Sunday, 21 October 2007

Dissassociative Identity Disorder

Multiple Personality Disorder /
Dissociative Identity Disorder

DSM-IV locates the symptoms of multiple personality disorder (Failure to remember significant items and events) with other such dissociative conditions; hence multiple personality disorder is now called ‘dissociative identity disorder’ (DID)
(The ‘split’ in schizophrenia refers to the loss of contact with reality.)

In Dissociative Identity Disorder (DID) this integrity of the overall personality is said to break down and one or more independent sub personalities may appear.

Defining DID:
· Disassociation is a disorder in which a disruption ion memory leads to a separation of one part of a person’s identity from another. Disassociative Identity Disorder (DID) occurs when two or more distinct personalities (Referred to as ‘Alters’ or sub personalities’ exist within one person.
· Alters have their own distinct identity, personal history and self image. They often have their own name and age. Two or more of these control the persons behaviour from time to time.

Thigpen & Cleckley (1954; 1957) reported the case of ‘The three cases of Eve’
· Conducted 14 month long case study on the patient including over 100 hours of interviews, hypnosis, and several kinds of psychological tests.
· Chris Sizemoore was Eves real name;
· Wife and mother;
· Quiet and shy;
· Troubled housewife who sought psychotherapy;
· Complained of hearing an imaginary voice and suffered blackouts – did not disturb her;
· Had three distinct personalities – Eve white, eve black & Jane;
· Eve Black was confident and appealing;
· Much later eve claimed that she had 22 different personalities and they assisted in coping with difficulties;
· Multiple personality disorder usually involves average of 15 personalities.
o Each with different appetites, handwriting, skills, IQ and facial expressions and dress codes.
o Persons with DID display two or more personalities, often called ‘;sub personalities’ each with a unique set of behaviours, emotions and thoughts.
§ At any given time, one of the sub personalities dominates the persons consciousness and interactions with other people.

Not everyone believes that DID is a legitimate mental disorder. Some claim that it emerges as a patients response to therapy. Spanos (1994) states this is due to demand characteristics.
Just about all the cases of DID have been in N. USA. Relatively few exist elsewhere.
What is DID?
A cluster of problems that involve changes in a persons memory, sense of identity or consciousness.
Taking on a new identity and wandering from home for a time;

Four major sub-types of disassociate disorders are defined by DSM-IV-TR:
1. Dissociative Amnesia:
· Individuals unable to recall important personal information.
2. Dissociative Fuge:
· Dreamlike altered state of consciousness.
3. DID:
4. Depersonalisation disorder:
· Self perception is altered in a disconcerting way.

Alters (Ego states)
· In order to be diagnosed as suffering DID under current DSM guidelines an individual must have at least two separate modes of internal state and response.
· They should exist separately from one another and in extreme cases not even be aware of the others existence.
· Typically between two and four alters exist. Possibly more, this being not uncommon.
(Davison et al 2004)



Theoretical Explanations of Dissociative Identity Disorder

Psychodynamic Explanations:

· Supporters of the existence of DID claim the ‘alter’ protects the child’s personality from the memory of the trauma.
· Traumatic events could disrupt normal personality functioning and we can develop a means of coping with this potential disruption.
o Therefore our unconscious mind may deploy a defence mechanism.
§ Defends our rational ego from our irrational Id which are often in conflict
§ Painful thoughts and memories about early experiences may disrupt early personality development and therefore defence mechanisms are deployed here too.
§ A child suffering from abuse and neglect may develop another personality (Alter) to escape from the pain suffered by the child with the dominant or host personality.

§ N.B. Many children suffer abuse and neglect but few of them seem to develop DID.

§ Many children suffer abuse and neglect but few of them seem to develop DID.



Process map:

Healthy

Defence Mechanism

Alter(s) Development

Conflict Resolution / Defences fail

DID.

Case Study: Sybil.

1980’s รจ DID sufferer, eager for help
Screened on horizon in 1999 titled ‘Mistaken identity’
Professor Hubert Spiegel – doubts DID is a disorder.
Sybil “Do you want me to be Helen?”
Replies that’s unnecessary but you may if you would like to..
She preferred not to.
Relived experiences as if in another person when recalling them.
Did not display alters.
Overnight DID – a formerly fairly unknown / unheard of illness became more common.
Could this be behavioural reinforcement?

Kluft (1984) supports the role of abuse in DID – finds 97% of cases studied to involve physical or sexual abuse.

However, DID is relatively rare in comparison to known incidence of child abuse.


Behavioural Explanations.
Majority of behaviour is learned through the process of reinforcement where the consequences of something were unpleasant – the process of negative reinforcement, that this becomes reinforced.
Seligman (1971) claims that people may be biologically pre-programmed to react in several way, including exhibiting DID. This challenged behaviourists who only recognise factors in the environment as being able to provide reinforcement.









Psychodynamic model
Behavioural Model
Agree
Early traumas lead to DID
DID relieves otherwise damaging situations

Disagree
DID results from unconscious conflicts
DID reflects the. personality
DID is a learned response
DID reflects behaviour

Socio-cognitive explanations

State dependant learning
Knowledge acquired when in one emotional state is best remembered when in that state again. Memories when feeling sad may cluster into a sub personality, which could be recreated when made to feel sad again.

Self-hypnosis
Argues that children, who are highly suggestible to external influences, escape into a dream world through a form of self hypnosis. There are too many unknowns about what hypnosis is to be convinced by this explanation.
Comer (2004) argues that people with DID are particularly susceptible to hypnosis.
Others suggest that while using hypnosis to treat psychological problems therapists have unwittingly created ‘alters’ that DID sufferers report (Cohen 1995)

Trance like state Vs normal social, attention and cognitive processes in which it is a social role where people carry out their perceived obligations in line with their expectations of that role (Demand characteristics).

Despite these facts Coons (1989) found that most DID patients had not been hypnotized.

DID as a spontaneous ‘iatrogenic’ phenomenon.
Here it is claimed that people seek psychological help for a variety of reasons .
During therapy they start to talk about themselves as if they were someone else – creating another personality. The therapist asks them to elaborate on their behaviour as someone else. – They ere creating another personality. Iatrogenic means ‘created by the treatment – or mistreatment by - itself.’ In short induced unintentionally by therapeutic practice.
Spanos (1994) suggests that DID is created by role play influenced by their therapists goals and expectations
Gleaves (1996) notes that although the disorder occurs in other cultures, it is extremely rare in Europe and Japan leading to some e.g. Mersky (1992) suggesting its merely a ‘North American fad.’




Two explanations are put forward for DID:

The Post Traumatic Model
Sees DID resulting from traumatic early experiences as already described.

The Socio-Cognitive model (SCM)
Claims that DID is largely the result of iatrogenic factors.

Evaluation: DID as a spontaneous or Iatrogenic Disorder

Can iatrogenic factors alone explain DID?:

Gleaves (1996) argues that no disorder can be solely due to Iatrogenic factors.
This may be a common cause of DID but DID can occur spontaneously in their absence.
e.g. occurring in societies where exposure to mental health professionals is minimal.

Scroppo et al. (1998) suggests that people suffering from DID show increased imaginative activity, a reduced ability to integrate mental components, a complex and driven cognitive style and a highly unconventional view of reality.

Lilienfield et al (1999) argues that supporters of SCM do not deny that ‘much of the psychopathological raw material from which DID is sculpted exists prior to professional intervention.’ In short it contributes to DID no more than other social influences.

Shaped during therapy or spontaneous?:

It is recognised that in some instances DID may be feigned in order to avoid responsibility for criminal actions or to attract attention. This throws doubt on the existence of DID.

SCM model enthusiasts do not claim that DID is not a real phenomenon, they do however wonder if the condition’s best described as a response to trauma (PTSD) or as a ‘socially influenced product that unfolds largely in response to the shaping influences of therapeutic practices culturally based scripts and social expectations (Lilenfield et all (1999)

Are the patterns of abnormality consistent between sufferers of DID?
Sceptics maintain that iatrogenesis is one of the main reasons for the reported increase in numbers and believe that DID patients do not really share any underlying causes or psychological processes that one would expect to see in a real mental disorder (Cohen 1995)


In a study of 21 DID and 21 non DID patients Scroppo et al (1998) reported that the DID patients demonstrated fairly consistent patterns of behaviour in a number of different areas and also showed a distinctive and theoretically consistent set of perceptual and cognitive characteristics that clearly differentiated them from the non-DID participants.

Commentary: The increase in reported cases of DID

DID diagnosis have been on the increase for 30 years. This raises the question of whether it is really becoming far more common or whether clinicians are simply diagnosing it more frequently.

Tightening up the DSM.
Turkington & Harris (2001) state early editions of the DSM led to diagnosis of a wide range of abnormal behaviours being classified as DID. Fewer people with problems of identity which previously overlapped with schizophrenia are now classified as having DID. (Comer 1994)

Differences in acceptance of DID between the USA and the UK:
Although rates of reported cases of DID have soared in recent years, the vast majority have been due to diagnosis in the USA
Cohen (1995) in new Scientist describes a population of 1200 American doctors of whom 70% stated they have seen at least 1 case of DID. Only 12% did not believe in the diagnosis. Cohen found the condition contrived. If this is the case the increase may be due to largely due to a different interpretation of the DSM compared to UK clinicians.

The motivation for developing DID.
Mowrer’s View of the ‘Neurotic paradox’ (1948) is relevant here, people without a home, friends, possessions, and hope may feel prison is a refuge or sanctuary with food. Most view it as a punishment. This is the paradox.



References:

Davison et al. (2004) - Typically between two and four alters exist.
Possibly more, this being not uncommon.

Kluft (1984) - Supports the role of abuse in DID – find 97% of
cases studied to involve physical or sexual abuse.

Seligman (1971) - claims that people may be biologically pre-
programmed to react in several way, including exhibiting DID. This challenged behaviourists who only recognise factors in the environment as being able to provide reinforcement.
Comer (2004) - argues that people with DID are particularly
susceptible to hypnosis.

Coons (1989) - found that most DID patients had not been
hypnotized.

Spanos (1994) - suggests that DID is created by role play influenced
by their therapists goals and expectations

Gleaves (1996) - notes that although the disorder occurs in other
cultures, it is extremely rare in Europe and Japan

Mersky (1992) - suggested that DID is merely a ‘North American
fad.’

Gleaves (1996) - argues that no disorder can be solely due to
Iatrogenic factors. This may be a common cause of DID but DID can occur spontaneously in their absence. e.g. occurring in societies where exposure to mental health professionals is minimal.

Scroppo et al. (1998) - Suggests that people suffering from DID show
increased imaginative activity, a reduced ability to integrate mental components, a complex and driven cognitive style and a highly unconventional view of reality.

Lilienfield et al (1999) - argues that supporters of SCM do not deny that
‘much of the psychopathological raw material from which DID is sculpted exists prior to professional intervention.’ In short it contributes to DID no more than other social influences.

Lilenfield et all (1999) - SCM model enthusiasts do not claim that
DID is not a real phenomenon, they do however wonder if the condition’s best described as a response to trauma (PTSD) or as a ‘socially influenced product that unfolds largely in response to the shaping influences of therapeutic practices culturally based scripts and social expectations

Cohen (1995) - Sceptics maintain that iatrogenesis is one of the
main reasons for the reported increase in numbers and believe that DID patients do not really share any underlying causes or psychological processes that one would expect to see in a real mental disorder

Scroppo et al (1998) - In a study of 21 DID and 21 non DID patients
reported that the DID patients demonstrated fairly consistent patterns of behaviour in a number of different areas and also showed a distinctive and theoretically consistent set of perceptual and cognitive characteristics that clearly differentiated them from the non-DID participants.

Turkington & Harris (2001) - state early editions of the DSM led to diagnosis of a
wide range of abnormal behaviours being classified
as DID.

Comer (1994) - Fewer people with problems of identity which
previously overlapped with schizophrenia are now classified as having DID.

Cohen (1995) - In new Scientist describes a population of 1200
American doctors of whom 70% stated they have seen at least 1 case of DID. Only 12% did not believe in the diagnosis. Cohen found the condition contrived. If this is the case the increase may be due to largely due to a different interpretation of the DSM compared to UK clinicians.








Concepts to note:
Define these terms:
· Alters
· Defence mechanism
· Dissociative identity disorder (DID)
· Dissociation
· Iatrogenic
· Multiple personality disorder (MPD)
· Negative reinforcement
· Post-traumatic model (PTM)
· Socio-cognitive model (SCM)
· State-dependent learning


What did they do or say?
· Freud
· Gleaves
· Mersky
· Mowrer
· Seligman
· Skinner
· Spanos
· Thigpen and Cleckley

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