Saturday, October 24, 2015

Analysis of Case Characteristics, Theory and Treatment Plan: A Case Study of Dissociative Identity Disorder

The following is a brief review of the current research concerning etiology, treatment and diagnosis of Dissociative Identity Disorder including brief discussion of the proposed models of development, diagnostic tools available and suggested treatment strategy.   

A Review of the Current Research Concerning Etiology, Treatment and Diagnosis of Dissociative Identity Disorder
Dissociative Identity Disorder, formerly called Multiple Personality Disorder, is a disorder in which the patient suffers from disturbance in normal integrative functions of memory, identity, and consciousness. The DSM-IV-TR (2012) has classified Dissociative Identity Disorder under the following criteria: “The presence of two or more distinct identities or personality states that recurrently take control of the person’s behavior, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self with an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (American Psychological Association, 2012, Butcher, 2009, p.292). This disturbance is “not caused by physiological effects of a substance like blackouts or chaotic behavior during Alcohol Intoxication or a general medical condition like complex partial seizures” (American Psychological Association, 2012; Butcher, 2009, p. 2009). Lastly, in children, these “symptoms are not attributable to imaginary playmates or other fantasy play” (American Psychological Association, 2012).
Current research of Dissociative Identity Disorder has focused on understanding the memory disturbances, clinical features, best treatment and as always proving the etiological validity of the diagnosis. The etiological validity of the diagnosis has been of particular interest to researchers because this diagnosis has historically been discounted as not-real because of a controversy surrounding its pathology. Spano’s (1994) suggested the sociocognitive model of Dissociative Identity Disorder that suggested this disorder is constructed iatrogenically through therapists and maintained by clients who enact social roles. However, most, if not all, of the current research discredits the sociocognitive model of Dissociative Identity Disorder and supports the trauma models which suggests that development of did nearly always occurs in the face of early trauma and childhood abuse (International Society for the Study of Trauma and Dissociation, 2011).  In fact, the data supports the validity of three different trauma models.
The Four Factor Model
The Four Factor Model suggests that the following for factors precede the development of Dissociative Identity Disorder: the child has the capacity for dissociation, the experiences that overwhelm the child’s non-dissociative coping capacity, there is secondary structuring of Dissociative Identity Disorder  in which alternate identities with individualized characteristics such as names, ages, genders; and there is a lack of soothing and restorative experiences rendering the child isolated or abandoned and needing to create ways of managing distress on their own (International Society for the Study of Trauma and Dissociation, 2011).
Structural Dissociation Model
The Structural Dissociation Model of development in Dissociative Identity Disorder supports that this disorder develops as a result of the failure to integrate aspects of personality, including ideas and functions, following traumatizing events. In this model, the whole personality system is first divided into two parts including the “apparently normal part of the personality” dedicated to daily functioning and an “emotional part of the personality” dedicated to defense i.e psychobiological functions of survival in response to life threat, such as fight/flight (International Society for the Study of Trauma and Dissociation, 2011). This theory suggest that chronic traumatization, neglect, and/or child abuse can lead to “secondary structural dissociation and the emergence of additional emotional parts of the personality” (International Society for the Study of Trauma and Dissociation, 2011).
Developmental Model
In the Developmental Model of Dissociative Identity Disorder, this disorder is thought to begin in childhood when early attachment needs are not met, childhood integration does not occur and personalities states do not integrate into one continuously unified personality state (International Society for the Study of Trauma and Dissociation, 2011). Attachment to primary caregivers is biologically programmed need and attachment style is in important factor in childhood development and the development of relationships later in life (Howell, 2011, p.89-104). Healthy attachment occurs when the primary caregiver and the child form a secure bond. A secure bond is form when the caregiver responds to the babies needs in a way that soothes him or her and keeps the baby happy and safe, thus the baby develops a feeling that their caregiver is a secure base which they can leave to explore and then return to when distressed (Howell, 2011, p.89-104). However, when the child forms a bond because this caregiver is the only source of the attachment and the relationship must be preserved, even in the face of abuse, a disorganized attachment is often the result (Howell, 2011, p.89-104).
No one is born with a unified sense of self or personality this is created though linking behavioral and personality states (Simeon, 2008). A sense of a unified identity develops from experience in childhood when behavior states become linked over time and grouped together in sequences that flow effortlessly (Howell, 2011). For proper integration and identity development this linking of behavioral and personality states must occur (Howell, 2011). For this linking to occur, the child must have a secure attachment that responds to the child in such a way that the child begins to create an internal singular representation of themselves (Howell, 2011). In the face of severe ongoing trauma and neglect which is repeated consistently throughout early childhood and other important developmental stages integration or the development of a unified sense of identity is delayed (Howell, 2011).
A child has the natural ability to separate many of their feelings and memories from consciousness (Howell, 2011). This innate ability allows children in the face of abuse to escape to a fantasy world and create alternate states (Howell, 2011). In the face on ongoing neglect and trauma, these alternate states can endure the abuse or neglect while the child maintains attachment. Sadly, if this pattern of abuse and attachment continues through development these dissociated parts (most commonly referred to as alters) can develop a sense of self, accompanied by their own memories, state of consciousness, biophysical characteristics, and manifest their own speech mannerisms, physical behavior, handwriting, somatic manifestations of disease, sense of body, sense of history (Howell, 2013). Commonly terminology to describe alters includes describing them by their function or characteristic, i.e. hosts, children alters, abuser alters, differently gendered alters, animal alters, manager alters, inner-self helpers, protector alter, caretakers alters and abuser alters (Howell, 2011).
Dissociative states are a normal response to trauma and stress found in all humans across all cultures and studies indicate that the etiology models of DID that explain the symptom patterns found in Dissociative Identity Disorder patient that include chronic childhood trauma have validity for the entire human race (Ross & Ness, 2010). Dissociative Identity Disorder differs from simple dissociative states because the dissociated states develop a sense of self and identity and there are dissociative barriers or an amnesic boundary between the fragmented states of self called alters (Dissociative Identity Disorder, 2013). Interestingly, research demonstrates these different alters show variable “visual acuity, medication responses, allergies, plasma glucose levels in diabetic patients, heart rate, blood pressure readings, galvanic skin response, muscle tension, laterality, immune function, electroencephalography and evoked potential patterns, functional magnetic resonance imaging activation, and brain activation and regional blood flow using single photon emission computed tomography and positron emission tomography with switches” (International Society for the Study of Trauma and Dissociation, 2011, p. 121).
While this sounds as though it may appear dramatic in easy to spot this actually contrary to the truth, in fact, less than 6%  of the population with Dissociative Identity Disorder will present so obviously (International Society for the Study of Trauma and Dissociation, 2011).  More likely they will not appear in an over dramatized histrionic presentation that is often presented in the media, instead the person will likely be “intellectualized, obsessive, introversive, with an avoidant and/or self defeating personality profile with co-morbid disorders both dissociative and post-traumatic symptoms, as well as many apparently non-trauma-related issues such as depression, substance abuse, eating disorders and anxiety” (Jewels, 2013). The symptoms displayed can be categorized more accurately in three major groups’ straight forward dissociative symptoms, Schneiderian first-rank symptoms and psychotic-like dissociative symptoms (Dell, 2006). Straight forward dissociative symptoms include “amnesia, voices, conversion, self alteration, derealization, depersonalization, flashbacks, trances, identity confusion and awareness of alters” (Dell, 2006). Schneiderian first-rank symptoms include “voices arguing, voices commenting, thought withdrawal, thought insertion, made impulses, made feelings, and made actions” (Dell, 2006). Lastly, for Psychotic-like dissociative symptoms including both “auditory hallucinations and visual hallucinations” are also commonly reported by these patients (Dell, 2006).
Tragically, the classification of the DSM-IV-TR barely touches many of the important factors associated with making a diagnosis of Dissociative Identity Disorder such as causation and etiology, terminology, functional dynamics, symptomaolgy and most importantly non-observable symptoms such as state dependent amnesia, conversion symptoms, self-alteration, derealization, depersonalization, flashbacks, trances, identity confusion, awareness of alters, voices, thought withdrawal and insertion, made impulses, feelings and actions and non psychotic auditory and visual hallucinations (Dell, 2006). Accurate diagnosis of this disorder can be done with diagnostic tools such as Dissociative Experiences Scale (DES), the Somatoform Dissociation Questionnaire (SDQ-20), and the Structured Clinical Interview for Dissociative Disorders (SCID-D), as well as, through patient self-reports and clinician observation (International Society for the Study of Trauma and Dissociation, 2011). Sadly, despite diagnostic availability often these patients spend 11.9 years seeking treatment before they receive an accurate diagnosis (International Society for the Study of Trauma and Dissociation, 2011). Misdiagnosis for a Dissociative Identity Patient really is tragic because treatment can significantly reduce symptoms and with integration therapy help the patient form a more unified and functioning sense of self.
Treatment that is given with a focus on relieving dissociative symptoms has been shown to be effective in reducing a range of symptoms associated with dissociative disorders including dissociation, depression, posttraumatic stress disorder, distress, and suicidality (Brand, Classen, McNary & Zaveri, 2009). Effective therapy for these patients often includes phase oriented treatment plan starting with phase one establishing safety, stabilization, and symptom reduction (International Society for the Study of Trauma and Dissociation, 2011, p.135). The focus of early treatment is helping the patient understand, accept, and access the alternate identities that play an active role in their current lives will help the patient develop internal cooperation and increase co-consciousness (International Society for the Study of Trauma and Dissociation, 2011, p.139). In phase two, the therapeutic focus is on confronting, working through, and integrating traumatic memories (International Society for the Study of Trauma and Dissociation, 2011, p.135) The later stages of therapy are focused on identity integration and rehabilitation (International Society for the Study of Trauma and Dissociation, 2011, p.135).
Dissociative identity disorder has been closely linked to early childhood abuse, trauma memories and disorganized attachment patterns that delay the normal process of normal personality development and memory integration in early childhood. Dissociative Identity Disorder is a challenging mental health disorder to recognize and treat because of multiple causative factors and confusing symptomaolgy. It is important for those are working in the field to be aware of the etiology of Dissociative Identity Disorder, the symptoms and presenting presentation, current diagnostic tools, terminology, and treatment for this disorder because this disorder is often misdiagnosed or left undiagnosed and untreated. Treatment of this disorder mainly consists of psychotherapy geared at relieving dissociative symptoms and the integration of dissociated memories and personality states. This treatment is unique to this group of patients and medication alone will not relieve the dissociative symptoms, which is why an accurate diagnosis is vital to symptom reduction and treatment.   

American Psychiatric Association (2000-06). Diagnostic and Statistical Manual of Mental Disorders-IV (Text Revision). Arlington, VA, USA: American Psychiatric Publishing, Inc. pp. 526–529. ISBN 978-0-89042-024-9. Retrieved from DOI:10.1176/appi.books.9780890423349.
Brand, Classen, McNary, Zaveri. (2009) A Review of Dissociative Disorders Treatment Studies Journal of Nervous & Mental Disease Volume 197 - Issue 9 - pp 646-654. Retrieved from doi: 10.1097/NMD.0b013e3181b3afaa.
Butcher. (2009). DSM-IV-TR Dissociative Identity Disorder  Abnormal Psychology, 14th Edition. Pearson Learning Solutions. VitalBook file
Dell P. (2006). "A new model of dissociative identity disorder". Psychiatric Clinic North America. Retrieved from
Dissociative Identity Disorder. (2013). Dissociative Identity Disorder: Etiology. Dissociative Identity Retrieved from
Gillig, P, M. (2009). Dissociative Identity Disorder A Controversial Diagnosis. Psychiatry Edgmont 6(3): 24–29. Retrieved from
Gleaves, D, H. (1996). The Sociocognitive Model of Dissociative Identity Disorder: A Reexamination of the Evidence. Texas A&M University. American Psychological Association, Inc. Retrieved from
Howell E. (2011). Understanding and Treating Dissociative Identity Disorder. New York: Routledge. ISBN 0415994969.
International Society for the Study of Trauma and Dissociation (2011) Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, 12:2, 115-187 retrieved from
Jewels, K. (2012). An Examination of the Evidence: Misdiagnosis and Dissociative Identity Disorder. A Literature Review on Dissociative Identity Disorder. Retrieved from
 Ross C, & Ness L. (2010). Symptom Patterns in Dissociative Identity Disorder Patients and the General Population. Journal of Trauma & Dissociation.11(4): 458-468. Abstract. Retrieved from  DOI:10.1080/15299732.2010.495939

Simeon D. (2008). Dissociative Identity Disorder: Patient's Reference. Merck Manual for Health Care Professionals. Retrieved from