Dissociative Identity Disorder: Multiple Personality Di

Dissociative identity disorder (DID), formally and popularly known as multiple personality disorder was surrounded by controversy in its inception and still faces the doubts of many critics today. DID involves the presences of two or more personalities or alters in one individual. Its inclusion in the DSM-V formalized its realness and significance, paving the way for clinicians to assess, diagnose and offer treatment. The current paper aims to present an analytical overview of the methods for diagnosing and assessing the disorder, to examine the current treatment therapies and evaluate the availability of treatment resources within the local community.

Diagnosis

Despite the controversy surrounding its etiology DID was integrated into the DSM-IV.

The DSM-IV criteria for diagnosing DID requires the presence of at least two distinct personalities. Additionally, it states that each personality must present its unique patterns in relating to the environment and also recurrently take control of the person’s behaviour (Ross, 1997). Further inclusion states the presence of amnesia not otherwise caused by psychological effects of a substance or other medical conditions (Ross, 1997). Diagnosis is prevalent in females, and those diagnosed present a greater number of alters than found in diagnosed males. In clinical populations, prevalence is estimated to be between 0.5 and 1.0 (Maldonado, Butler, & Spiegel, 2002. However, prevalence in the general population is greater at an estimated 1% to 5% (Rubin & Zorumski, 2005).
In his book entitled Dissociative Identity Disorder, Collin Ross (1997).

Presents 4 pathways to the formation of DID: childhood abuse pathway, childhood neglect pathway, factitious pathway and iatrogenic pathway. Childhood abuse pathway patients have undergone severe abuse often in the form of physical or sexual abuse, but those patients who faced neglect “described mothers who were [psychologically ill] and emotionally unavailable. Ross explained neglect in the form caging in small places. The factitious [sic] pathway as he describes presents no dissociative symptoms before initial therapy despite some history of abuse and neglect. He furthers that such patients fake aspects of DID and are often self-injurious. Ross suggests that such individuals are predominately antisocial. The last pathway he defined is iatrogenic which occurs as a result of poor therapy techniques, he further suggests that patients in this category tend to present a dependent

personality.
Many of the clinical cases of DID often occur as an escapist coping mechanism from severe trauma often in the form of childhood abuse or neglect. Diagnosis of DID almost always involve a comorbid diagnosis of schizophrenia, depression borderline personality, etc. (Ross, 1997). The symptomatology of dissociative identity disorder is complex in nature; however, competing symptoms from other diagnoses complicate treatment and assessment.
Case Study
Although a diagnosis of dissociative identity disorder can occur at any age, the average age is thirty (Kaplan & Sadock, 2008). Underlying causes can often be traced to childhood trauma; 88% of cases report physical or sexual abuse as children (Ross, 1997). The following case study of the 45-year-old housewife diagnosed with DID was presented by Vedat Sar and Hamdi Tutkun in 1997. At the age of fourteen Halime had not only lost her father but she was also forced to become engaged to someone she had never met. Against her will, she was married at sixteen.
Her first encounter with therapists was due to somatic complaints. She reported a previous psychosis that lasted for two weeks. Upon their first encounter, symptoms that authors described to Sar and Tutkun included: amnesia, headaches, talking to herself, visual and auditory hallucinations, inappropriate laughing and crying, and childish talking. These symptoms became evident during treatment. Sar and Tutkun reported that at times Halime would stare and say nothing (she was unaware of her surroundings). On the contrary, she might stare blankly and converse with herself. Halime recounted experiences of trances that lasted up to six days – when she came out of these blank spells, she was oblivious to her previous state.
Her alters revealed that Halime had been abused by her brother and later her aunt’s husband at the tender age of six. The authors (her therapists) reported that within the first ten interviews, they had encountered sixteen alters who were mostly aware of each other; however, the host/central personality remained amnesic about their existence. Halime’s personalities increased from sixteen to twenty-one over the course of her treatment.
Of her seven child alters, the therapists explain that six relived the experience of sexual abuse by the aunt’s husband while one relieved the sexual abuse by her brother. There were three nine-year-old alters, two of whom held memories of rape by the brother and the other presented memories of Halime hiding in the closet from her mother. Pharmaceutical drugs were used to control some of her symptoms, and fusion therapy was employed to integrate the alters. Halime was treated in twenty-seven months by Sar and Tutkun without being hospitalized. Assessment
Of the various models, Ross (1997) suggests use of the Dissociative Experiences Scale (DES), the Structural Clinical Interview for the DSM-IV Dissociative Disorders (SCID-D), the Dissociative Disorders Interview Schedule (DDIS) and Dissociation Questionnaire (DIS-Q). He asserts that together they provide a practical standardized assessment that can be used in a variety of settings.
The Phillips Dissociation Scale of the MMPI is a 20-item scale (Ross, 1997).

In a study with a sample of 20 psychiatry patients who have either been diagnosed with dissociative identity disorder or dissociative disorder not otherwise specified (DDNOS). The DID patients scored an average of 11 while those with DDNOS only scored 2.2 (Ross, 1997). The items of the scale have been integrated into the MMPI-2 which includes questions such as, “I often feel as if things are not real” and “My memory seems to be alright” (Ross, 1997). This integration is a positive one because prior to the Phillips Dissociation scale, the issue of differentiating DID from borderline personality disorder was highly problematic; furthermore there was no scoring system for the diagnosis of DID. The issue would have been evident if the MMPI were used to assess Halime, she likely would have received an erroneous diagnosis because of the ambiguity of her presentation. Such misdiagnosis would have resulted in potentially harmful treatment – treatment that may have worsened her symptoms (Levy & Swanson,

2008).
In a study using 719 DID patients, it was discovered that DID patients spent an outstanding 11.5 years in the mental health system to before proper diagnosis (Levy &Swanson, 2008). This finding is supported by the Ross’ conclusion after reviewing the MMPI, Rorschach, MCMI, and the SCL-90, which none of these tests differentiate dissociative identity disorder from psychosis (1997). Looking at the case study we see that although the initial diagnosis of hysterical psychosis may have sent Halime to the Istanbul Medical Faculty Hospital, psychosis was actually a symptom of her DID (Sar & Tutkun, 1997). To avoid misdiagnosis future assessment measures need to ensure items and scoring methods that differentiate DID from psychosis.
With the goal of accuracy and differentiation, the Dissociation Experience Scale (DES) was by Bernstein and Putnam was developed for the screening of DID (Levy & Swanson, 2008; Ross, 1997). The DES only contains 28-item, giving it the advantage of taking little time to complete and being quick to score (Ross, 1997). Within 15 to 20 minutes of test administration, the clinician can screen for the frequency of DID in a patient (Levy & Swanson, 2008; Ross, 1997). The normative language used in the questionnaires dissuades respondents from malingering: “some people have the experience of finding new things among their belongings that they do not remember buying” (Ross, 1997).