presence of the key symptoms of identity confusion, identity alteration and amnesia.

People with DID are commonly diagnosed with a co-morbid disorder while the underlying diagnosis of DID is missed. As well as borderline personality disorder other common co-morbid conditions include depres- sion, eating disorders, substance abuse and obsessive compulsive disorders.3 Somatic symptoms from dissoci- ated trauma memories may suggest physical illnesses.

People presenting with symptoms of DID may be malin- gerers or have factitious or iatrogenic disorders. How fre- quently this is the case is not known, though in the authors’ experience it is uncommon. People will of course find it difficult to tell their stories to people who think they are malingerers. In turn, it will be difficult for the professional who believes people with DID symp- toms are malingerers to ever make a diagnosis of DID.

Clinical example

A 40 year old woman with a 15 year history of repeated admissions for severe depression and/or psychosis was admitted with an episode of profound depression asso- ciated with auditory hallucinations urging her to kill herself. Each morning she awoke in hospital with blood stained sheets and messages scratched on her arms say- ing such things as ‘slut’ or ‘die’. She was amnesic about having inflicted these injuries on herself. A history of prolonged, organised sadistic abuse from early child- hood to her teens was obtained. The scratched messages and the hallucinations were the work of alters and stopped with the diagnosis of DID and appropriate treatment.

Treatment and challenges

The main treatment for DID is individual, outpatient psychotherapy. Treatment guidelines11 recommend a three-phase approach: firstly achieving stability; sec- ondly working with the trauma and its consequences and finally working towards integration. People with

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DID may sometimes need admission for intensive, indi- vidual, focused psychotherapy available in only a small number of units. On the other hand, people with DID may be admitted, for many reasons both diagnosed and undiagnosed, to any psychiatric hospital. If diagnosed, they are more likely to receive appropriate treatment and referral even if psychotherapy is not available. Our experience treating such patients in Albert Road Clinic over the last 15 years informs the following observations and recommendations.

Providing a safe and therapeutic environment for DID inpatients poses special problems. They may cause con- fusion by shifting from one alter state to another, in turns appearing confident or frightened, friendly or sus- picious and hostile, competent or vague and disorien- tated. Voices or accents may change. They may act in regressed ways, e.g. playing with dolls or doing childish drawings. They may wander in fugue states and put themselves in danger.

Self-care, nutrition and physical health may be neglected. Insomnia is common as they associate nights with times of abuse. It is helpful if they can lock their rooms and are not awoken abruptly etc.

They are usually in chronically over-aroused states which may dramatically worsen as switches into alter states are triggered and they relive trauma episodes. The triggers are very individual and include the accident of someone’s appearance and anniversaries of times when they were regularly abused.

People with DID may appear to be dishonest. While in alter states they may do things which later they don’t remember. One inpatient brought a knife, secreted by an alter, onto the ward and was puzzled when it was found on her person. Staff thought she was being deliberately deceptive.

Ongoing abuse

Incestuous abuse12 and that of organised groups13 can continue well into adult life, even into middle age. We have found it important to recognise this possibility as patients may need protection from further abuse occur- ring while they are under our care

Needs of staff

Reactions of staff range from disbelief and rejection to fascination and over involvement. The trauma histories

of DID patients may provoke vicarious traumatisation in staff who may become exhausted, frustrated and nihilis- tic and who therefore may need support. Many have lit- tle knowledge and experience of DID, so education to improve recognition and management of people with DID is particularly important.

Summary

DID is not uncommon in clinical presentations to psy- chiatric services but is often overlooked or misdiagnosed due to lack of awareness of the disorder. This results in much inappropriate, ineffective and expensive treat- ment, disruption of services and increased risk, while implementing effective intervention benefits patients, services and the community.

Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

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