Dissociative Identity Disorder

 I have been working with the aftereffects of trauma and abuse for my entire career.   It was in 1999 I received my first referral of an individual diagnosed with Dissociative Identity Disorder.  I was well versed in the issues of abuse and neglect.  I  had experience working with severe dissociation.  Over the course of my career I had learned about this obscure diagnosis, at one time called Multiple Personality Disorder.

I was assured by hospital staff this client was very stable and gaining connection to her inside selves.  She had initially been referred elsewhere, however that therapist did not have the availability to see her twice a week.  The hospital felt she needed that level of support initially.  

It is now 2004.  This client and I have been working together for three and a half years.  I have come to not only respect her courage and persistence, but I have learned more from her and the other DID's who followed than I have from any textbook, workshop or consultation I have ever attended.  This article is dedicated to all  of you who rise like the phoenix and deliver yourselves from that fiery hell.

To The Group This is our December. May it be a time of cold weather on the outside, And warm healing on the inside. May we find comfort when and where possible. May our blessings be found, and to our liking. May unconditional love light our paths. Blessed Be                             Bonnie 12/2003

As the diagnostic name Dissociative Identity Disorder implies, the condition is typified by extreme dissociation.  The level of  dissociation is so extreme as to disrupt the individual's sense of a singular identity.  The experience presented in individuals is a sense of having others within.  Or as one of my clients likes to say she is a person with people.  To many professionals in the field this diagnosis seems extraordinary if not quite unreal.  Often presenting with other symptoms the client with DID may be accurately diagnosed with a variety of diagnoses including, Major Depression, Post Traumatic Stress, Anxiety Disorders, Eating Disorders, Substance Abuse issues and even a Borderline or Dependant Personality.  Personally the idea of dissociation as a defense mechanism has always made total sense to me.  So it was not that far of a leap to think if dissociation had been utilized successfully especially in early childhood, the formation of other personalities or alters would be a feasible reality for those victimized as children.  The purpose of this article is to identify the disorder and attempt to demystify a credible diagnosis as much as possible.  Whether you agree of disagree with the reality of the disorder I am here to share only what I have learned, experienced and witnessed through my association with "People with People"

Conditions related to dissociation and DID has been studied for many years. Dr. Richard Kluft, defined four factors that lead to the development of DID.  a. The biological ability to dissociate. b. Repeated traumatic experiences beginning in childhood  c. Disassociation that leads to the shaping of well defined alters. d. Inadequate social  and emotional supports and protection   Child abuse and trauma perpetrated by those adults who are caregivers to the child, disrupts the child's ability to trust and form attachments to others.  The Erickson model of development suggests the first developmental state a child needs to complete is trust vs.. mistrust.  A child needs to believe and understand his caregivers will support and protect him or her.  Without this knowledge the child grows up with a continued fear and mistrust of all other relationships in their lifetime.  A deep sense of shame related to the acts of abuse and neglect effects  self esteem and disturbs the child's interpersonal relationship skills.    Children learn what they are taught.  The abused child's experience of life limit and compromise later development.  

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revisions ( DSM IV-TR), Dissociative Identity Disorder is classified along with other Dissociative Disorders.  The term dissociation is used to define a primary ego defense mechanism that allows us to separate or isolate pieces of experience from each other.  Eliana Gil, PhD in her book United We Stand describes it this way.  " Dissociation can be a very useful way to survive because it allows a child who is being hurt to escape mentally.  The body and the mind seem to separate.  While the body is being hurt, the person no longer feels it, because the mind (or soul) manages to escape to a safe place."    The threatening dissociated information such as feelings, thoughts, memories, impulses, behavioral patters, perceptions is then kept separated from non threatening information.  For children this process is a key to survival.  As children we do not have the adult information, insight or cognitive abilities to make sense of abuse.  Even as adults understanding and coping with the overwhelming feelings is difficult at best.  So children who dissociate naturally keep separated the abuse from positive events in their lives.   The problem with this process is that the individual is then unable to work through and understand this threatening material, because in fact they do not have conscious access to the material.  

Dissociation occurs in a continuum ranging from normal non traumatic dissociation to severe traumatic dissociation.  This severe end of the spectrum is where the development of DID or multiple personalities is found. Dissociation is a natural process.  We all have periods of time where we can get lost in a book or a movie, loose track of time or feel as though the time has just flown by.  There may have been a time that you have hurt yourself in some way- such as bumping into a table as you were engrossed in conversation.  As we move further on the continuum we see individuals who use dissociation for protection. This dissociation is generally employed in childhood and remains a readily utilized  defense mechanism.  We see this in individuals who cannot remember parts or the entirety of their childhood.  These individuals may enter therapy with the belief if they could just remember their past they could stop wondering what they have forgotten.  Dissociation does work.  It is a way of dealing with pain and allowing the individual to continue to function.  However, the pain does not disappear.  Eventually the pain must be released so it can be healed.

At the extreme end of dissociation we find individuals who dissociate to the point they can find another  personality who seems more capable of coping with the abuse.  For example Betty's father would take her to participate in a pornography and prostitution ring. If during these sessions Betty did not make enough money the father would physically abuse one of her younger siblings. Over the course of that time several alters were created to cope with the ongoing sexual abuse.  One of those alters was teenaged boy who could do what was asked so effectively that the father was satisfied and the younger children at home remained safe. Ddissociation to this extreme becomes an automatic reflex.  The individual may not even know when the dissociation occurs.  The behavior gives a instant feeling of safety.  Additionally severe dissociation can be startling and even dangerous.  Individuals who dissociate can "come out" or "wake up" and find things out of place,  or more disturbingly themselves in a place they do not know.  The level of confusion is severe enough they can be confused about what is real and unreal.  At times questioning if they are even real.

DID is clinically characterized in the following way:

A. The presence of two or more distinct identities or personality states ( each with its own relatively enduing pattern of perceiving, relating to and thinking about the environment and self).

B. At least two of these identities or personality states recurrently take control of the person's behavior.

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g. blackouts or chaotic behavior during alcohol intoxication) or general medical condition (e.g.. complex partial seizures) NOTE: in children , the symptoms are not attributable to imaginary playmates or other fantasy play.                                                               ( DSM IV-TR 2000)

"Multiple personality disorder is rooted in the secrecy surrounding prolonged and severe physical, sexual and emotional abuse and or neglect starting in early childhood.  The patient in treatment is typically eager to sustain that secrecy at almost any cost: thus discussing abuse amounts to a violation of the self protective vows made by the victim in response to the abuser's threats.  For those patients who are aware of the connection between trauma and dissociation, to reveal multiplicity is to signal the existence of an abuse history." (Cohen and Cox 1991)

DID does not present itself in therapy in any consistent manner.  Often the host if they are aware of the alters has a fear or disclosing any information about the alters.  Too often the presentation of symptoms goes unnoticed or disbelieved in the clinical setting.  Going back to that concept of not feeling real, an individual may believe themselves to be "crazy" and does not want to present to a new therapist the extent of their 'insanity"  Also there is an issue of trust.  Understanding that the alters have presented in an attempt to over the years to protect the host and themselves from abuse, there is a resistance to showing themselves to the outside world.  "Popping out" in the past has been a reflexive response to harmful situations.  Some DID clients can see therapy as a harmful situation. Fear of hospitalization, fear of disclosure, fear of making a connection, fear of change are all issues which keep the inside on alert. Most often the alters avoid detection.

An individual may present in treatment unaware of his or her alters.  There may be a life crisis to address, or a severe mood disorder.  Over the course of treatment an alert clinician will begin to see patterns which indicate a history of dissociation and abuse.  Over the course of treatment with a supportive and consistent therapist the presence of alters may become known to both the therapist and the host. I think I was fortunate in my introduction to this disorder.  During the initial assessment I met with a polite, quiet, unassuming yet hyper vigilant woman who clearly had significant difficulties remembering important aspects in her life  (e.g. the four years she spent in college).  After setting up the next session and saying good bye, I was warned by an aggressive sarcastic presence that if she ever called me and I had to return the call I was never to say " I am returning your call"  In her mind that would indicate I was only calling as part of a duty and she did not want me to do anything solely out of duty.  I thanked them for that information.  The sarcastic smile returned to say "You don't even know who drove her here today.  How do you know that we wont take her somewhere and just leave her to find her way home?"  What I did not know at that time was I was being introduced to the darkness.  All I could think to say was  " You're right I don't know that.  All I can do is trust you will take her home."  The self satisfied snicker that was returned was an acknowledgement I had just past the first of many tests.

There are many clinical features that present along side of DID.  One of the most common is depression.  The level of depression may range from distinct periods of  mild to severe depression with psychotic features.  The presentation may also be of the long term chronic variety.  The host is often expressing feelings of helplessness and confusion.  They may feel unsuccessful in daily living.  There may be period of time suicidal thoughts appear and frighten the host.  The host often is unable to explain the thoughts and impulses nor can they relate these feelings to any current life stressor.   As the alters are presented, it is common to find alters who process high levels of depression and  knowledge of past life events which are related to the depression.   

Anxiety and panic may also be present.  Often times the host will present as hyper vigilant and/or with psychosomatic symptoms.  Biologically the body has been in a constant state of hyper arousal. This may effect for example the stomach and lead to frequent vomiting or ulcers.  The alters lack the ego strength to cope with the past history of child abuse and current life events.  They may present as clearly overwhelmed.  There is a constant state of fear that can be identified.  The host and alters are facing the fears of the past along with the fear of current life events.  Without a foundation in trust it is difficult not to perceive the world as a big frightening place.  Some DID clients may have specific phobias that seem to have no traumatic association.  However eventually it is common to find there is a connection between the fear and a traumatic event.  For example one client is phobic when it comes to fire.  She compulsively un plugs all electrical equipment when she has to leave her house.  She refuses to use either the stove or the microwave oven.  The host and several of the alters have no knowledge of ever being around a fire or being scared by any form of fire.  However there are some alters who are much less afraid of the prospect of fire.  Those alters w ill not go through the ritualistic unplugging. This results in increased fear with those alters who are more fearful.

Psychosomatic complaints are common. These symptoms are often transient but can be particularly serious symptoms. The presents of severe headaches can identify a conflict between the host and the alters or illustrate the significant distress of an alter.  It is also possible for an alter in an act of harassment give the headache to  the host. At one time one of my clients was  frequently distressed by what was thought to be severe migrant headaches. The symptoms were so severe vomiting and dehydration would occur.  On two occasions she was hospitalized medically to receive IV fluids and pain medication.  To diagnose the treat the migraines an MRI was scheduled.  As was related later, the host was too afraid of the procedure so one of the alters presented.  As a result there was no indication of abnormal or adverse  symptoms.  Therapists must be aware,  the body remembers.  Often a client with a traumatic background will have physical sensations or pain for which there is no current physical cause.  This could be a chocking pressure, back pain, pain in the genital region.  As the body remembers the trauma it will express the physical pain so long hidden by the dissociation.  Other psychosomatic issues can be visual disturbances, general weakness, problems with equilibrium, gastrointestinal problems, chest pain etc.

Flashbacks are common and can occur spontaneously with no identified trigger present.  Flashbacks are a revisiting of the traumatic experiences.  As therapy continues the power of the flashbacks can be come more intense.  This is a normal reaction to the therapeutic process which initiates the expression of feelings related to the past abuse history.

Many DID clients and alters have a sense of depersonalization.  This is a disruption in a persons sense of who they are.  It creates a separation and leaves an individual not feeling like themselves.  Additionally there is a sense of derealization.  In a sense there is a perception their experiences are not real.  In a severe case I have a client who has difficulty watching TV.  She cannot tell what is real e.g. news programs and what is unreal e.g. sitcom. We often talk about what is real and unreal.

Often confused with Schizophrenia because of the presence of hallucinations, DID hallucinations must be carefully assessed.  The auditory hallucinations are the internal voices of the alters. A good question to ask is whether the voices are heard inside the head or if they sound like voices coming from the outside.  More often in schizophrenia the hallucinations are the latter.  Additionally visual or olfactory hallucinations are present.  These symptoms can confound the clients belief he or she must be "crazy".  

Behaviorally there can be a great deal of acting out among the alters.  There can be a range of uncontrolled affect such as rage, suicidality, self- mutilation  and other behavior the host may find embarrassing e.g. sexual acting out, substance abuse.  This uncharacteristic acting out is often the first clue regarding the nature of the disorder.  Friends and family who have been acquainted with the individual over many years may associate these changes in behavior with moodiness.  If the behavior is quite out of the ordinary close associates may be puzzled and concerned.  If the individual or any of the alters abuse substances their behavioral outbursts are often related to the use of alcohol or drugs.  The use of alcohol or drugs can conceal the dissociative dysfunction.  Blackouts are associated with the drug use as opposed to the dissociative amnesic episode.

The essential feature in DID clients is the symptoms of amnesia.  Individuals will call it loosing time, blacking out, or going away.  This loss of awareness in effect blocks the host from information either historical in nature or occurring presently.  As the host and possibly other alters are unconscious of the outside world another alter acts as an executive who pursues  goals or acts out independently of the host.  This loosing time can vary in its duration from minutes to even years.  Each time the host is returned to consciousness they are left feeling confused and disoriented.  Often they are alarmed if they "awaken" in places unfamiliar to them or far from home.  This repeated loss of awareness prevents the host from a continuous and stable sense of time and events.  It disrupts the individuals ability to understand cause and effect, the understanding of their own histories and the sequence of events.

Dissociative Identity Disorder is a multifaceted diagnosis.  It requires a careful and continued assessment to identify and address the complex issues found within.  It is not an mental illness.  Individuals are not born with it.  It is caused in an attempt to survive severe and profound abuse and neglect.  If you or a loved one believes you may be experiencing the after effects of abuse, get help.  There are competent and well trained therapists through this country and the world.  No one should suffer a minute longer the effects of abuse.  

To find a therapist near you contact the National Association of Social Workers at NASWDC.org,  contact your local crisis hotline,   The International Association of EMDR EMDRIA.org, The national therapist referral organization 1-800Therapist.com

Donna M. Hunter, LCSW, SAP, CAP

References;

American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revisions. Washington DC, APA.

Bloch,James P. (1991) Assessment and Treatment of Multiple Personality and Dissociative Disorders.  Sarasota, Fl. Professional Resource Press,

Cohen Barry M., Cox, Carol Thayer. (1991) Telling Without Talking. NY, NY Norton Press,

Gil, Eliana; ( 1990). United We Stand , , Ca  Launch Press Walnut Creek

Napier, Nancy J. (1993). Getting Through the Day,  NY, NY Norton and Company.

Ross, Colin. (1989). Multiple Personality Disorder; diagnosis, Clinical Features and Treatment. NY NY , Wiley