Dissociative identity disorder or DID is a psychiatric condition where an individual shows multiple distinct identities coupled with its own specific pattern of perceiving and interacting with the environment. The International Statistical Classification of Diseases and Related Health Problems call this type of condition as multiple personality disorder. Dissociative identity disorder is less frequent in comparison to other dissociative disorders and is known to affect about 1% of human population. It is often comorbid when compared with other dissociative disorders. The individual also saves from memory loss or temporary forgetfulness. The disorder is often characterized by identity fragment rather than a proliferation of separate personalities. Once the disease comes into action the diagnosis acquires the label of controversy. Some people believe that the patients suffering from this disease are hypnotized as their symptoms are iatrogenic while brain imaging studies indicate identity transitions.
Before the nineteenth century individuals suffering from the dissociative identity disorder were placed in the category of possessed. The deep interest of people in spiritualism, parapsychology and hypnosis continued throughout the nineteenth and early twentieth century and the views of John Locke were very famous. The views suggested that there is an association of ideas that require co-existence of feelings along with the awareness of feelings. Hypnosis came into existence late in the eighteenth century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puvsegur who had a hard blow to John Locke's association of ideas. Hypnotists reported how two separate entities can co-exist together. During the nineteenth century Rieber estimated that there are about 100 cases of dissociative personality disorder among human population. Epilepsy was also considered as one of factors associated with the personality disorders. By the end of the nineteenth century critiques as well as researchers gave an accepted view that emotionally traumatic experiences can also cause this type of disorder. The disorder can occur at any stage for example, Louis Vive experienced a dangerous encounter with viper at the age of 13 and he remains a subject of medical study for many years.
Between 1880 and 1920 many international conferences on medical science devoted their time on the topic of dissociation. Jean-Martin Charcot was the first to state that nervous system actively participates in the emergence of personality disorders. Pierre Janet, one of the students of Charcot used his ideas in generating theory of dissociation. The first individual identified and studied scientifically with multiple personality disorder was Clara Norton Fowler. American neurologist Morton Prince studied Fowler during 1898-1904 and described details of case of Clara in his monograph, Dissociation of a Personality published in 1906. In 1910, Eugen Bleuler introduced the term Schizophrenia to replace dementia praecox. A review published in Index Medicus brought a dramatic reduction in the number of cases reported for multiple personality disorders especially in the United States for a period of 1903 to 1978. In 1927, the number of cases of schizophrenia was reported that had symptoms similar to those occurring in multiple personality disorder. Bleuler also included multiple personality disorder while classifying schizophrenia. During 1980s it became clear that the individuals suffering from multiple personality disorder are often misdiagnosed and are termed as schizophrenic.
Signs and symptoms
Individuals suffering from dissociative identity disorder exhibit a wide variety of symptoms that fluctuate broadly across time. The symptoms may impair the functioning of normal day to day activities. The common symptoms are multiple mannerisms, attitudes and beliefs that do not resemble each other. Somatic symptoms, loss of subjective time, depersonalization, de-realization and depression are other symptoms. Memory loss, trauma, sudden anger without any cause, anxiety attacks and unexplainable phobias are also considered as chief symptoms. Individuals also show symptoms that resemble those appearing in epilepsy, schizophrenia, anxiety disorders, mood disorders, post-traumatic stress disorder, personality disorders and eating disorders. Other common symptoms of this disorder include headache, amnesia and some individuals often exhibiting a tension of self violence.
Literature is loaded with many psychophysiological investigations about dissociative identity disorder. Many investigations have been carried out on single individuals by considering different aspects at different time intervals. Different states have shown distinct physiological symptoms. Studies carried out by using electroencephalogram showed different symptoms. Neuroimaging studies have found that individuals with this disorder have higher levels of memory encoding than the normal individuals as well as smaller parietal lobe. One study has found alterations in the intensity of concentration, mood changes, and degree of muscle tension with some inherent differences in brains of such individuals. Although a link between epilepsy and this disorder was also postulated but it is still controversial. Some brain imaging studies have shown differences in the cerebral blood flow in the sufferers. A different imaging study has also shown smaller hippocampal and amygdala volumes in patients of this disorder. One study carried out on twin individuals showed that heredity also plays an important role in appearance of dissociative identity disorder.
Theoretically dissociative identity disorder is coupled with the attacks of stress, traumatic antecedents, child abuse and an innate property to dissociate memories. Child abuse is very much responsible for this order and the percentage of individuals is somewhat higher. Physical and sexual abuse received by the individuals during early to mild childhood also results in this disorder. Some believe that the symptoms appear due to iatrogenic treatments. A development theory is generally postulated while studying the dissociative identity disorder sequentially as physical or sexual abuse received by the child in the childhood is responsible the appearance of symptoms. If the child is harmed intensely by a trusted caregiver it results in splitting off the awareness and memory of the child to survive in relationship with that person. These events enter the subconscious mind of the child resulting in emergence of a separate personality. The events reoccur if the individual receives traumatic events again. Dissociation becomes a coping mechanism for such individual if he or she faces stressful situations again and again.
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has described certain criteria while diagnosing this disorder. The DSM-II has used the term multiple personality disorder while DSM-III has identified four types of dissociative disorders and DSM-IV-TR uses the term dissociative identity disorder. The ICD-10 however, uses the term multiple personality disorder. The diagnostic criterion described in section 300.14 of DSM-IV is based on the non-physiological reasons where the individual sufferers from intensive memory lapses but while dealing with children the criterion focuses on other matters. The diagnosis of dissociative identity disorder can be performed by therapist, psychiatrist and psychologist by using personality assessment tools.
The diagnostic criterion given in DSM-V suggests that if there is a disruption in the identity of an individual due to the presence of two or more personality states or an experience of possession that alters cognition, behavior or memory then the individual may suffer from this disorder . Other criterion says that if the individual finds difficulty in recalling day to day information or traumatic events that are coupled with forgetfulness or social impairment he or she may suffer from personality disorders. Certain religious practices or general medical conditions may also be coupled with this disorder. The SCID-D can be used while diagnosing the disorder where an interview is carried out for 30-90 minutes depending upon the experiences of the subject. The Dissociative Disorders Interview Schedule (DDIS) is strictly based on the criteria given in DSM-IV and may last from 30-45 minutes. The Dissociative Experience Scale (DES) is a simple, quick and rapid questionnaire used to screen the symptoms of the dissociative disorder. The DES scale is constructed differently for children as well as adults.
The treatment of dissociative identity disorder attempts to join the different identities into one single identity with intact memory and functioning like normal brain. The treatment also focuses on relieving the symptoms of the disease for the benefit and safety of the patient. Treatment strategies may combine psychotherapy and meditation in order to provide relief to the individual. Some behavior experts while dealing with the individuals of personality disorders use the method of responding to one only type of identity and then use some of the conventional methods for faster recovery of the patient.
Prospects and Epidemiology
Dissociative identity disorder does not suddenly cause and the symptoms also vary with time. Individuals with symptoms of post traumatic stress however recover earlier with treatment. Patients with comorbid addictions, mood and eating disorders however take longer time to recover. Individuals still attached with the abusers show worst results with treatment. Changes in personality and memory loss may sometimes lead the individual to commit suicide. Studies do not clearly indicate the exact frequency of occurrence of this disorder but the number has significantly increased in the last few years. A possible explanation for increase in the number of cases is generally due to wrong diagnosis by confusing it as schizophrenia, bipolar disorder or other mental disorders.