Dissociative Identity Disorder: Treatment and Management 303139853X, 9783031398537

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Hassaan Tohid Ian Hunter Rutkofsky Editors

Dissociative Identity Disorder Treatment and Management

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Dissociative Identity Disorder

Hassaan Tohid  •  Ian Hunter Rutkofsky Editors

Dissociative Identity Disorder Treatment and Management

Editors Hassaan Tohid California Institute Of Behavioral Neurosciences and Psychology Fairfield, CA, USA

Ian Hunter Rutkofsky HCA - Aventura Hospital and Medical Center Aventura, FL, USA

ISBN 978-3-031-39853-7    ISBN 978-3-031-39854-4 (eBook) https://doi.org/10.1007/978-3-031-39854-4 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

I dedicate this book to my wife Sidra, and daughters Ayla and Inara for their unconditional support and love. Dr. Hassaan Tohid MBBS, SUDCC I dedicate this book to my wife, Ann, who proves that her love is unconditional every day, to my parents who made so many sacrifices to assure my success both in life and medical school, to my sister, Marni, who gave me confidence and encouraged me to become a psychiatrist, and to my daughter, Gavrielle Ehwa Rutkofsky, who will be arriving to this world very soon! Gavrielle, life may be hard at times when you are young, and school may be challenging, but if you work hard enough, through the sweat and tears, you will become anything you want to become! Dr. Ian Hunter Rutkofsky, MD

Preface

My interest in mental health and psychology led me to pursue board certification in substance use counseling after my medical degree and eventually oversee the editing of this book. Dr. Ian Rutkofsky, a board-certified psychiatrist, served as the second editor who made the goal of finishing this book smooth and easy. I have long been captivated by the topic of dissociative identity disorder (DID) and have dedicated myself to studying this fascinating, albeit peculiar, mental disorder. I have even gone so far as to discuss the subject at personal gatherings and events, and my passion for DID ultimately led to my TED talk, “The Myth of Demonic Possession.” The next major step of my learning journey is this book, which includes roughly 50 chapters written by distinguished mental health practitioners, such as psychiatrists, psychologists, and therapists from around the globe. Our goal in compiling this book was to comprehensively cover every dimension of DID and provide readers with a detailed resource on the subject. We believe that this book will be an invaluable tool for mental health clinicians, psychology and psychiatry students, psychology and psychiatry residents, medical students, and anyone interested in the subject of DID worldwide. Writing this book was a daunting task, and it took us 2 years to complete. The main challenge was to ensure that the book was one of the most comprehensive works on the subject. To accomplish this goal, we enlisted the help of a team of passionate, talented, and hardworking authors who were mostly clinicians, including psychiatrists, psychologists, and psychotherapists. Despite their busy schedules, the authors worked diligently and completed the chapters. I thank all the authors who made this book a reality, and I would like to acknowledge the support of my wife, Dr. Syeda Sidra, and my daughters, Ayla and Inara. As well as my uncle Tahir Ahad who always encouraged me to study more and more. After reading all the chapters and overseeing the editing of the book, I realized that we still have much to learn about DID, and that our current knowledge only scratches the surface. I hope that this book will add to the body of knowledge on this psychiatric mystery and that readers will find it both informative and enjoyable. Fairfield, CA, USA

Hassaan Tohid

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Acknowledgment

The editors are grateful to Dr. Bilal Haider Malik and Saffa Arshad for assisting through the editing process.

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Contents

1 History  of Dissociative Identity Disorder (DID)������������������������������������������������������   1 Danial Hassan 2 Dissociative  Identity Disorder and the DSM �����������������������������������������������������������   7 Vikram Kumar and Krithika Krishnamurthy 3 Dissociative  Identity Disorder: Theory vs. Facts�����������������������������������������������������  15 Safeera Khan 4 Different  Kinds of Dissociative Disorders, Including Dissociative Identity Disorder���������������������������������������������������������������������������������������������������������  21 Saikat Kar 5 Ketamine:  Should Such a Dissociative Agent Be Used for Anesthesia, Anti-­­Depression/Suicidality, and Analgesia in DID Patients? �������������������������������  33 Kristy A. Fisher and Thalia Adrian 6 Culture and Dissociation �������������������������������������������������������������������������������������������  41 Kristal C. Khan, Bilal Haider Malik, and Ian Hunter Rutkofsky 7 Epidemiology  of Dissociative Identity Disorder�������������������������������������������������������  49 José Hawayek 8 Multiple  Personality in Popular Culture �����������������������������������������������������������������  53 Amir Arad and Bilal Haider Malik 9 Dissociative  Identity Disorder in Hollywood and Other Movies ���������������������������  57 Amir Arad and Bilal Haider Malik 10 An  Effective Approach to Treatment of PTSD and Other Dissociative Disorders: One Practitioner’s Experience���������������������������������������������������������������  61 Dody J. Reustle 11 DID and Depression ���������������������������������������������������������������������������������������������������  67 Diana Diaz, Clara Alvarez, Zerimar Ramirez, and Shivani Kaushal 12 Dissociative  Identity Disorder and Anxiety �������������������������������������������������������������  73 Kosha Srivastava 13 Dissociative  Identity Disorder and Trauma�������������������������������������������������������������  77 Deepak Goyal, Prerana Upadhyaya, Michael Jordan Weaver, and Ian Hunter Rutkofsky 14 Dissociative  Identity Disorder and Other Specified Dissociative Disorder (OSDD)���������������������������������������������������������������������������������������������������������  85 Christopher Privette, Santroy Samules, and Mohammad Sadik 15 Dissociative  Identity Disorder and Schizophrenia���������������������������������������������������  93 Sindhura Kompella and Shivani Kaushal xi

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16 Child and Adolescent DID����������������������������������������������������������������������������������������� 101 Young Jo, Neena E. Thomas, and Sara Khan 17 DID  in Male Patients ������������������������������������������������������������������������������������������������� 105 Sindhura Kompella, Felicia Gallucci, Sara Jones, Joseph Ikekwere, and George Ling 18 DID  in Borderline Personality Disorder������������������������������������������������������������������� 109 Sindhura Kompella and George Ling 19 Dissociative  Identity Disorder and Bipolar Disorder ��������������������������������������������� 115 Sindhura Kompella, Felicia Gallucci, Sara Jones, and George Ling 20 Understanding  Dissociative Identity Disorder��������������������������������������������������������� 119 Rasha Almousa 21 Dissociation in Animals���������������������������������������������������������������������������������������������� 127 Hasan Belli 22 Genetics  and Dissociative Identity Disorder (DID)������������������������������������������������� 133 Nana Bonsu, Venkatesh Sreeram, and Faiz M. Hasan 23 Dissociative  Identity Disorder and the Human Brain; Neuroanatomy����������������� 137 Faiz M. Hasan, Nana Bonsu, and Venkatesh Sreeram 24 Pathophysiology  of Dissociative Identity Disorder ������������������������������������������������� 141 Justin Mark, Qaas Shoukat, Jack Bayer, and Emily Harris 25 Risk  Factors of Dissociative Identity Disorder��������������������������������������������������������� 145 Neena E. Thomas 26 Causes  of Dissociative Identity Disorder ����������������������������������������������������������������� 147 Aaron Marbin, Nadia Obaed, James Allen Mcalister III, and Emanuella Brito 27 DID and Diagnosis ����������������������������������������������������������������������������������������������������� 153 Shivani Kaushal, Jordan Calabrese, Anam Roy, and Jose Isaac Reyes 28 DID  and Differential Diagnoses��������������������������������������������������������������������������������� 159 Shivani Kaushal, Jordan Calabrese, Anam Roy, and Jose Isaac Reyes 29 Struggle  of Family of DID Patients. ������������������������������������������������������������������������� 165 Venkatesh Sreeram, Nana Bonsu, and Faiz M. Hasan 30 DID  and Religion: Possession������������������������������������������������������������������������������������ 169 Krithika Krishnamurthy and Vikram Kumar 31 Dissociative  Identity Disorder and Clinical Trials��������������������������������������������������� 175 Safeera Khan 32 Recovery  from Dissociative Identity Disorder��������������������������������������������������������� 179 Vedat Sar 33 Prognosis of DID��������������������������������������������������������������������������������������������������������� 197 Justin Mark, Miguel Belaunzaran, Qaas Shoukat, and Amar Gill 34 The  Impact of DID on a Family’s Life ��������������������������������������������������������������������� 203 Jill D. Chasse 35 Pharmacological  Treatment of Dissociative Identity Disorder������������������������������� 207 Jordan Kalosieh and Acelyne Summerson

Contents

Contents

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36 Psychotherapy  and Non-Pharmacologic Treatment of Dissociative Identity Disorder��������������������������������������������������������������������������������������������������������� 213 Charmi Balsara, Steven Garcia, Skyler Coetzee, Miguel Belaunzaran, and Clara Villalba-Alvarez 37 Dissociative  Identity Disorder and the Law������������������������������������������������������������� 233 Vikram Kumar and Krithika Krishnamurthy 38 Popular  Cases of Dissociative Identity Disorder����������������������������������������������������� 245 Brian Blum and Samuel Neuhut 39 Dating and DID����������������������������������������������������������������������������������������������������������� 249 Nadia Obaed and Ian Hunter Rutkofsky 40 Dissociative  Identity Disorder and Social Media����������������������������������������������������� 255 Reginald Deligent and Sean Klonaris 41 Tips  for Dissociative Identity Disorder Patients to Live a Good Life ������������������� 259 Bilal Haider Malik and Ian Hunter Rutkofsky 42 Tips  for Family Members of DID Patients��������������������������������������������������������������� 267 Aaiz Hussain, Lavi Singh, Shaheer Hussain, Amar Gill Singh, and Ian Hunter Rutkofsky 43 Neuroimaging and DID ��������������������������������������������������������������������������������������������� 271 Steven Garcia, Skyler Coetzee, and Miguel Belaunzaran 44 Gender  Differences in Dissociative Identity Disorder��������������������������������������������� 283 Ansha Panachikkal Abubacker 45 A  Psychiatrist’s Perspective on DID������������������������������������������������������������������������� 285 Sindhura Kompella, Felicia Gallucci, and Joseph Ikekwere 46 Biography  and Interview of a Patient with DID ����������������������������������������������������� 289 Ian Hunter Rutkofsky, Hassaan Tohid, and Shirley Davis 47 Comorbid  Conditions in Dissociative Identity Disorder Patients: What to Look for?������������������������������������������������������������������������������������������������������� 295 Hassaan Tohid 48 Dissociative  Identity Disorder: The Editor’s Perspective��������������������������������������� 297 Hassaan Tohid and Ian Hunter Rutkofsky Index������������������������������������������������������������������������������������������������������������������������������������� 299

About the Editors

Hassaan  Tohid, MBBS, SUDCC, CCATP  is a four times TEDx Speaker, an Entrepreneur, a Neuroscientist, a clinician with California Board Certification in Addiction Counseling, Book Editor and a Published Author. He has a career with three domains. An entrepreneur, an academic (neuroscientist and a teacher), and a clinician (addiction treatment). As an entrepreneur, he is the founder of California Institute of Behavioral Neurosciences and Psychology where he leads the organization as the CEO.  His training includes Research Writing and Research Data Analysis and publications. He is also the CEO and Founder of the Institute of Addiction Treatment in California. As an academic, he is a Neuroscientist and delivered TED talks on his specialty neuroscience at TEDx UCDavissf, TEDx UAlberta, and TEDx WhyteAve. He has published over 60 scientific articles including book chapters and served as the senior editor of the Springer Books on International Medical Graduates and Clinical Misdiagnosis, respectively. While as a clinician he counsels substance use disorder patients. He currently resides in California. Ian Hunter Rutkofsky, M.D.  is Board certified by the American Board of Psychiatry and Neurology (ABPN). He is a psychiatrist, author, and neuroscientist. Dr. Rutkofsky practices in his specialized fields of General Psychiatry, Neuropsychopharmacology, and Neuroimaging where he treats patients using a combination of medication and/or supplements at Amen Clinics. He is also the Medical Director at Covenant Psychiatric and Mental Health Services, where he works with the community, directing the Assertive Community Treatment (ACT) team. He completed his residency training in General Psychiatry at Aventura Hospital, in Miami, FL where he was appointed as the chief resident twice, for 2 years. In addition, he completed his intern year in Primary Care as a Transitional year in Macon, GA. Dr. Rutkofsky has been involved in many academic research projects and has published numerous book chapters and manuscripts in several prestigious journals. Dr. Rutkofsky remains on faculty at the California Institute of Behavioral Neurosciences and Psychology where he educates many doctors from around the world on empirical methods used in medical research. Dr. Rutkofsky is also the founder of Rutkofsky Medical Consulting Inc., a mission to help traditional private psychiatric practices transition into integrative psychiatric practices.

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1

History of Dissociative Identity Disorder (DID) Danial Hassan

Introduction Dissociative identity disorder (DID) is a mental health disorder wherein a person has more than two personalities. Earlier it was recognized as multiple personality disorder or split personality disorder [1]. A person diagnosed with DID often suffers from memory gaps and symptoms vary from person to person. Some common conditions that occur in DID are eating disorder, personality disorder, somatic symptom disorder, obsessive compulsive disorder, substance use disorder, suicidality, anxiety disorder and more. In the 1980s and 1990s, psychology made significant progress in its understanding of dissociative illnesses, particularly multiple personality disorder [2]. It is claimed that the captivating history of dissociative identity disorder might be traced back to Palaeolithic cave paintings portraying shamans. Similarly, some researchers say that the history of dissociative identity disorder could be traced back to clarifications of demonic possession that are nowadays known to be dissociative identity disorder situations. Dissociative identity disorder, in any case, has a long history and is not a new subject.

 istory of Dissociative Identity H Disorder (DID) Early History The first case of dissociative identity disorder or multiple personality disorder was recorded in the year 1815  in a woman named Mary Reynolds. She experienced strange attacks at the age of 16 which were “apparently hysterical” as per the research [3]. During the attacks, she used to sleep for right hours and after she woke up she had memory gap, penmanship and temperament problems. After Dr. S.  L. Mitchell published her story in the Medical Repository in D. Hassan (*) Public Health, Harvard TH Chan School of Public Health, Boston, Michigan, USA

1817, the patient came to recognize two different states of being in her, and stories of her experience became a subject of much interest and fascination among researchers. However, earlier in 1971, a detailed case of multiple personality disorder was recorded in a 20-year-old German woman who abruptly began to speak French during her attack. She used to behave like French lady and spoke German with a French accent. When she spoke French and behaved like a French woman, she used to remember everything she did but when she behaved like German, she used to refuse about behaving like a French woman. Dissociative identity disorder has a long history of being mistaken for possession by people. Those with DID were labelled as hysterics when such a viewpoint was no longer socially acceptable [4]. Hysteria was thought to be largely traumatic in origin, with abnormalities in memories, consciousness, emotions, personality and bodily systems, which are the same symptoms currently identified with dissociative disorders, notably dissociative identity ailment.

Twentieth Century During the period of 1820–1920, numerous global medical conferences about dissociation took place. In this environment, Jean-Martin Charcot first conceived the concept of neural shocks as a basis of a range of neurological disorders [5]. Pierre Janet, one of Charcot’s pupils, used these concepts and built his own dissociation theories. Dissociation and multiple personalities declined in popularity in the early twentieth century due to a variety of factors. Janet’s relationship with Charcot discredited his beliefs of dissociation after his demise in 1893, since several of his hysterical patients were revealed to be frauds. Sigmund Freud changed his mind about early trauma and dissociation. In 1908, a new term was identified called “schizophrenia” where patients used to interpret the reality abnormally [6]. Once the diagnosis of schizophrenia turned out to be common, notably in the United States, an inspection of the Index Medicus from 1903 to 1978 revealed a substantial drop in the incidence of cases of multiple personalities.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_1

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 ybil S After the highly popular book Sybil was published in 1973, the diagnosis of multiple personality disorder increased in the 1970s. Many cases of DID were recorded in the 1970s than in the entire history of DID ever since 1816 and the prominent case of Mary Reynolds [7]. Approximately 500 cases of DID were brought to an only dissociative disorders treatment clinic in Dallas, Texas, amid 1991 and 1997. In the year 1974, a book was published called “Sybil” which became very famous and in 1976, it was adapted into a miniseries, which was remade in 2007 [8]. Sybil was based on the true incident of Shirley Mason. She experienced 16 different personalities and was unaware of them. The trauma inside her developed through experiencing childhood abuse [9]. The case of Shirley was very prevalent and of utmost importance in the study and understanding of the reality of dissociative identity disorder or multiple personality disorder. The example of Mason helped psychologists with a proper standardized protocol for diagnosing and evaluating other people with comparable symptoms. The book presented a detail discussion about the disorder by Sybil Dorsett. The book and films assisted in popularizing the treatment and diagnosis of DID. Later evaluation of the case recommended a variety of interpretations, varying from Mason’s concerns being caused by psychiatrist, Cornelia B. Wilbur’s treatment methodologies, to an unintended fraud perpetrated in part because of the hugely profitable distribution rights; however, this conclusion has also been questioned [10]. From 1984 to 2003, academic studies as well as publications on dissociation disorder and dissociative amnesia were linked to further mental health diseases like anorexia nervosa, alcohol consumption disorder and schizophrenia in a 2006 study [11]. The results were made to be abnormally dispersed, with a reduced rate of publishing in the 1980s accompanied by a huge rise which peaked in the middle of 1990s before substantially falling the following decade. As compared to 25 further diagnoses, the middle 1990s’ “bubble” of DID journals was different. The researchers of the analysis conclude that the results indicate that during a period of “fashion,” the two diagnoses did not prove worldwide scientific validity [9]. DID and Hypnosis In the nineteenth century, this state was identified as sleepwalking disorder and scholars stated that patients often switch between normal conscious and “somnambulistic state” [12]. All over the nineteenth and early twentieth century eras, the interest rose in spiritualism, personality psychology and hypnosis, which coincided with John Locke’s belief that there is a connotation of concepts necessitating the co-occurrence of sentiments with consciousness of the feeling [12]. Hypnosis that was popularized through Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques

D. Hassan

de Puységur in the late eighteenth century, posed a challenge to Locke’s association of concepts. Secondary personas emerged during hypnosis, as per hypnotists, and they wondered how cognitions could coexist. Around 100 cases were reported in the nineteenth century and in most of the cases epilepsy was common which led to continuation of this debate into the modern era [13].

DID in Twenty-First Century Psychologists in Germany reported in 2015 on an uncommon case of a woman suffering from “dissociative identity disorder,” which is now recognized as “multiple personality disorder” in the United States (DID). The woman had several fragmented personas (“alters”), including some that claimed to be blind [14]. Although the woman’s eyes were open, the doctors were capable to determine that the brain activity normally linked with vision was not there when a blind change was in charge of her body. Surprisingly, once a seeing alter took command, normal brain activity resumed. This was a powerful demonstration of extreme types of dissociation’s actually blinding ability, a state wherein the brain creates several, functionally distinct centres of consciousness, with their own unique internal thoughts [14]. DID is genuine, as per modern neuroimaging techniques; in a 2014 study, psychiatrists conducted brain functional scanning on both DID patients and individuals imitating DID. While comparing the readings of the real patients with those of the individuals, considerable discrepancies were discovered, indicating that dissociation has a distinct brain activity fingerprint. To put it differently, dissociation processes in the brain have a distinctive appearance [14]. As per the current research, solid clinical evidence has been found which states that multiple changes could be present at the same time and perceive themselves as separate identities [15]. The modern research of dissociation is influenced by a number of variables. The words Psychogenic Amnesia and Psychogenic Fugue were interchanged by Dissociative Amnesia (DA) and Dissociative Fugue (DF) after the publication of the DSM-IV.  Dissociative Identity Disorder (DID) has taken the place of Multiple Personality Disorder (MPD) in recent times [15]. The dissociative identity disorder (DID) has been listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Any person suffering from DID experiences the following symptoms: • Loss of memory about specific person, time or events. • Feeling of out of body experience as if an individual is watching a movie of oneself. • Mental health issues like depression, nervousness, stress, suicidal thoughts.

1  History of Dissociative Identity Disorder (DID)

• Person gets detached from one’s emotions [9]. • A person experiences lack of self-identity. • Sleep disorder and symptoms of psychosis.

Types of Dissociative Identity Disorder Dissociation is well defined as a disturbance, interference and/or dislocation of the normal, interpretive assimilation of actions, memory, individuality, conscious experience, feelings, interpretation, body recognition and motor coordination, as per the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) [16]. Following are the DSM-5 dissociative disorders: Dissociative identity disorder (DID): This is currently identified as multiple personality disorder where a person experiences more than one identity. In this condition, more than one voice controls a person who experiences memories in gaps. Men, rather than amnesia or fugue states, are more expected to ignore symptoms and trauma pasts and to engage in further violent behaviour [17]. This could result in a higher number of false-negative diagnoses. The symptoms cause problem in occupational and social settings. Dissociative amnesia (DA): The inability to recollect facts about oneself is referred to as dissociative amnesia. This amnesia is frequently caused by a severe or stressful incident and can include events that are localized, generalized or selective. Dissociative amnesia is linked to traumatic experiences as a child, notably psychological abuse and neglect [17]. Individuals may be unaware of or have just a limited awareness of their memory loss. Individuals may indeed undermine the credibility of memory loss related to a certain event or period of time. Depersonalization/derealization disorder (DPDRD): As if they were watching a movie, this disorder causes people to feel detached from their behaviours, emotions, attitudes and experiences (depersonalization). Others people and objects in the world around them may appear to be unreal at times (derealization). Depersonalization, derealization, or both might well be experienced by an individual [18]. Symptoms might appear and disappear in a matter of seconds or years. Depersonalization events could start as soon as early childhood and last until the age of 16. After the age of 20, only about a quarter of people with this illness begin to have episodes. Other specified dissociative disorders (OSDD): This is a mental well-being diagnosis for pathological disconnection which meets the DSM-5 criteria for a dissociative disorder. However, this does not fulfil all the norms for any of the explicitly addressed subtypes like dissociative amnesia, dissociative identity disorder or depersonalization/derealization disorder. Chronic and progressive combined dissociative symptoms syndromes, identification disturbance caused

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through lengthy and intensive coercive persuasion, disorders comparable to dissociative identity disorder, abrupt dissociative responses to traumatic situations and dissociative hypnosis are all symptoms of OSDD [19]. OSDD is the most frequent type of dissociative disorder, responsible for 40% of all cases. Unspecified dissociative disorder (UDD): This categorization refers to cases wherein symptoms typical of a dissociative disorder are prevalent and end up causing noteworthy distress or damage in social, work-related and other areas of functioning, and therefore do not encounter the recommended guidelines for any of dissociative disorders diagnostic group’s abnormalities [20]. The unspecified dissociative disorder category can be used when a therapist decides not to identify why the criterion for a particular dissociative disorder have still not been met, and it encompasses appearances in which there is limited information to make a more formal diagnosis.

Impact of Social Media on DID Social media is an ideal platform for fun and attracts people of every generation. However, it has its own side effects. It is tied closely to mental health as social media has become a space where people establish and make connections, create self-identity, express them and gain knowledge about external world [21]. As per the research conducted by Royal Society for Public Health, excessive use of social media impacts mental well-being of people. In this study, some common social media platforms like Facebook, YouTube, Instagram and Twitter have been studied. It was found that 91% of youth are addicted towards these platforms. They are likely to adapt virtual personalities as per the demand of multiple social media sites [21]. In order to portray themselves as best in front of everyone, people use various filters to hide their real identity. As a result, they are developing multiple personality disorders and face severe consequences. In the study called #status of mind, the prevalence of anxiety, pressure and depression amongst social media users has increased significantly over the last 25  years, approaching 70%. Generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), social anxiety disorder and panic disorder were some of the most common disorders identified [21]. Users who watched such networks for more than 2 h per day were the ones that suffered the most. These mental disorders are triggered by comparing oneself with peers and believing that have better lives. This also raises bar for the youth to perform better in all areas and this causes mental stress if they do not succeed, or fail. This can cause serious depression and could also impact one’s personal and professional life.

D. Hassan

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Prevalence and Diagnosis DID is a rare psychiatric condition that affects around 1.5% of the global population. This condition is frequently misinterpreted, and an accurate diagnosis often necessitates repeated assessments. Self-harming and suicide attempts are common in patients. Females are 9:1 more likely than males to be diagnosed with DID [22]. Doctors usually diagnose DID based on the patient’s symptoms and historical information. Several tests are performed to diagnose the disease. Evaluations might involve processes like: Physical exam: Doctors often enquire about history and present life by asking in-depth questions, as well as review of symptoms. Certain tests are performed to detect brain injury, sleep deprivation and other brain disease [23]. Psychiatric exam: The mental experts ask questions regarding patient’s emotion, behaviour and feelings in everyday life. Diagnostic principles of DSM-5: This makes the doctors compare symptoms using the principles stated in DSM-5 [23].

Possible Treatment and Management The possible treatment for DID include: Cognitive behavioural therapy: This is among the best treatment for DID.  This involves disorder identification, steps to recover memory and integrating the changes together. This assists in altering the negative thoughts as well as behaviour which often triggers depression. Hypnotherapy: Clinical hypnosis could be used in combination with psychotherapy to support uncover old memories, control a few of the troublesome behaviours related with DID and combine the personality into one. Psychotherapy: This uses methods to find out what factors trigger DID.  The objective is to “fuse” the numerous personality features into a joined personality proficient of regulating the triggers. Family members are often involved in this type of therapy [23]. Adjunctive therapy: Art and dance therapy, for instance, have been confirmed to help patients in relinking with states of their minds that they have turned off in terms of dealing with trauma [23]. Medications: Possible medications for treating DID include antipsychotic drugs, anti-anxiety medications, antidepressants and anxiolytics. Possible management techniques to manage various DID are: • Encouraging healthy coping behaviour by educating patient about fighting their own symptoms, make them learn to handle dissociation, intense fear from flashbacks and more [24].

• Making a list of simple and complex activities that can help in easing the symptoms. • One must be able to monitor symptoms of patients. • Experiencing, processing and integrating painful memories. • Reconciliation and restoration of identities [24].

Conclusion Dissociative identity disorder is still under-researched and due to this it is misdiagnosed. In many cases, patients are often treated for schizophrenia. Nowadays, there are plenty of information available on media about DID.  People are mainly confused about themselves and they search the internet to identify symptoms, diagnosis and treatment on their own. This increases the chance of a false definitive diagnosis, that is problematic for the patient as employing DID treatment with people who do not have autonomous dissociative sections may be ineffective or even worsen their disease. Hence, proper awareness is still required in this field. In this regard, government should initiate proper mental health awareness programs that could educate people about their symptoms and possible treatment. In the past decades, psychiatrist experts have made significant progress in diagnosing and addressing the condition, but there is still much more work to be done. There is a growing acceptance among this disorder by people and information is becoming more prevalent due to latest researches about the types, symptoms and diagnosis. More success is possible by exploring these fields further and helping people overcome multiple personalities.

References 1. Rojo-Pantoja A.  Body and hysteria: dissociated body. In: Psychopathology in women. Cham: Springer; 2019. p. 295–313. 2. van der Hart O.  History of trauma-related dissociation, with a focus on dissociative identity disorder. In: Shattered but unbroken. London: Routledge; 2018. p. 61–87. 3. Middleton W, Dorahy MJ, Moskowitz A.  Historical conceptions of dissociative and psychotic disorders: from Mesmer to the twentieth century. In: Psychosis, trauma and dissociation: evolving perspectives on severe psychopathology. New York: Wiley; 2018. p. 31–42. 4. Harms AH.  The psychological approach to personal identity and dissociative identity disorder. Doctoral dissertation. Long Beach: California State University; 2021. 5. Deeley Q. Hypnosis as a model of functional neurologic disorders. Handb Clin Neurol. 2016;139:95–103. 6. Alvarado CS.  Dissociation and the unconscious mind: nineteenth-­ century perspectives on mediumship. J Sci Explor. 2020;34(3):537–96. 7. McCorristine S.  Spiritualism, mesmerism and the occult, 1800– 1920. London: Routledge; 2021. 8. Reinders AA, Chalavi S, Schlumpf YR, Vissia EM, Nijenhuis ER, Jäncke L, Veltman DJ, Ecker C.  Neurodevelopmental origins of

1  History of Dissociative Identity Disorder (DID) abnormal cortical morphology in dissociative identity disorder. Acta Psychiatr Scand. 2018;137(2):157–70. 9. Reinders AA, Veltman DJ. Dissociative identity disorder: out of the shadows at last? Br J Psychiatry. 2021;219(2):413–4. 10. Bakım B, Baran E, Güleken MD, Tankaya O, Yayla S, Akpinar A, Sengul HS, Ertekin H, Ozer OA, Karamustafalioglu KO. Comparison of the patient groups with and without dissociative disorder comorbidity among the inpatients with bipolar disorder. Fam Pract Palliat Care. 2016;1(2):35–42. 11. Laddis A, Dell PF, Korzekwa M.  Comparing the symptoms and mechanisms of “dissociation” in dissociative identity disorder and borderline personality disorder. J Trauma Dissoc. 2017;18(2):139–73. 12. Reategui AA. Dissociative identity disorder: a literature review. the undergraduate. J Psychol. 2019;31:22–7. 13. Hidayat A, Rozelin D, Santi CF.  Dissociative identity disorder (DID) in split’s film. Ellture J. 2019;1(1) 14. Bernardo KE. Could multiple personality disorder explain life, the universe and everything? Scientific American Blog Network; 2022. https://blogs.scientificamerican.com/observations/could-­multiple-­ personality-­disorder-­explain-­life-­the-­universe-­and-­everything/ 15. Loewenstein RJ.  Dissociation debates: everything you know is wrong. Dialogues Clin Neurosci. 2022;20(3):229–42. 16. Ashraf A, Krishnan R, Wudneh E, Acharya A, Tohid H. Dissociative identity disorder: a pathophysiological phenomenon. J Cell Sci Ther. 2016;7(251):10. 17. Dissociative Disorders | NAMI: National Alliance on Mental Illness. Nami.org. 2022. https://www.nami.org/About-­Mental-­Illness/ Mental-­H ealth-­C onditions/Dissociative-­D isorders/Overview. Accessed 2 June 2022.

5 18. Lemche E, Surguladze SA, Brammer MJ, Phillips ML, Sierra M, David AS, Williams SC, Giampietro VP.  Dissociable brain correlates for depression, anxiety, dissociation, and somatization in depersonalization–derealization disorder. CNS Spectr. 2016;21(1):35–42. 19. Ross CA, Ridgway J, Neighbors Q, Myron T. Reversal of amnesia for trauma in a sample of psychiatric inpatients with dissociative identity disorder and dissociative disorder not otherwise specified. J Child Sex Abuse. 2022;31(5):550–61. 20. Tyrer P.  Dissociative identity disorder needs re-examination: Commentary on… dissociative identity disorder. BJPsych Adv. 2019;25(5):294–5. 21. Ladage R.  Multiple personality disorder, OCD and depression, new study reveals side effects of social media. BGR India. 2022. https://www.bgr.in/news/multiple-­personality-­disorder-­ ocd-­a nd-­d epression-­n ew-­s tudy-­r eveals-­s ide-­e ffects-­o f-­s ocial-­ media-­463355/. Accessed 2 June 2022. 22. Mitra P, Jain A.  Dissociative identity disorder. Ncbi. nlm.nih.gov. 2022. https://www.ncbi.nlm.nih.gov/books/ NBK568768/#:~:text=Dissociative%20identity%20disorder%20 (DID)%20is,injurious%20behavior%20and%20suicide%20 attempts. Accessed 2 June 2022. 23. Mayo Clinic. Dissociative disorders—diagnosis and treatment. Mayoclinic.org. 2022. https://www.mayoclinic.org/diseases-­ conditions/dissociative-­d isorders/diagnosis-­t reatment/drc-­ 20355221. Accessed 2 June 2022. 24. Pietkiewicz IJ, Bańbura-Nowak A, Tomalski R, Boon S. Revisiting false-positive and imitated dissociative identity disorder. Front Psychol. 2021;12:637929.

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Dissociative Identity Disorder and the DSM Vikram Kumar and Krithika Krishnamurthy

DSM has to stay simple, but psychiatry doesn’t. Allen Frances, MD.

Introduction

dissociative amnesia (F44.0), depersonalization/derealization disorder, other specified dissociative disorders (F44.89), In a chapter on dissociative identity disorder and the DSM, it and unspecified dissociative disorder (F44.9) [4]. is only prudent to cover what the DSM is first. The DSM, as Dissociation is a discontinuity in or disruption of comis commonly known, is the canon used by every psychiatrist monly integrated body functions such as emotions, consciousto diagnose and treat mental illnesses. In its current fifth edi- ness, identity, behavior, and motor control. One common tion, the DSM is by no means just a “manual”; it is over 800 theme behind most, if not all, dissociative disorders is a pervapages long and comprises over 150 different mental disor- sive undercurrent of trauma. Sensibly, they are grouped closely ders. Since its inception in 1952, the DSM has come a long after trauma and stressor-related disorders. Many symptoms way with multiple editions and text revisions. Translated into overlap among these disorders and are seen in disorders of many different languages, it is used by clinicians, academics, other classes, such as the manifestation of dissociative sympallied mental health practitioners, courts, and insurance com- toms in acute stress disorder and PTSD. Therefore, a thorough panies. It has set the gold standard for diagnosing and treat- evaluation is necessary, not just of the patient but of their enviing mental health conditions [1, 2]. ronment, to make a diagnosis [3]. The emergence of dissociative disorders into the realm of The world is constantly stimulated through traditional mental health occurred at the end of the eighteenth century. print and social media. Many psychiatric diagnoses have The DSM-I focused on grouping these conditions. With the fallen prey to scrutiny throughout the ages, leading to overdiadvent of the DSM-II, these disorders were included in the agnosis and overprescribing. There is a vast and insidious category of “hysterical neurosis” with dissociative and con- circle, of awareness attracting unwanted attention, not just version subtypes. The DSM-III then eliminated the term hys- from the hoi polloi but also from entities such as “big teria and reclassified neurosis into categories such as pharma” and insurance companies. Through insurance somatoform disorders, dissociative disorders, histrionic and approvals and pharmaceutical companies being able to borderline personality disorders, and post-traumatic stress advertise directly to the masses, psychiatric disorders become disorders [3]. Due to its lack of precision, the word hysteria fad diagnoses. Moreover, that is when the focus shifts from was scrapped. In the DSM-V, dissociative disorders are patient care and rehabilitation, to “clicks, likes, dislikes, and cloistered in between the classes of trauma and stressor-­ hearts.” For example, what may have started as a sincere venrelated disorders and somatic symptom and related disor- ture with Billy Milligan turned into a dog and pony show ders. They include dissociative identity disorder (F44.81), where he was paraded around TV stations like he had won the hunger games. With the newest kid on the block, DSM-V TR, further revisions and new disorders have been included. V. Kumar (*) Department of Psychiatry, Larkin Community Hospital, Therefore, the onus is on the clinician to remain as objective South Miami, FL, USA as possible in a field that has become as subjective as possiK. Krishnamurthy ble. Through this chapter, we will explore DID’s place in the Department of Population and Public Health Sciences, University DSMs, its past, present, and, most importantly, its future. of Southern California, Los Angeles, CA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_2

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Discussion The Evolution of the DSMs Prior to the DSM-I in 1918, the Statistical Manual for the Use of the Institutions for the Insane was developed by the American Medico-Psychological Association, now known as the APA. There were 22 diagnostic categories in this edition that primarily sought to link behavioral problems with organic brain dysfunction [1]. It took another 34  years to create a new classification system, the DSM-I.  This was mainly due to the acceptance and prevalence of the psychodynamic theory, which was made famous in psychiatry’s clinical and academic areas by 1946. The first edition included 102 diagnostic categories and was divided into two groups: conditions due to socio-environmental stressors and organic brain dysfunction. This tradition of expounding psychodynamic theories continued with the DSM-II, published in 1968. With the DSM-II, the scope of mental illness was further expanded to include the broadening of the psychodynamic theories and the addition of severity specifiers. “Reaction,” a term in the DSM-I used to indicate maladaptation to the socio-­environmental sources, was also removed from the DSM-II [1]. Due to rising criticism from the psychiatric community, there was an increasing need for a newer, better way of classifying and diagnosing mental health disorders. These movements led to the DSM-III, which was published in 1980. The DSM-III proved to be a turning point in the world of psychiatry, with many significant changes; most notably, the term “neurosis” was done away with, as it provided a very restrictive and improper definition of maladaptive mental health problems. The number of mental health categories was increased to 265  in the DSM-III from 182  in the DSM-II.  Many disorders were re-categorized, and many novel disorders arose, such as PTSD. The diagnostic criteria were revised to include several standards of diagnosis, such as duration and the number of symptoms required. With the DSM-III also came the multiaxial system, which many clinicians still use today. Furthermore, the DSM-III also sought to distinguish just what is a mental disorder and what is not,

V. Kumar and K. Krishnamurthy

with the category of functional impairment in multiple settings being included. Further editions of the DSM started to include more disorders and underwent further refinement of criteria. Additional information regarding prevalence, age, and gender-­related differences and comorbidities were included, thereby increasing the specificity. The cultural variabilities of mental illness were recognized, with “culture-bound syndromes” being added to the DSM-IV and the DSM-IV-TR [1]. The development of the DSM-V began in 1999 and garnered the most attention due to the rise of the internet. The goal was to provide classification systems in combination with neurosciences and psychometrics [5]. Initially conceptualized, the goal was to include biomarkers. However, this did not come to fruition [5]. The DSM-V continued to receive criticism from multiple avenues, researchers, academics, and clinicians alike. The pharmaceutical companies do their marketing based on DSM-V diagnoses, leading to an emphasis on medications alone. Repeated questions about its validity and reliability have been raised. Unsurprisingly, the same questions and concerns have been raised about the DSM-V-TR.

DID and DSM-V: Diagnostic Criteria The DSM-V defines dissociative disorders as “a disruption of and discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.” It classifies dissociative symptoms as either positive or negative, i.e., fragmentation of identity, depersonalization, derealization being positive symptoms, and amnesia being negative. The DSM-V affirms that these disorders are strongly linked to trauma and places this class of disorders next to trauma and stressor-related disorders for the very reason. The Dissociative Disorders class involves Depersonalization/Derealization Disorder, Dissociative Amnesia, Dissociative Identity Disorder, and Other Specified Dissociative Disorder. For the scope and purposes of this book, we will focus on dissociative identity disorder. Below listed are the diagnostic criteria:

2  Dissociative Identity Disorder and the DSM

Criterion A of dissociative identity disorder, as put forward by the DSM-V, is characterized by two or more personality states or even possession states as per cultural connotations. Although “clearly” defined, this criterion is subject to various interpretations. Research has shown that in cases of dissociative identity disorder, there is not just the presence of distinct personalities but also different classes of personalities, such as the “aggressor” personality and the “protector” personality. These distinct classes and types of personalities arise from the trauma endured, which, in identified cases, is pervasive and very severe. The types of abuse include long-term sadistic physical and sexual abuse and ritual abuse. When these pressures or stressors are severe, these personalities arise depending on time and need. The manifestations of these personalities can be highly varied, depending on the situation. The DSM-V uses the term “overt” while describing possession states and “covert” for the rest. The latter part of criterion A describes the sudden alterations and discontinuities in the sense of self and agency, delineating these dissociative states. These states also involve the presence of recurrent dissociative amnesias, which is highly characteristic of the disorder. Patients often describe long gaps in memory, ending up in locations for which they have no explanation, and this contributes to the heightened distress endured by the patient. When delving into literature

9

involving the pathophysiology of this disorder, behavior scientists and mental health researchers theorize that the trauma endured is so severe that there is a “split” or “disruption” in the core personality, also termed the “host” personality. Often accompanied by repression, these traumatic and unendurable aspects of one’s consciousness are theorized to have dissociated into these new personality states. During states of depersonalization, these individuals view themselves and their speech and actions but describe themselves as powerless to stop them. Distressing emotions and impulses appear without a sense of self-ownership. As DSM-V describes it, this lack of self-control or sense of agency is also accompanied by another remarkable feature of dissociative identity disorder, namely episodes of amnesia or memory gaps. The DSM-V describes that these amnestic episodes may present in three distinct ways, including tasks and daily actions that they have no recollection of doing, remote memory gaps, including that of childhood, or significant life events that happened, such as the death of a relative and dependable memory lapses in which there is amnesia of learned skills such as driving. Fugue states involving traveling are also commonly seen in these cases. These lapses are usually apparent to the individual and others, such as spouses and family living in proximity to the individual. Criterion A of DID also talks about possession from a cultural context. In states of possession, there is the channeling

10

of a “spirit” or supernatural entity, characterized by the individual speaking and acting in a manner distinct from the self. These possession states may also include ghosts of people who have died, where the individual speaks and acts like them as if they were alive. Possession can also involve demonic entities, which can result in severe impairment not just by way of possession itself but also through the formal process of exorcism. These states may be transient (for example, a case of rapture) or long-standing. The identities that come from these states can be recurrent and involuntary and cause significant impairment or distress. We will be covering the concept of possession and religion through the lens of DID in the chapter Dissociative Identity Disorder and Religion, Demonic Possession.

 he Prevalence, Development, T and Course of DID In a small community study done in the United States, the 12-month prevalence of DID was estimated to be 1.5% [5]. Ross et al. studied the prevalence of DID among college students, the general population, and adult inpatients in the United States, Canada, Turkey, and Switzerland, and the lifetime prevalence of dissociative disorders was found to be 10%. The study estimated the prevalence of DID to be 1%. These mainly included the milder cases found in the treatment. The SCID-D or structured clinical interview for dissociative disorders has aided chiefly in making the diagnoses and establishing the prevalence of DID [6]. Regarding gender, the prevalence was 1.4% for females and 1.6% for males [5]. As is the recurring theme in this disorder, DID is often preceded by childhood and, in many cases, pervasive and ongoing severe abuse, including ritual abuse, incest, and sadism. Research has shown that DID can manifest at any age, early childhood or later. Childhood cases of DID often do not manifest as several distinct personalities; instead, they report identity disruption and loss of the sense of agency. Patients may present with symptomatology consistent with mood or psychotic disorders. Cognitive problems have also been noted in these cases due to the dissociative and amnestic components of the disorder. Precipitating events are wide-­ ranging and can include the death of a loved one, traumatic events such as motor accidents, and life events such as leaving home. In some instances, when the individual’s children reach the same age as the individual was abused, the disorder is shown to present. In over 90% of the diagnosed cases of DID, severe abuse is common. Prostitution, especially in childhood, terrorism and war, and complex medical and surgical procedures have also been cited as precipitating events. In cases of disorders such as DID, which has been widely publicized in media, there is another aspect to consider: the iatrogenic creation of the disorder through psychotherapy.

V. Kumar and K. Krishnamurthy

With many outspoken critics of DID espousing this facet of the disorder, the literature suggests that though some of the symptoms can be created by iatrogenic influence, the whole disorder presenting due to the same is unlikely. History has shown that persons diagnosed with DID, especially those facing criminal liability, have faced intense attention from media and the hoi polloi and take on somewhat of a “celebrity status.” Interestingly, the same psychiatrist who worked on the premier case of Sybil, Dr. Cornelia Wilbur, was the same physician to work on Milligan as well. When combined with other disorders, such as antisocial personality disorders, this fame and attention can lead to malingering and trying to cite the insanity defense to get out of the crimes. The flip side to this argument remains that, when viewed through the lens of DID being purely simulated, authentic and genuine cases can be ignored. Therefore, the onus is on the team of mental health professionals to maintain utmost objectivity.

 iagnostic Issues in the DSM-V and Functional D Consequences The patient’s cultural background plays a significant role in influencing the course of DID. In settings and situations where possession states are standard, the identities or alters can take the form of spirits, demons, and ghosts within the scope of their religious experiences. Similarly, acculturation also plays a vital role in shaping personalities, for example, dressing in a way similar to and speaking in the language of a different culture. Individuals with DID may also present to the primary physician with neurological complaints, such as sensory losses, seizures of non-epileptic variety, or even paralysis of limbs. While considering possession, the DSM-V stratifies it into two different experiences: culturally accepted possession states and possession-form dissociative identity disorders. Culturally accepted possession states are, as the name suggests, the possession-form cases of DID tend to be highly distressing, involuntary, persistent, and uncontrollable. They are also notable for presenting outside the norms of culture or religion. When considering the gender-related issues of DID, it is notable that in females, DID is predominant in adults and not in childhood clinical settings. Male patients with DID are found to poorly report trauma and abuse history, which makes the a false-negative diagnosis even more likely. Acute dissociative symptoms are predominantly seen in female patients, including states of amnesia, amnestic travel such as fugue states, flashbacks, and psychotic symptoms, to name a few. The presence of other comorbid disorders increases the chances of false-negative diagnoses as well. Due to the rising prevalence of substance use disorders and personality disorders such as antisocial personality disorders in males with DID, criminal behavior is more prominent. Other common triggers also include physical or sexual assault, combat or

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war-related traumatic experiences, and conditions including confinement such as incarceration. In genuine cases of DID, the functional impairments are often less likely to be reported by symptomatology. In high-­ functioning individuals, the impairments may be reflected in their personal life more profoundly than in professionals; however, the latter may eventually follow without proper treatment. Response to treatment in individuals with DID has been slow and gradual. Supportive, long-term care is necessary to improve functionality in these individuals. Many individuals with dissociative identity disorder end up disabled and spend twice as long in therapy than patients with DID without disability. Patients’ most disabling and impairing symptoms tended to be depression, memory problems, and rapid switching between alters. Difficulties with task completion, complex attention, and concentration are also prevalent in individuals with DID and tend to be severely distressing. However, these same areas are vital in setting treatment guidelines and improving overall functioning [7].

2. Some clinicians and literature continue to mention the fact that DID gets included in DSM-V because of personal interest than anything else. Thoughts?

Interview with an Expert Psychiatrist

4. What are your thoughts on DID’s current place in the DSM-V?

Dr. Allen Frances Questionnaire

DSM-IV eliminated the name MPD and introduced DID, and we set up a standard for making changes, which required significant evidence. DID may not be fully eliminated or added as a diagnosis. I take a utilitarian view of diagnosis in general but DID does more harm than good. With the DSM-IV we sought to do a balance and avoid controversies. 3. During the inclusion of DID into DSM-IV, what were the challenges faced? Was there any difference in the conceptualization, apart from the addition of a new criterion? Oh, there were many (laughs). For one, we changed the name to make it less dramatic. The concept was it became ridiculously popular diagnosis at that time and was not uncommon. And yes, we added the new criterion.

That it should not be present. Dr. Allen Frances is a much-acclaimed psychiatrist, academic, and author with decades of invaluable contributions to the field. From serving as the chairperson of the DSM-IV taskforce, to being the Professor Emeritus and chairman of Duke University Department of Psychiatry, Dr. Frances has been a champion of mental health. Dr. Frances has also authored multiple books such as Saving Normal, which has been a major source of inspiration for this chapter, and Twilight of American Sanity. In this telephonic interview, Dr. Frances has shared some of his thoughts on DID and its place in the DSM moving forward. 1. What is your take on dissociative identity disorder, as a diagnosis and its validity? Is it really a fad diagnosis? To quote “Multiple personality disorder has been popular, for only in very brief periods, in very special places.” It is my take that it is a fad diagnosis. The fad died out sometime around 1998, when insurance companies stopped paying and malpractice suits against therapists started to increase in number. Aside from the media publicity, there were many charismatic lectures, the giving of workshops, especially by individuals who were excited by the diagnosis, which only added to the growing movement.

5. What has your experience of DID been like? One of the cases that comes to mind is a patient with 162 personalities. Personalities kept appearing at a higher rate. From Morton Prince in early 1900s it was popular for a while, then popular with Eve and Sybil came into the picture and everything blew up. In my experience I also saw that individuals kept coming up with more and more personalities. Nowadays there has been a reduction in the diagnosis due to the legal liabilities, not the DSM, and also the fact that it did not help people. 6. How do the course and presentation of symptoms differ? It depends on the person having it. Lots of people express symptoms which seem credible when viewed through the DID lens, it also depends on who they were before the presentation of symptoms. The way they express the symptoms depends on many things, their personalities, previous problems, etc. For example, someone with preexisting personality disorder, they can express it in a particular way and for some, it’s another way there is no uniform course of symptoms.

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7. What, in your words, is the best way to diagnose a case of DID? Is there any specific approach? In my take, the best way is to NOT diagnose it. My personal view is to try to curtail it than encourage it. 8. In which direction do you see DID headed in, in the future DSMs? Do you have any personal recommendations for the same? Honestly, I have no idea. There is no way to predict definitively, and it will mainly depend on society, if there is another popular book or movie, what is being said on the internet. For instance, eating disorders are more common now because of the internet. We could either use it as a tool to organize or propagate such views. 9. How you think social media has affected all this? TikTok phenomenon. That worries me. At this point, you don’t need another Sybil. However, if QAnon could take off, why not this? 10. Can you provide us some perspective on why you thought Billy Milligan was malingering, beyond what you shared in the Documentary? He was taught how to do it. He was working with the same psychiatrist who worked with Sybil, and they taught Sybil about it at that time as well. Dr. Spiegel, who has been most influential in advocating for DID, he did some interviews with Sybil and thought she was faking it. The influence of her therapist only made it worse. In fact, Sybil even lived with that same therapist until the end of the therapist’s life. It’s not surprising that Sybil admitted to Spiegel that she said things to please the therapist, same thing happened in Billy’s case. 11. In the recent years, DID has increased in incidence, especially in the legal domains due to its link with crime. Do you think it’s a valid reason for the insanity defense? DID never was, nor do I think will be a viable defense for crime. If QAnon can happen, anything is possible. I can’t say for sure, but I don’t think it is going to be effective in courts. It depends on the judges if they allow extra witness testimonies. It is good that the Milligan fiasco was not repeated and not allowed, that was a one off. However, once it gets to a jury, anything can happen. The world is only getting nuttier! This interview with Dr. Frances brings to light many interesting aspects of dissociative identity disorder and how

V. Kumar and K. Krishnamurthy

it has come to be viewed through the eyes of mental health professionals. Dr. Frances points out that in his opinion, it is more of a fad than a diagnosis, as it has only been popular at specific, brief periods of time during which the condition had the full attention of media. From the time of Sybil to that of Milligan, DID cases were widely reported and exaggerated as Dr. Frances puts it, which became a self-fulfilling prophecy with insurance companies paying for it and more and more mental health professionals organizing workshops and giving talks on it as well. When conceptualizing the DSM-IV, according to Dr. Frances, the paramount idea that he had about DID (which was then called MPD) was to provide a balance and avoid controversies. Even the name was changed to make it sound less dramatic. However, Dr. Frances suspects that if another case were to rise capturing media attention, it could very well take on a mind of its own. The fact that dissociative identity disorder can be an iatrogenic artefact to therapy and that the symptoms can be coached (as in the case of Sybil and Milligan) are aspects that are highly concerning. Finally, we end the interview with a note that only time will tell, as according to Dr. Frances, the world is only getting nuttier!

Conclusion This chapter on dissociative identity disorder and the DSM-V looks at the evolution of the diagnostic and statistical manuals and dissociative identity disorder’s place in them. Once we have established the diagnostic criteria, we look at each criterion to define and establish the unique symptomatology that constitutes dissociative identity disorder. The dissociative episodes and disruption of identity are at the forefront and, as defined by the DSM-V, “a loss of sense of self or sense of agency.” Significant gaps also accompany these every day and even biographic memory episodes, which can involve fugue states and travel. Types of personalities such as the “aggressor and protector” are also seen. Possession states are also included in criterion A per the DSM-V and are differentiated into possession-form dissociative identity disorder and culturally defined possession states. The prevalence of dissociative disorders and DID is estimated at 1.5%, with a noted male predominance. Furthermore, diagnostic issues such as culture and gender-related issues are also examined. Research has shown that DID leads to significant long-term disability, which is impairing and requires treatment and rehabilitation. Finally, we have an interview with Dr. Allen Frances, the chair of the DSM-IV taskforce, where he offers his insights into dissociative identity disorder. Acknowledgments  We would like to extend our gratitude to Dr. Allen Frances, MD, chair of the DSM-IV taskforce for his wisdom, experience, and invaluable insight into this chapter.

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References 1. Kawa S, Giordano J. A brief historicity of the diagnostic and statistical manual of mental disorders: issues and implications for the future of psychiatric canon and practice. Philos Ethics Humanit Med. 2012;7(1):2. https://doi.org/10.1186/1747-­5341-­7-­2. 2. Wikipedia Contributors. DSM-5. Wikipedia, the Free Encyclopedia. https://en.m.wikipedia.org/wiki/DSM-­5. 3. Putnam FW. Dissociative disorders. In: Handbook of developmental psychopathology. Boston: Springer US; 2000. p. 739–54.

13 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). 5th ed. American Psychiatric Publishing; 2013. 5. Ross CA, Duffy CMM, Ellason JW.  Prevalence, reliability and validity of dissociative disorders in an inpatient setting. J Trauma Dissoc. 2002;3(1):7–17. https://doi.org/10.1300/j229v03n01_02. 6. Mueller-Pfeiffer C, Rufibach K, Perron N, Wyss D, Kuenzler C, Prezewowsky C, et al. Global functioning and disability in dissociative disorders. Psychiatry Res. 2012;200(2–3):475–81. https://doi. org/10.1016/j.psychres.2012.04.028. 7. Özdemir O, Özdemir PG, Boysan M, Yilmaz E. The relationships between dissociation, attention, and memory dysfunction. Nöro Psikiyatri Arşivi. 2015;52(1):36.

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Dissociative Identity Disorder: Theory vs. Facts Safeera Khan

Dissociative disorders are psychological or mental disorders that cause a person to experience a disconnection from reality. They experience a loss of continuity between their thoughts, memories, surroundings, and identity and involuntarily lose their connection with reality. This disrupts their everyday life and makes it hard for them to function normally [1]. The disorders are considered a reaction to childhood trauma or an involuntary defense mechanism that can help them keep the traumatic and harsh memories away. Based on their dissociation stage, they may present anywhere between the range of mild amnesia and the development of alternate identities. The four main dissociative disorders include dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative identity disorder (DID) [1].

Dissociative Identity Disorder (DID) Dissociative identity disorder, formerly known as multiple personality disorder, is characterized by developing different and distinct alternate personalities. These alternate personalities or alters co-exist, will be distinct, and may differ from the original personality. These different alters may act or behave in a completely unknown way to the original personality, which causes a lot of confusion surrounding this disorder. DID is also sensationalized and stigmatized in mainstream media and movies; this disorder is a misunderstood condition leading to beliefs about it or myths far from reality. People often confuse the condition with demonic possessions to explain their different alters.

S. Khan (*) California Institute of Behavioral Neurosciences and Clinical Psychology, Fairfield, CA, USA

 yths Regarding Prevalence M of the Condition Myth  DID is a rare condition DID, although uncommon, is not very rare and affects around 1–1.5% of the general population [2]. However, some studies showed it as high as 6% [2]. Considering all the uncertainty involved with the condition and difficult diagnosis, several cases remain undiagnosed, which means the actual cases are even higher. This high prevalence rate involves young women with bulimia or obsessive-­ compulsive disorder (OCD). Since many trauma survivors are still in a state of denial or secrecy, gathering proper data is difficult. However, the therapists evaluating any patients may encounter many such cases, making the actual prevalence way higher than reported and a concerning mental health issue.

 yths and Theories Confusing It with Other M Psychiatric Disorders Myth  Dissociative identity disorder (DID) is not a real disorder but a condition created by therapists, and maybe it’s just attention-seeking behavior or an exaggerated bipolar disorder (BPD). Some people even consider this condition to be not real. However, dissociative identity disorder is a real and diagnosable disorder. Failure of this recognition impedes the provision of proper treatment to these patients. Significant evidence is available from researchers about this disease, and newer guides for proper diagnosis and identifying symptoms are already listed in DSM-V [3]. It is the only condition with prominent and pronounced ‘amnesic gaps’ or missed times that are not explained by any other condition.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_3

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Myth  DID is a type of personality disorder DID is a dissociative identity disorder previously known as a personality disorder. However, according to DSM-V, DID is a dissociative disorder involving dissociation and loss of contact with oneself [3]. Contrary to that, a personality disorder involves having fixed personality traits inhibiting the person from living a normal life. Myth  Dissociative disorder is similar to schizophrenia Schizophrenia is a psychotic disorder that includes a whole set of symptoms with hallucinations and paranoia as a major part. The misconception of these two conditions being similar is focusing on some key parts or symptoms instead of viewing it as a condition as a whole. Dissociative identity disorder, on the other hand, is where completely distinct personalities exist as alters [4]. Similarly, DID is also mistaken for several different conditions [4].

Myths Regarding the Alters Myth  Patients with DID can have only a few alter and are not aware of their alters or their condition Some people with DID may have only a few ‘alters,’ whereas there may be a case where several alters co-exist, and some that were not apparent were discovered during therapy. Although people who have undergone extreme abuse like child trafficking or ritual abuse may even have hundreds of alters in the DID system, there is no direct association between the number of alters and the severity of trauma. It is common that patients may not be aware of the exact condition of their alters, their trauma, or the challenges that come or they subconsciously face. However, they may become aware of their traumatic experiences at any point during an illness or when they start therapy and become aware of their condition. They may recall situations when they find things they do not remember getting [5].

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understanding of the situation and world around them by dissociating from it.

Concepts and Myths Related to Introjects Myth  Introjects are evil and may represent the abusers of the person Introjects are those alters that are a mirror representation of an actual outside person; they may even have similar names and characteristics. Introjects are not inherently a negative influence or evil. These individuals may have strongly influenced the person, which may be positive or negative, or at times may even be a fictional character. The abusers as introject are also prevalent and prominent enough to create a myth that introjects are always evil and abusers. Introjects function well enough despite being an outside person because of the amount of time spent with them by the person. Abuser introject may not have any protective or helpful purpose but rather re-enact the abuse or trauma at times, re-enforcing the belief that abuse should be stopped. They are not necessarily evil but are extremely traumatized and have a twisted understanding of safety and care. Introjects, at times, can be a person from history or any other famous person, which may lead to misdiagnosis of the condition even further. Myth  The negative, evil, or harm-causing ‘alters’ should be trimmed or removed These ‘alters’ develop as a part of the process and act in a certain way for their reasons. They process their pain differently from normal processing by dissociating from reality and adopting their understanding of reality as a child. Trying to eliminate one or other alters may not necessarily work or cause more damage than benefit. Understanding the alter and attempting fusion may be a better approach to the situation. A part of the conscious mind cannot be killed or removed as their memories, thoughts, and experiences will remain. Killing or removing an alter altogether may be extremely dangerous.

Myth  The alters always are other human personalities. NON-human ‘alters’ cannot exist

Myth  Alters cannot have mental or other health issues if the main survivor is healthy

Since the cause of DID is rooted in childhood trauma and the abuse is inflicted by other humans, the children are usually afraid of the adults, and these ‘alters’ develop to dissociate them from their memories [6]. The inhuman ‘alters’ are fairly common as well. A harmless animal, a feared robot, or an entity may feel safer than the terrifying world around them. The appearance or development of alters is not a person’s conscious decision or is never decided by the person. Instead, they develop based on their

It does seem unrealistic, but the alters can have depression, mental health issues, and eating disorders. The alters may behave according to the condition they are facing. Similarly, there may also be variations for other health conditions, like having different visual acuity or physical conditions. The alters may operate on a different neuronal pathway; hence, they may feel and act differently. This makes them respond differently to various stimuli, allergies, and other conditions.

3  Dissociative Identity Disorder: Theory vs. Facts

 yths Regarding Patient’s Behavioral M Symptoms Myth  People with dissociative identity disorder are dangerous, violent, and may have alters that may do extreme harm or are criminals and can use the excuse to avoid consequences People with dissociative identity disorder are similar to the general population in being violent with no extra prevalence. This idea mainly stems from the portrayal of DID in movies where one of the alters is either violent or criminal. However, no criminal association or link is found with DID [7]. This increases stigmatization of the people affected by this disorder caused by the fear created by this association in media. They, on the contrary, may be the victims of violence themselves because of their alters or may experience trauma or abuse repeatedly [7]. Unlike shown in the media, the disorder is not commonly used as a criminal defense to avoid the consequences of the actions. Since it is not insanity, the defense may not hold up well in the courtroom. Myth  General public understands the representation and portrayal of dissociative identity disorder in movies and TV as being over-sensationalized. The portrayal of DID in media has caused more confusion about the symptoms, and not everyone is aware of the actual symptoms. How dissociative identity disorder is shown and portrayed in the media has created confusion regarding the symptoms of this disorder. Some of the depictions in media portray certain characteristics right and may have clarified some of the misconceptions; others may have wrongly exaggerated some symptoms to sensationalize them, causing more confusion. Some symptoms are also entirely fictional, such as the sudden switching of characters. In reality, switching to a different alter is subtle and is a covert shift instead of a sudden one, e.g., movies displaying DID are Sybil, Split, etc. People with DID may feel stigmatized because of the negative portrayal, preventing them from seeking help. Myth  Dissociative identity is apparent and easy to diagnose. Dissociative identity disorder is a tricky diagnosis. A person with DID, on average, goes through at least four misdiagnoses before getting accurately diagnosed. Researchers have found that, on average, a person is misdiagnosed up to four times before being accurately diagnosed with a dissociative identity disorder. A person may spend 12 or more years in the mental health system getting evaluated or treated for misdiagnoses before the correct diagnosis. One of the

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factors contributing to the misdiagnosis is the hesitance of the patients seeking help compared to the help they may seek for other disorders like mood dysregulation. Another factor leading to misdiagnosis is the unawareness of the existence of multiple alters. Since the person seeking psychological consultation for trauma or any other condition may still be misdiagnosed as they may not even be aware of their multiple personalities, this may remain undiagnosed unless the patient goes through the personality shift during the therapy session. Myth  The switches between personalities will be sudden, dramatic, and apparent A very small percentage of the patients with DID, around 5–6%, will have an overt presentation of their alters [4]. Most of the time, the changes may be subtle and switch as a normal behavioral change, as little as a facial tic or small movement like switching positions. However, therapists or close friends may sometimes see some of the changes. The alters may learn to blend in and act similarly to the host, even with different traits. The younger or child alters sometimes may be apparent in the presence of adults. They may have subtle shifts in their traits, like changing handedness [8]. Myth  Because of the trauma, the mind splits into various alters which present multiple times. This was a previously considered model for DID and is believed by many therapists who have not updated themselves with the current knowledge. The underlying mechanism of action is the theory of dissociation, according to which DID occurs because of failure to coordinate and integrate into one personality, contrary to division into parts. Even any two alters of the same age or gender may be different from one another. Any two ‘child alters’ may behave and feel entirely different. One may be traumatized, broke, rebellious, or happy and an extrovert. Some may be very athletic, whereas others may be blind or unable to function normally. However, all these alters can grow and transform individually [9]. Myth  DID can develop and manifest at any age According to researchers, DID develops in early childhood, mainly between 6 and 9  years of age. Some of the papers have listed as early as four. Any repeated trauma after that age can cause complex PTSD, which will not be DID despite having some overlapping symptoms. Other dissociative disorders, like other specified dissociative disorders (OSSD), may resemble DID closely with a lesser alter differentiation and amnesia and may occur in some trauma survivors instead of the DID spectrum of illness.

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Myth  The alters can be switched as needed by the patient for a task or called easily by others or the therapist The switch, as discussed, is not a straightforward one. Although the alters usually appear in certain conditions as a protective mechanism or for certain tasks it is not always certain if it will always be the case. During a therapy session, the psychiatrist or psychotherapist may be able to call upon the alters to understand the reasons while making a diagnosis. However, for any other reasons than medical management or by anyone other than the certified person, it will be highly unethical and will be a breach of personal space, and may be dangerous. Myth  Patients talk to their alters like talking to regular people, like seeing them outside as separate persons. Patients with DID often communicate with the alters internally as a conversation within their heads in an internal or alternate world, as communication happens with a distinct person in their mind even when they are not apparent [9]. This aspect of the condition causes a mix-up of the condition with schizophrenia, often confusing these alters as auditory hallucinations when they are like loud thoughts of a person instead of extrasensory perception or hallucination. They may also use other means of communication to talk to the other alter when that alter is the dominant alter, like journaling, writing post-it notes, videos, blogging, etc. Myth  DID can easily be treated by regular therapists, and any therapist dealing with trauma will be able to heal and help them DID is a complex condition and is not easily manageable even by specialists. The majority of the information out there is also outdated, making the management of conditions hard for therapists. The diagnosis itself takes in-depth and detailed consultations with multiple visits. One of the major knowledge gaps that exist is the unawareness of physicians and specialists about dissociation, memory processing, and alter fusion. Any physician with no experience with these cases may be able to diagnose them as PTSD and miss the key symptoms and alters. With concerns about patient safety or the tendency for suicide, the room for error is very narrow. Getting the necessary knowledge of the condition is important to avoid any errors. Specialized training in DID diagnosis and management can cover this gap and avoid misdiagnosis. Myth  DID can be treated with medications. People may mistake that there may be some medical option available to treat the condition because, to stabilize moods, other trauma-related conditions, like PTSD, anxiety,

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and nightmares, all have medical options to alleviate symptoms. However, there are currently no medications to treat DID. Psychotherapy is the only option used to diagnose and manage the condition. Myth  The goal of therapy is to integrate all the alters into a single individual identity. Like any other illness, every patient with DID is different and needs a personalized and individualized approach to treatment. Therefore, when the goal can be integrating into a single personality for some patients or the ‘final fusion,’ it may not be the case for all other alters. The goal in managing is to heal the patient completely by adequately processing memories, lowering barriers between dissociative personalities, and a common goal of healing and normal functioning. During the process, however, some may achieve the final fusion, some may downsize the alters, and some may learn to co-exist. Myth  Patients with DID may not be able to lead normal lives and be independent and will remain dependent on therapy and shifting between hospitals. Although the outcome may vary from patient to patient, successful therapy may differ for everyone. People with DID are functioning and working in all walks of life and are functioning normally. There are several cases where they have reached the top positions of life while living with the condition and after undergoing treatment. Myth  The word ‘alter’ or ‘part’ in DID is synonymous with the alter ego. This is another misconception about the condition, where the terminology used to describe distinct personalities can be misunderstood. In the context of DID, ‘alter’ means ‘an alternate state of consciousness or the alternate personality.’ The terminology altered personality fits the clinical context the most and is used by clinicians and researchers. The word alter ego, however, does not correlate with the actual disorder. Witkins and Witkins described the alters as different from egos because of having distinct personalities, memories, autobiographies, and habits [10]. Myth  Last but not least, the myth is of the common population’s belief that demons possess people with DID. In an attempt to explain multiple personalities with distinct characteristics, people may consider them supernatural or possessed. However, scientific research has explained the mechanism of action and why the condition develops. Simply praying it away or conducting rituals will not make the condition disappear [6].

3  Dissociative Identity Disorder: Theory vs. Facts

Myth  DID misunderstood by medical community DID is misunderstood not only by the common public but also by the medical community—this is due to lack of understanding and the presence of a huge knowledge gap about proper diagnosis and symptoms [4]. We do not disbelieve the existence of systemic and other psychiatric illnesses like eating disorders, cancer, or OCD just because some people fake having them, and the malingering rates are fairly high for these conditions. Why should DID be any different? The misconceptions should be clarified by raising awareness and proper education about the condition.

References 1. What are dissociative disorders? 2018. https://www.psyc h i a t r y. o r g / p a t i e n t s -­f a m i l i e s / d i s s o c i a t iv e -­d i s o r d e r s / what-­are-­dissociative-­disorders. 2. Mitra P, Jain A. Dissociative identity disorder. Treasure Island (FL): StatPearls Publishing; 2022.

19 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013. 4. Gillig PM. Dissociative identity disorder: a controversial diagnosis. Psychiatry (Edgmont). 2009;6(3):24–9. 5. Spiegel D.  Expert Q&A: dissociative disorders. 2020. https:// www.psychiatry.org/patients-­f amilies/dissociative-­d isorders/ expert-­q-­and-­a. 6. Brand Bethany L, Sar V, Pam S, Christa K, Korzekwa M, Alfonso M-T, Middleton W.  Separating fact from fiction: an empirical examination of six myths about dissociative identity disorder. Harv Rev Psychiatry. 2016;24(4):257–70. https://doi.org/10.1097/ HRP.0000000000000100. 7. Webermann AR, Brand BL.  Mental illness and violent behavior: the role of dissociation. Borderline Personal Disord Emot Dysregul. 2017;4:2. https://doi.org/10.1186/s40479-­017-­0053-­9. 8. Le C, Smith J, Cohen L.  Mirror writing and a dissociative identity disorder. Case Rep Med. 2009;2009:814292. https://doi. org/10.1155/2009/814292. 9. Alters in Dissociative Identity Disorder. 2022. Traumadissociation. com. http://traumadissociation.com/alters. Accessed 3 Nov 2022. 10. Watkins JG, Watkins HH.  The management of malevolent ego states in multiple personality disorder. Dissociation. 1998;1(1):67– 71. http://hdl.handle.net/1794/1333

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Different Kinds of Dissociative Disorders, Including Dissociative Identity Disorder Saikat Kar

Introduction An involuntary disturbance or discontinuity in the normal and subjective coherence of one or more components of psychological functioning, such as memory, identity, sensations, perception, thoughts, behavior, or motor control, is the defining characteristic of the condition known as dissociation. In general terms, many aspects of psychobiological functioning that ought to be related, coordinated, or linked are not. These disturbances or discontinuity can vary from day to day or even from moment to moment within a day. Dissociative disorders (DD) typically follow traumatic events, and the severity of many symptoms—including embarrassment, confusion, and the desire to conceal the condition—depends on how recently the incident occurred. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), dissociative disorders are placed after trauma- and stressor-related disorders, but they are not in that group, which shows how closely these two diagnostic groups are related. Both acute stress disorder and posttraumatic stress disorder have dissociative symptoms like amnesia, flashbacks, numbing, and depersonalization/derealization [1].

 onceptualization of Dissociative Spectrum C Disorders The French psychologist Pierre Janet made the first description of the disorder, called désagrégation mentale. The French word désagrégation means something different than what it means in English: “dissociation.” It means that mental contents are separate, even though they tend to come together or be processed together. When it comes to issues of consciousness, memory, identity, and perception, the problem is not a

S. Kar (*) Centre for Discovery Brain Science, Edinburgh Neuroscience, University of Edinburgh, Edinburgh, UK

surplus of pieces but rather a failure to integrate them. Janet thought that dissociation was a purely pathological process. Later, Jean-Martin Charcot, a famous neurosurgeon interested in hypnosis, who taught Sigmund Freud how to do it, believed that an artificial or experimental nervous state induced by hypnosis could be used to assess separated mental contents. In contrast, Freud’s psychoanalytic theory emphasized repression rather than dissociation as a model of motivated forgetting. In his early writings with Josef Breuer, Freud looked at similar cases of dissociation to learn about the unconscious. The way identity and memory are broken up in dissociative states made it easy to develop a theory about the unconscious, which is the processing of information that is not easily accessible to conscious awareness. They tried to explain this lack of integration as the idea of “hypnoid states.” Breuer and Freud thought in 1955 that the ability of some people to go into hypnotic states could cause dissociative symptoms, not the other way around, as Charcot had felt [2]. Repression is not the same as dissociation as a general model for keeping information out of conscious awareness. Dissociation often seems to happen as a defense mechanism after physical trauma, while repression happens when fears, wishes, and other dynamic conflicts are pushed away. Later, Ernest R. Hilgard developed a theory called neodissociation, which again revived interest in Janet’s psychological ideas and dissociative psychopathology. In contrast to Freud’s system, the neodissociation model allowed any blocked memory to come back into consciousness immediately. In Hilgard’s model, amnesia is a very effective way to separate one set of mental contents from another. So, using amnesia in a flexible way is thought of as a critical defensive strategy during dissociation.

Epidemiology The prevalence of the disorder appears to be associated with the demographic under investigation. It shows a 1–5% prevalence in the international population. It is estimated that over

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_4

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half of all US adults may experience symptoms of dissociative disorder at some point in their lives. A chronic dissociative disorder affects just 1–2% of those adults. Dissociative disorders are predicted to have a prevalence of almost 10% in clinical settings (inpatient and outpatient psychiatric clinics). The highest incidence of dissociative disorders is seen in populations who engage in risky behaviors, including drug use, prostitution, and exotic dancing [3]. The majority of people with dissociative disorders show symptoms before they become 20.

Etiology: Theories and Models of Dissociation Dissociative symptoms are the source of much debate since scientists and theorists have so far been unable to explain their etiology convincingly. In more severe cases of pathological dissociation, dissociation is typically triggered by intense emotional or psychological stress. When dissociative symptoms persist throughout a person’s life, as in the case of dissociative identity disorder (DID), they may manifest themselves even in the absence of trauma or extreme stress. The trauma model (TM) focuses narrowly on traumatic causes of dissociation. The sociocognitive model (SCM) considers a broader range of social, cognitive, and cultural factors, and the sleep model (SM) argues that the primary factor bringing about dissociation is a labile sleep–wake cycle, which is competing for theories of dissociation.

The Posttraumatic Model (TM) The trauma model is the most prevalent theory aiming to explain the origins of dissociative experiences. It was proposed by Pierre Janet that intense emotion may produce dissociation in susceptible persons. Since then, this idea has been broadened to encompass many forms of traumatic events that may interact with genetic predisposition or attachment patterns. Likewise, a large amount of research indicates that dissociation is highly linked to childhood trauma in both clinical and non-clinical populations. Repeated early trauma, also known as “attachment trauma,” depicts systematic abuse or neglect from caregivers throughout infancy and has been identified as a critical component in developing substantial dissociative symptoms. A theoretical explanation for these correlations is that dissociation is a coping technique for dealing with—or avoiding—aversive events by retreating mentally when physical escape is impossible. Trauma and dissociation theorists have proposed that while dissociation may help comfort overwhelming distress

in the near term, it becomes maladaptive over time as the predisposition to react with emotional detachment may be used non-selectively when encountered with even relatively minor stressors [4]. According to the posttraumatic model, these three primary dissociative disorders from the DSM-5 (American Psychiatric Association, 2013) best illustrate the traumatic roots of dissociation: • Depersonalization (perceiving oneself as an objective spectator of one’s own actions and emotions) and derealization (perceiving one’s surroundings and situations as unreal) are the hallmarks of depersonalization/derealization disorders (DDD). • Dissociative amnesia is characterized by a failure to recall significant autobiographical information that is inconsistent with ordinary forgetting; the experiences that are often lost are traumatic or otherwise unpleasant. • Third, dissociative identity disorder (DID, formerly known as multiple personality disorder) is a severe identity disruption defined by two or more different personality states and frequent gaps in the recollection of routine occurrences.

The Sociocognitive Model (SCM) According to the sociocognitive model, self-reports of trauma, dissociative experiences, and the diagnosis of dissociative disorders are encouraged by factors such as suggestibility, media influences (including portrayals of dissociative disorders in books, films, television, and social media), over-­ reporting/exaggerating symptoms, and cognitive failures/ memory lapses. People may come to believe they have more than one identity after being exposed to fictional depictions of people with multiple identities in media like The Three Faces of Eve, Sybil, etc., and coming to the conclusion that they, too, have experienced symptoms of puzzling psychopathology (such as affective instability and rapid mood swings) [5]. Belief in “multiple identities” and distorted recollections of abuse can be prompted or encouraged by a therapist’s cues or forceful and erroneous recommendations (such as, “You were mistreated and acquired dissociative symptoms to cope”). A suggestion may construct vivid, long-lasting false memories (such as being bullied as a youngster, riding in a hot air balloon, or seeing an exorcism), and misinformation about these symptoms can cause them to worsen. Furthermore, indicators of fugue/dissociative amnesia are linked to fabricated recollections.

4  Different Kinds of Dissociative Disorders, Including Dissociative Identity Disorder

Sleep Model (SM) The direct cause of dissociation, according to this hypothesis, is a variable sleep–wake cycle or, more importantly, the interference of sleep and waking states, which results in conflicting states of consciousness. In simple terms, dissociation could be described as the state of sleep seeping into the waking state, and the condition of waking can intervene in the state of sleep, as shown by parasomnias and other uncommon dreaming and sleeping experiences. Nightmares, vivid dreams, kinesthetic dreams, and hypnagogic and hypnopompic hallucinations (i.e., hallucinatory perceptions occurring during sleep–wake transitions) are all examples of sleep-related experiences (SREs) that are strongly linked to dissociation and were conceptualized initially by Watson as “dissociations of the night.” They are a sign of sleep disturbance in the form of alert and aroused dreaming and have been linked to stress and psychopathology in general. Dissociative events, including lapses in concentration, microsleeps, poor cognitive control, memory failure, fragmentation, and impaired reality assessment, are hypothesized to result from disturbances to the sleep–wake cycle, according to the SM. Many investigations have shown robust relationships between SREs and dissociation, supporting SM’s predictions. In addition, sleep deprivation can bring dissociative symptoms, whereas better sleep is linked to decreasing such symptoms [4]. Trauma may have a role in the development of dissociation; however, the SM proposes that the significant impact is mediated through disturbed sleep. This model claims that trauma is a potential distal cause of dissociation and that poor sleep is the proximal element causing it. According to the SM, it is the solution to the issue that the trauma model lacks a mechanism for explaining how trauma causes dissociation (the proposed mechanism being alterations in sleep).

Dissociation and Memory System Declarative and procedural, episodic and semantic, or explicit and implicit memory are the two main types of memory. These two rudimentary memory systems are for distinct purposes. Explicit memory, also known as episodic memory, is the recollection of self-referenced experiences. The second kind of memory is known as procedural or implicit memory. Simple tasks like driving a vehicle or typing on a keyboard fall within this category. Most of these routine tasks might be accomplished with less attention to detail yet are still of high quality. These two forms of memory are retained in separate regions of the brain.

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The limbic system, specifically the hippocampus formation and the mammillary bodies, seems to play a pivotal role in episodic memory. Conversely, it seems that the basal ganglia and cortical functioning are responsible for procedural memory. The existence of distinct memory systems may explain some forms of dissociation experiences.

Dissociation and Information Processing Instead of being placed in a preset category, sensory information appears to be processed based on the co-occurrence of activation patterns. As a result, errors in the integration of mental contents are theoretically probable in parallel distributed processing system models. When activation patterns are the same, it can look like there are connections between two pieces of information that do not really exist. Few cognitive models predicted that the brain would struggle to produce a cohesive and harmonious output when there are problems in processing input data (a model for traumatic input). This might then result in the emergence of information–data dissociation, which would show itself in the subject’s incapacity to efficiently digest all incoming information [2].

 urrent Understanding of Dissociative C Disorders: Diagnosis and Treatment According to the DSM 5 (American Psychiatric Association, 2013), dissociative episodes manifest as (a) unwanted breaches into consciousness and action, together with an absence of consistency in individual experience (i.e., “positive” dissociative symptoms such as splitting of identity, depersonalization, and derealization), and/or (b) incapacity to retrieve information or manage brain processes that are ordinarily accessible or controllable (i.e., “negative” dissociative symptoms such as amnesia) [1].

Dissociative Identity Disorder Dissociative identity disorder is a form of identity disruption in which a person experiences significant breaks in their sense of self and agency due to the coexistence of two or more separate personality states. There is a unique way of being in the world, perceiving things, thinking about things, and connecting to one’s own body, other people, and the world around it for each personality type.

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In this disorder, a person’s cognition and behavior shift between at least two different personality states regularly, either in reaction to external stimuli (such as parenting or job) or internal triggers (such as mood or stress) (e.g., those that are perceived as threatening). The senses, emotions, thoughts, memories, and abilities to plan and execute actions are only some of the areas of cognition that are affected by a change in personality state. Some people experience significant episodes of amnesia that do not fit the pattern of everyday forgetfulness.

(d) This disruption is not a typical element of any major religious or cultural ritual. Note: Imaginary friends and other forms of fiction play do not provide a satisfactory explanation for these symptoms in children. (e) The signs and symptoms cannot be attributed to the physiological effects of a drug (such as unconsciousness or erratic behavior during excessive alcohol consumption) or another health problem (e.g., complex partial seizures) [1].

Epidemiology

Symptoms usually associated with dissociative identity disorder are as follows:

Dissociative identity disorder (DID) is a rare psychiatric condition that affects around 1.5% of the world’s population. This disease is often misdiagnosed and therefore needs multiple assessments for a proper diagnosis. Patients with dissociative identity disorder may undergo treatment up to 12.5  years before receiving a diagnosis. Patients with DID are more likely to engage in both suicidal and non-suicidal acts of self-injury. Etiology: Severe childhood trauma, most often abuse, is closely associated with dissociative identity disorder. Patients of all ages with dissociative identity disorder report experiencing significant trauma in childhood, with estimates ranging from 85 to 97%. The most often reported types of childhood trauma are physical and sexual abuse. While researchers have recently begun to evaluate the role of genetics carefully, early investigations have shown little evidence of a substantial genetic influence. Diagnosis and clinical features: DSM-5 (American Psychiatric Association, 2013) criteria for the diagnosis of DID are as follows: (a) Disorienting experiences characterized by the coexistence of two or more distinct personalities are called “possession experiences” in particular cultural contexts. Disruption of one’s identity entails a loss of self-­ awareness and agency and modifies one’s emotional state, conduct, consciousness, recollection, perception, cognition, and sensory-motor abilities. Either the individual themselves or others around them may notice the changes. (b) Memory lapses that occur often and cannot be explained by routine forgetting; may include forgetting about routine daily activities, important personal information, or painful experiences. (c) In clinical terms, this means that the symptoms significantly hinder social, vocational, or other key aspects of daily life.

Posttraumatic stress disorder symptoms • Intrusive symptoms involve a range of features, including cognitive (intruding thoughts), affective (intruding effects such as fear, anger, or shame), perceptual (e.g., intruding voices or fleeting visual perceptions), sensory (e.g., intruding sensations such as being touched, pain, or altered sense of the perceived size of the body or of part of the body), motor (e.g., involuntary movements of an arm and hand), and behavioral (e.g., an action that lacks a sense of agency or ownership). • Symptoms of numbing and avoiding, as well as hyperarousal. Somatic symptoms • Conversion. • Seizures. • Painful episodes. • Discomfort in the head, stomach, muscle, or pelvis. • Psychophysiological symptoms. • Asthmatic disease and respiratory disorders. • Perimenstrual disorders. • Irritable bowel syndrome. • GERD. Affective symptoms • Apathy, sadness, or a lack of interest. • Intermittent or transient changes in mood. • Thoughts of suicide or actual efforts at self-harm. • Helpless and hopeless feelings. Obsessive-compulsive symptoms • Repetitions of traumatic memories. • Repetitive singing and counting. • Arranging. • Washing. • Checking.

4  Different Kinds of Dissociative Disorders, Including Dissociative Identity Disorder

Differential Diagnosis All of the following are the differential diagnosis of dissociative identity disorder • Bipolar disorders: A common misdiagnosis for people with DID is bipolar disorder, specifically bipolar II disorder. • Psychotic disorders, especially schizophrenia. • Major depressive disorder. • Anxiety disorder. • PTSD. • Personality disorders. • Neurocognitive disorders. • Neurological and seizure disorders. • Somatic symptom disorders. • Malingering. • Other specified dissociative disorders. • Deep-trance phenomena. Patients suffering from genuine DID are often perplexed, conflicted, humiliated, and upset by their symptoms and trauma background. Whereas symptom exaggeration, lying, using symptoms as a justification for antisocial conduct (e.g., forgetfulness solely for bad behavior), symptom amplification while under surveillance, unwillingness to allow collateral interactions, legal issues, and pseudologia fantastica are all examples in cases of malingering or factitious condition.

Course Although the illness may first appear in childhood, it is most often diagnosed between adolescence and 30 years of age, and the symptoms rarely manifest after the age of 40 years. However, there is sometimes a long lag time between the onset of symptoms and a diagnosis. DID is a chronic and recurring condition when the illness is left untreated. Data currently available indicate that spontaneous remission is uncommon. Untreated dissociative identity disorder patients may continue to engage in violent relationships, subcultures, or both, which might traumatize their descendants and increase the risk of the disorder spreading further within the family. It may take some time for symptoms to become noticeable, even once they have begun to appear. Dissociating patients find it challenging to efficiently and adequately self-monitor their symptoms or personal histories, which may raise diagnostic suspicion. Most DID patients are unaware of the total degree of their dissociative manifestations. When they do, they typically avoid discussing symptoms because they are unsure about their condition, feel ashamed of it, or have encountered clinical judgment. The fear of reprisal and the guilt from past victimization might sometimes prevent peo-

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ple from disclosing their symptoms. It is worth emphasizing that attempted suicides are widespread among these individuals, having been documented in more than 70% of DID patients [6].

Treatment Psychotherapy: The physician providing psychotherapy for a patient with dissociative identity disorder must be familiar with various psychotherapeutic methods and be prepared to shape the treatment actively. This category includes psychoanalytic psychotherapy, cognitive therapy, behavioral therapy, hypnotherapy, and experience with the psychotherapeutic and psychopharmacological care of the traumatized patient. Cognitive therapy: Cognitive therapy treatments gradually affect the many cognitive distortions involved with dissociative identity disorder, and effective cognitive therapies may lead to more significant discomfort. Like any severely and consistently sick psychiatric patient, these patients need long-term treatment focusing on symptomatic containment and supervision of their overall life dysfunction. Hypnosis: Interventions based on hypnotherapy may often lessen the urges to engage in self-destructive behavior and/or minimize symptoms. It is possible that providing the patient with training in self-hypnosis can assist them in coping with issues outside of session time. With the use of hypnosis, it is possible to induce states of mental relaxation that allow one to analyze stressful experiences in one’s life without experiencing excessive worry. Clinicians need to be conscious of the debates now taking place around hypnosis and memory recall accuracy and ensure that their patients provide valid informed permission before using hypnosis. Psychopharmacological interventions: The treatment of depression and mood stabilization often need antidepressant medicines. Many symptoms of PTSD, especially invasive thoughts and heightened alertness, respond well to treatment. SSRI, tricyclic, monamine oxidases (MAO) antidepressants, clonidine (Catapres), anticonvulsants, and benzodiazepines have been shown to significantly reduce intrusive symptoms, hyperarousal, and anxiousness in individuals with dissociative identity disorder, according to clinical reports. Risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), and olanzapine (Zyprexa) are all examples of atypical neuroleptics, which may be more effective and more tolerated than standard neuroleptics for patients with dissociative identity disorder who experience overwhelming anxiety and intrusive PTSD symptoms [6]. Electroconvulsive therapy: According to clinical experience in higher healthcare institutions for seriously ill patients with DID, clinical manifestations of significant depression with chronic, resistant melancholy symptoms across all alter phases may indicate a favorable reaction to ECT.

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Adjunctive Treatment Group therapy: Alter personalities may interrupt treatment sessions with typical psychiatric patients by generating excessive curiosity or scaring other patients. Therapy groups made entirely of dissociative identity disorder patients are more beneficial. Still, they must be appropriately planned, have substantial limitations, and concentrate on here-and-­ now coping and adaptation concerns. Family therapy: Family or couples therapy is frequently necessary for long-term stability and addressing problematic family and marital dynamics in DID individuals and their families. Education on dissociative identity disorder and its treatment may assist family members in dealing with PTSD and DID in loved ones. Family education and support groups are also helpful. Dissociative identity disorder patients may become phobic of personal touch, and spouses may not know how to assist them. Expressive and occupational therapies: Art therapy may assist control and structuring severe dissociative identity disorder and PTSD symptoms and allow patients to communicate ideas, emotions, mental pictures, and conflicts they cannot verbalize. Movement therapy may help traumatized people normalize body sensations and images. Occupational therapy may assist with focused, organized tasks and symptom control. Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a relatively new therapy option for PTSD. The research is divided on the utility and effectiveness of this therapy approach, and published efficacy trials are contradictory. The International Society for the Study of Trauma and Dissociation states that only clinicians with specialized EMDR training, expertise in phasic trauma therapies for dissociative disorders, and have received supervision in the application of EMDR in dissociative identity disorder should use EMDR on this patient population.

Dissociative Amnesia Epidemiology: Most cases of dissociative amnesia are diagnosed in people in their thirties and forties. Dissociative amnesia affects 1.8% of the population, according to research. There seems to be no sex disparity in this occurrence. In most people, the first cases are discovered in their late adolescence. Preadolescent children may have difficulty describing their subjective experiences, making it challenging to diagnose dissociative amnesia in them [7]. Etiology: Many patients with severe dissociative amnesia report being exposed to extreme levels of conflict in their lives, including feelings of humiliation, guilt, despair, fury, and desperation.

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These fallouts come from struggles with undesirable desires or impulses, such as strong sexual, suicidal, or violent inclinations. It may be triggered by traumatic events, such as sexual or physical abuse. Trauma may sometimes be brought on by the betrayal of a vital, relied-upon person (betrayal trauma).

Diagnosis and Clinical Features Symptoms are characterized by • Unusual forgetfulness is when one cannot recollect significant autobiographical memories, usually of recent traumatic or stressful situations. • Neither any other mental disorder, such as posttraumatic stress disorder, complex posttraumatic stress disorder, or a neurocognitive issue like dementia, nor trance disorder, possession trance disorder, or dissociative identity disorder may also explain memory loss. • Memory loss significantly impairs personal, familial, social, educational, occupational, or other essential areas of functioning. • The symptoms are not due to the effects of a drug or medicine on the central nervous system (such as alcohol), including withdrawal effects. • The symptoms are not due to a disease of the nervous system (such as temporal lobe epilepsy); • The symptoms are not related to head trauma. Patients may suffer symptoms such as altered consciousness, depersonalization, derealization, hypnotic episodes, involuntary age regression, and persistent anterograde dissociative forgetfulness. Many patients experience depression and thoughts of suicide. Even though family or personal history of dissociative episodes has been demonstrated to predispose persons to develop acute amnesia in stressful situations, no one personal profile or preceding history is consistently identified in these instances. Many of these patients have histories of prior adult or childhood abuse or trauma [6]. Types of dissociative amnesia • Localized amnesia: Inability to remember things that happened within a certain time frame. • Selective amnesia refers to the capacity to recall some, but not all, events that occurred over a certain period. • Generalized amnesia: It describes the incapacity to recall one’s whole existence. • Continuous amnesia: Failure to recollect subsequent events as they happen. • Systematized amnesia refers to failure to remember a category of information, such as all recollections of one’s parents or a specific individual.

4  Different Kinds of Dissociative Disorders, Including Dissociative Identity Disorder

Differential Diagnosis (a) Nonpathological amnesia and ordinary forgetfulness: Normal forgetting is nonstressful. In dissociative amnesia, memory loss is more severe. Infantile, childhood, sleep, and hypnotic amnesia are nonpathological kinds of amnesia. (b) Medically caused dementia, delirium, and amnesia: In dementia, delirium, and amnestic diseases owing to medical conditions, personal memory loss is entrenched in cognitive, linguistic, attentional, behavioral, and memory issues. Other cognitive deficits generally accompany the loss of personal identification memory. Korsakoff’s psychosis, CVA, postoperative amnesia, postinfectious amnesia, anoxic amnesia, and transitory global amnesia are organic amnestic diseases. (c) Electroconvulsive therapy (ECT) may produce momentary amnesia and chronic memory issues. Here, autobiographical memory loss is unrelated to traumatic or overpowering situations and tends to encompass various personal experiences, most typically before or during ECT treatments. (d) Posttraumatic amnesia induced by brain damage generally involves physical trauma, a period of unconsciousness or amnesia, or both, and clinical signs of brain injury. (e) Epilepsy: Most seizures have identifiable ictal events and consequences, unlike dissociative amnesia. Patients with pseudoepileptic seizures may have dissociative symptoms. Recurrent, complicated partial seizures seldom cause strange behavior, memory issues, anger, or aggressiveness, creating a diagnostic dilemma. Telemetry or ambulatory EEG monitoring helps clarify the diagnosis in certain circumstances. (f) Drug-induced amnesia: Intoxicants and drugs may cause amnesia in many cases. (g) DID patients may have amnesia and fugue. These individuals have many symptoms, but just a few are typical with dissociative amnesia. Most individuals with DID and dissociation disorder not otherwise specified report several kinds of complicated amnesia, as well as repeated blackouts, fugues, inexplicable possessions, and variations in abilities, behaviors, and understanding. (h) Acute stress disorder, PTSD, and SSD: A significant proportion of people with dissociative amnesia also meet the entire or part clinical definition for one or more acute stress disorders. (i) Factitious amnesia and malingering: Dissociative amnesia cannot be distinguished from malingered amnesia. Malingerers lie even during hypnotically or barbiturate-­ assisted interviews.

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Course: The clinical progression of dissociative amnesia is poorly understood. Many cases of acute dissociation amnesia improve on their own if the individual is away from dangerous or distressing situations. At the opposite end of the spectrum, some patients acquire chronic forms of widespread, continuous, or severe localized amnesia, leading to significant disability and a need for high levels of social assistance, such as nursing home placement or extensive family caretaking. Treatment: There are currently no effective pharmaceutical therapies for dissociative amnesia since there has not been any controlled research done on the subject. Psychotherapy: When individuals with dissociative amnesia are removed from stressful or hazardous situations, feel comfortable, or are exposed to personal signals from their past (such as home, pets, and family members), they often experience spontaneous recovery. Drug-facilitated interviews may be helpful when exposure to a safe setting is insufficient to restore normal memory function. Hypnosis: According to formal testing, most individuals with DDs are highly hypnotizable and thus hypnotic procedures like age regression can be easily used. Such patients may be able to change their temporal orientation while under hypnosis, giving them access to memories that would otherwise be dissociated and inaccessible. Patients may abreact or show intense emotion when these memories are aroused if the warded-off memories have painful material. They can be seen as a reinfliction of the traumatic stressor by the patient. Such patients need psychotherapy assistance in bringing these blocked memories and the corresponding emotions into awareness to achieve control over them. Screen Technique: By putting horrific memories in a larger context where trauma patients may also see adaptive components of their reaction to the event, projective methods like the “screen technique” may help make the memories more tolerable. This technique’s ability to allow for the memory of painful experiences without setting off an uncontrollable reliving of the trauma makes it very helpful. Self-hypnosis may be used to help people teach their bodies to enter a comfortable, safe state of floating. They may do this by seeing themselves in a secure and relaxing environment, such as floating in space, a hot tub, a bath, or a lake.

 issociative Fugue (A Subtype D of Dissociative Amnesia) Dissociative amnesia with dissociative fugue is characterized by all the attributes of dissociative amnesia along with a dissociative fugue, which includes a loss of self-identity and an abrupt departure from one’s place of residence, place of

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employment, or close relationships for a prolonged period of time (days or weeks). Dissociative fugue is currently classified as a subtype (specifier) of dissociative amnesia since it was removed from the DSM-5 as a major diagnostic category. Patients with both dissociative amnesia and dissociative identity disorder may exhibit dissociative fugue. Due to its clinical significance, the disorder retains a distinct diagnosis in the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). It is described as a separate entity in the Synopsis.

Epidemiology Although no rigorous statistics exist on this issue, the condition is assumed to be more frequent after natural catastrophes, conflict, or periods of great societal upheaval and violence. Adults are more likely to experience this condition than children, and those who have already received a dissociative disorder diagnosis are also more likely to do so. Etiology: The majority of fugue episodes include traumatic events (such as rape, repeated childhood sexual abuse, and natural catastrophes) as their root cause. In certain circumstances, psychological trauma is not present at the outset of the fugue episode, but a comparable antecedent history is seen. Excessive feelings or impulses (such as extreme dread, remorse, humiliation, or powerful incestuous, sexual, suicidal, or violent inclinations) that are at odds with the patient’s conscience or ego values characterize these instances rather than external risks or traumas [8]. Diagnosis and Clinical Features: Depending on the circumstances, symptoms of the dissociative fugue may include all of the following: Throughout the Fugue State: The following are symptoms patients may experience in a fugue state: Anxiety caused by not knowing who they are, a lack of confidence in their history, and the discomfort of having their sense of self questioned. It is vital to remember that a person suffering from dissociative fugue may not exhibit any external indicators of mental illness. The reason for this is that the new identity is the person’s true identity in their eyes. The only time this could cause trouble is if it is questioned. After the Fugue State Ends: In addition to forgetfulness, the patient may have perplexity, bewilderment, trance-like behaviors, depersonalization, derealization, and conversion symptoms after the conclusion of a fugue. Some individuals may have generalized dissociative amnesia at the end of a fugue.

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The following criteria had to be satisfied for diagnosis when it was first classified as a separate disorder in the DSM-IV • An unexpected or sudden trip away from home or employment. • Inability to recall previous events. • Confusion about their identity and the adoption of a new one. • These problems cause significant anguish and disability. However, it is crucial to note that even though a person experiencing a dissociative fugue may not show any visible symptoms of it and may be difficult for others to notice, it is sometimes only diagnosed after the event. As a result, a diagnosis is generally determined only after the fugue ends, either suddenly or gradually. Due to its rarity, the fact that it is not always accompanied by aimless wandering, and the fact that it invariably accompanies dissociative amnesia, the dissociative fugue is classified as a subtype of dissociative amnesia in the DSM-5.

Differential Diagnosis Dissociative amnesia also causes confused wandering many times during amnesia episodes. In a dissociative fugue, the person purposely travels away from home or everyday activities, frequently fixated on a single notion and a desire to get away. Dissociative identity disorder patients may experience dissociative fugue recurrently. Patients with DID typically experience several complicated amnesias and a wide range of altered personalities that start to emerge in early childhood. During complex partial seizures or postictal states, individuals display wandering or semi-purposeful activity, for which amnesia ensues. Epileptic fugues frequently cause disorientation, perseveration, and strange or repeated motions. Aura, motor irregularities, stereotyped behavior, perceptual disturbances, incontinence, and a postictal state are typical. Serial or telemetric EEGs demonstrate pathological behavioral anomalies. Dissociative fugue might be mistaken for wandering behavior in general medical illnesses, hazardous and drug-­ associated disorders, delirium, memory loss, and organic memory impairment syndromes. Background information, physical examination, laboratory testing, or toxicological and pharmaceutical screening may rule out somatic, toxic, neurological, or substance-­ related disorders. Alcohol or drugs may trigger dissociative fugue [8].

4  Different Kinds of Dissociative Disorders, Including Dissociative Identity Disorder

Manic bipolar illness or schizoaffective disorder may cause wandering and deliberate travel. Manic patients may not remember euthymic or sad conduct and vice versa. In mania, deliberate travel is accompanied by grandiose notions and improper conduct. Some schizophrenia patients exhibit peripatetic behavior. Due to the patient’s cognitive problem, remembering wandering experiences may be challenging. Patients with dissociative fugue do not show psychotic symptoms. Malingering of dissociative fugue may occur in people attempting to avoid legal, financial, or personal problems or in troops avoiding war or disagreeable military obligations. No test, battery of tests, or process can separate actual dissociative symptoms from malingering. Course: The average duration of a fugue is from a few hours to a few days. While most people seem to get better, some people may still be affected by refractory dissociative amnesia. According to some research, most people who present with an episode of dissociative fugue experience repeated fugues. Treatment: Dissociative fugue often improves on its own without treatment. Once again, hypnosis may help patients retrieve previously separated memories. Hypnosis may be helpful in the treatment of dissociative fugue by allowing the patient to access parts of their memory and sense of self that would otherwise be inaccessible. A reorientation can restore the fugue’s overt identity and memory loss, but once that is done, it is time to address the underlying interpersonal or intrapsychic difficulties that were likely driving the dissociative defenses in the first place. Since they can detach so well from their stress responses, such people are typically oblivious to how they are responding to it. Therefore, good psychotherapy is preventative, intending to assist patients in becoming more self-aware and altering their propensity to prioritize the needs of others above their own. Patients with dissociative fugue may benefit from psychotherapy that helps them recall and understand the emotional roots of behaviors that seemed involuntary and uncontrollable before. Psychosocial stresses, such as marital conflict, should be discussed with the people experiencing them. If a patient’s present level of psychosocial stress is causing their fugue, then relieving that stress will help them feel better and make them less likely to return.

Depersonalization/Derealization Disorder According to DSM-5, this group of disorders is characterized by chronic or recurring episodes of depersonalization, derealization, or both 1. Depersonalization: Unreality, alienation, or being an external spectator of one’s own ideas, emotions, sensa-

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tions, physique, or activities. Examples include perceptual changes, altered perception of time, unreal or absent self, and emotional and physical numbness. 2. Derealization: Unreality or alienation from one’s surroundings. For example, individuals or things may seem surreal, dreamy, hazy, lifeless, or visually deformed. Epidemiology: In the general population, transient depersonalization or derealization episodes spanning a few hours to several days are frequent. Roughly 50% of all adults have experienced depersonalization or derealization at least once in their life. Symptoms that fit the diagnostic criteria for depersonalization/derealization disease are far less prevalent than those that are just transient. The lifetime prevalence in the United States and other nations ranges from 0.8 to 2.8%, with an average of 2%. The condition has a 1:1 gender ratio.

Etiology Traumatic Stress: In clinical depersonalization case series, a considerable percentage of patients—typically between 33% and 50%—report serious trauma histories. According to research on accident victims, up to 60% of persons who face a life-threatening situation report at least momentary depersonalization either during the incident or immediately thereafter. During military training, stress and exhaustion often elicit feelings of depersonalization and derealization, which are adversely connected to performance. Psychodynamic: The ego’s dissolution was stressed in traditional psychodynamic formulations, and depersonalization was seen as an emotional reaction in defense of the ego. These justifications emphasize how very unpleasant experiences or conflicting urges may act as triggers. Neurobiological Theory: The relationship of depersonalization with migraines and marijuana, its typically good sensitivity to selective serotonin reuptake inhibitors (SSRIs), and the rise in depersonalization symptoms found with the depletion of l-tryptophan, a serotonin precursor, all suggest serotoninergic participation [9]. Diagnosis and Clinical Features: The experience of depersonalization consists of many separate parts, including a sensation of (1) physical changes, (2) dual self as participant and spectator, (3) being disconnected from others, and (4) being cut off from one’s own emotions. Patients that are depersonalized often struggle greatly to articulate their emotions. Depersonalized individuals may be unable to appropriately describe the misery they experience to the examiner by using common expressions like “I feel dead” or “Nothing seems to be true.” Even while they may bitterly lament how this is wrecking their lives, they may yet come off as remarkably unbothered [9].

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Differential Diagnosis: The differential diagnosis of depersonalization disease is made more difficult by the wide range of ailments connected to depersonalization. Depersonalization may be caused by a medical or neurological disease, drug intoxication or withdrawal, prescription side effects, panic attacks, phobias, PTSD, acute stress disorder, schizophrenia, or another dissociative illness. It can also be a symptom of other dissociative disorders. It is crucial to do a complete medical and neurological examination that includes an EEG, standard laboratory tests, and any necessary drug tests. Although chronic depersonalization may occur after an episode of intoxication with a number of drugs, such as marijuana, cocaine, and other psychostimulants, drug-related depersonalization is often transitory. Numerous neurological problems have been implicated as causes, including migraine, vertigo, Meniere’s disease, brain tumors, postconcussive syndrome, metabolic abnormalities, and seizure disorders. Course: The onset of depersonalization/derealization condition is often around the age of 16. However, it may occur sooner or later. Some individuals cannot recall ever being free of the symptoms. Less than 20% of people get it after 20  years, and 5% after 25. Onset can range from highly sudden to gradual. Episodes of depersonalization/ derealization disorder might persist for a few hours or several years. About one-third of patients have distinct episodes, a third have symptoms that are present all the time, and a third start off episodically but progress to continuous symptoms [6]. While some people’s symptoms come and go, others struggle with chronic issues for years or even decades. Some internal and environmental variables that impact symptom severity are typical. Stress, poor mood or anxiety, unusual or overstimulating environments, and physical variables like lighting or lack of sleep may provoke exacerbations. Treatment: There has been no breakthrough in the pharmaceutical therapy of depersonalization. Antidepressants and antipsychotics, two types of commonly used drugs, are relatively ineffective. However, early evidence suggests that certain medications, either single therapy (such as opioid receptor antagonists) or in combination, may have some positive benefits (i.e., SSRI plus lamotrigine; SSRI plus clonazepam). Some systematic data shows that SSRI antidepressants like fluoxetine (Prozac) may be useful for people with depersonalization disease. Psychodynamic, cognitive, cognitive behavioral, hypnotherapeutic, and supportive psychotherapies are only some methods used to treat depersonalization disorders successfully. Many people in this situation do not respond well to traditional forms of treatment. Some patients may benefit

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somewhat from stress management tactics, distraction techniques, lowering of sensory input, relaxation training, and exercise.

 ther Specified or Unspecified Dissociative O Disorder Symptoms share core clinical aspects with other dissociative disorders (i.e., involuntary interruption or discontinuity in the normal integration of identity, feelings, perceptions, moods, thoughts, memories, motor control, or behavior). Despite this, none of the other dissociative disorders seem like a good fit for the symptoms that have been described. No other mental condition (such as PTSD, complex PTSD, schizophrenia, or bipolar disorder) more adequately explains the symptoms. The manifestations are not sanctioned as part of a cultural or religious practice since the individual does not voluntarily choose them. The symptoms are not the result of drug or alcohol intoxication or withdrawal (such as blackouts or erratic behavior while under the influence of drugs or alcohol), nor are they the result of a disease of the nervous system (such as complex partial seizures), a sleep–wake disorder (such that symptoms occur during hypnagogic or hypnopompic states), head trauma, or any other medical condition. The person experiences severe disturbance or deterioration in individual, familial, social, academic, work-related, or other important areas of functioning as a result of the symptoms. It takes a considerable effort to keep things running if they do. Following are the types of presentation under other specified dissociative disorders according to the DSM-5 (APA, 2013) 1. Chronic and recurrent syndromes of mixed dissociative symptoms: Disruptions in one’s sense of individuality and agency, such as those seen in identity shifts or possession experiences, that are not accompanied by dissociative amnesia fall under this group. 2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have gone through severe forceful persuasion (such as brainwashing, thought remodeling, prisoner indoctrination, torture, lengthy political incarceration, recruitment by sects/cults or by militant groups) may exhibit persistent alterations in, or conscious questioning of, their identity. 3. Acute dissociative reactions to stressful events: Acute, transitory conditions fall into this group if they normally last less than a month and occasionally only a few hours or days. Inhibition of consciousness, depersonalization, derealization, perceptual problems (such as time slowness and macropsia), short period of amnesias, momentary leth-

4  Different Kinds of Dissociative Disorders, Including Dissociative Identity Disorder

argy, and/or changes in sensory-motor performance are the characteristics of these disorders (e.g., analgesia, paralysis). 4. Dissociative Trance Disorder: This disease is characterized by a significant lack of response or sensitivity to environmental stimuli and an acute constriction or total loss of consciousness of the surrounding environments. The lack of responsiveness, which includes temporary paralysis or consciousness loss as well as minor stereotyped behaviors that the person is unaware of and/or is unable to control, may be accompanied by minor stereotypical behaviors. Dissociative trance is not a typical component of a widely practiced communal religious or cultural activity [1]. Possession trance is the most common form of dissociative disorder in Asia; it occurs when a new one replaces one’s normal sense of self; this new self is thought to be under the control of a soul, power, God, or another person; and the afflicted individual may exhibit stereotypical “involuntary” movements or amnesia. Some examples are “amok” in Indonesia, “bebainan” in Indonesia, “latah” in Malaysia, and “possession” in India. Although possession trance is not included as an example of other specified dissociative disorders in the DSM-5, it might be utilized as a part of the “dissociative trance” specifier or even as part of the DID diagnosis (when recurrent). Possession trance entails the acquisition of separate other identities, in contrast to dissociative trance experiences. Furthermore, unlike dissociative trance episodes, possession trance episodes are frequently followed by severe amnesia for a significant period of the experience, during which the spirit personality controls the subject’s conduct [2]. Trance and possession syndromes represent the most commonly reported types of dissociative disorders (DDs) worldwide. Conversely, dissociative identity disorder (DID), which is significantly more prevalent in the United States, is rarely diagnosed in developing countries. Cultural and biological variables may cause heterogeneity in the prevalence and distribution of DD across communities. For instance, Eastern cultures tend to be more socio-centric than Western cultures. Therefore, the phenomenon of being “possessed” by an external force would be more accepted and understandable in the East. In contrast, a visible manifestation of distinct identities would be more consistent with the Western emphasis on individualism. Despite these cultural differences, the fundamental dissociative process that hinders perception, memory, and identity integration may imply a shared biological basis for diverse dissociative disorders [2]. False Memory Syndrome: Patients undergoing psychotherapy or hypnosis may recall traumatic events, such as sexual or physical abuse, that play a pivotal role in developing their condition. A process known as abreaction occurs

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when previously suppressed information is brought back into awareness and causes the individual to not only remember the event but relive it along with the appropriate emotive response. False memory syndrome occurs when a person recalls an incident that never really happened but behaves as if it did because they are certain it did. As a result of this condition, cases of alleged child abuse have been litigated [10]. Even if the traumatic event happened, the abuser is not the person in their life right now; instead, it is someone from their past. According to Thomas E. Gutheil, the patient’s psychological objectives are seldom served by legal action. Patients should be encouraged to stop seeing themselves as victims so that they may move beyond and heal from their traumas and get on with their lives. The dissociative subtype of PTSD: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-­ 5) introduces a novel dissociative subtype of posttraumatic stress disorder (PTSD). This subtype involves individuals displaying symptoms that fulfill all the standard diagnostic criteria for PTSD, along with chronic or recurring experiences of depersonalization or derealization. Although dissociative flashbacks and amnesia are not part of the standard PTSD criteria, these individuals exhibit symptoms of depersonalization and derealization. Data from the World Mental Health Survey, which included 25,018 individuals from 16 countries, suggested that 14.4% of those with PTSD also exhibit depersonalization and derealization symptoms. The symptoms of this subgroup of PTSD are marked by increased re-experiencing, the onset of PTSD during childhood, greater exposure to trauma and adversity, significant role impairment, and suicidal ideation. The dissociative subtype of PTSD is characterized by emotional overmodulation, which is influenced by midline prefrontal inhibition of limbic areas, including the amygdala, in contrast to the more prevalent hyperarousal with limbic excitation and frontal suppression. Individuals with depersonalization and derealization symptoms, in addition to PTSD, respond differently to cognitive behavioral therapy (CBT) for PTSD.  According to the literature review, individuals with the dissociative subtype of PTSD show limited benefit from typical desensitizing psychotherapy and, instead, require training in stabilization, self-soothing, and emotion regulation to achieve and sustain progress.

Ganser Syndrome Sigbert Ganser originally described Ganser syndrome in four inmates in 1897. The phenomenon was initially considered highly unusual and limited to forensic investigations. As a result, the term “prison psychosis” emerged to describe it. Approximate replies, clouding of awareness, somatic con-

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version manifestations, and hallucinations are essential clinical aspects of this illness. Epidemiology: There have been reports of cases in many different cultures, although the general frequency of these reports has decreased over time. There are almost two times as many male patients as female patients. Clinical Features: Ganser syndrome is distinguished by the symptom of passing over the proper response for a similar but wrong one. The approximate responses often miss the target but clearly relate to the question, showing that it was comprehended. When asked her age, a 30-year-old lady replied, “I am not ten.” When asked to do basic arithmetic (for example, 1 + 2 = 4), general information (the capital of the United States of America is California), identification of trivial things (a pen is a key), or name of colors (blue is grey), Ganser syndrome patients provide incorrect but understandable replies. There is also a clouding of consciousness, frequently shown by disorientation, forgetfulness, loss of personal knowledge, and some disturbance with reality testing. In nearly half of the cases, visual and auditory hallucinations occur [11]. Treatment: Given the rarity of this illness, no systematic therapy trials have been done. In most cases, the patient was hospitalized and given a safe and supportive environment. Low dosages of antipsychotic drugs have been shown to be effective in some instances. Hypnosis and amobarbital narcosynthesis have also been used effectively to assist patients in revealing the underlying pressures that preceded the formation of the syndrome, resulting in the cessation of Ganser’s symptoms.

Conclusion Clinical encounters with dissociative disorders are rare compared to other psychiatric diagnoses, and the patient’s cultural background primarily influences the clinical presentation of dissociative disorders. Most cases of disso-

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ciative disorders may be traced back to traumatic experiences or conflicts inside the mind that occurred in childhood. Before diagnosing dissociative disorder, it is essential to rule out the possibility of any underlying physical illness or substance abuse. While dealing with patients suffering from such disorders, the clinician should be competent in psychotherapeutic procedures, including psychodynamic and psychoanalytic psychotherapy, cognitive therapy, and hypnosis, wherever possible.

References 1. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Association; 2013. 2. Maldonado JR, Spiegel D.  Dissociative disorders. In: Psychiatry. Wiley; 2015. p. 1178–98. 3. Sar V.  Epidemiology of dissociative disorders: an overview. Epidemiol Res Int. 2011;2011:4538. 4. Buchnik-Daniely Y, Vannikov-Lugassi M, Shalev H, Soffer-­ Dudek N.  The path to dissociative experiences: a direct comparison of different etiological models. Clin Psychol Psychother. 2021;28(5):1091–102. 5. Lynn SJ, Maxwell R, Merckelbach H, Lilienfeld SO, van Heugten-­ van der Kloet D, Miskovic V. Dissociation and its disorders: competing models, future directions, and a way forward. Clin Psychol Rev. 2019;73:101755. 6. Sadock BJ, Sadock VA, Ruiz P.  Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. Philadelphia: Wolters Kluwer; 2015. 7. Staniloiu A, Markowitsch HJ.  Dissociative amnesia. Lancet Psychiatry. 2014;1(3):226–41. 8. Coons PM. Psychogenic or dissociative fugue: a clinical investigation of five cases. Psychol Rep. 1999;84(3):881–6. 9. Somer E, Amos-Williams T, Stein DJ.  Evidence-based treatment for depersonalisation-derealisation disorder (DPRD). BMC Psychol. 2013;1(1):20. 10. Santos G, Costa V. False memory syndrome: a review and emerging issues, following a clinical report. Eur Psychiatry. 2016;33:S561. 11. Petrykiv S, De Jonge L, Sibma W, Arts M.  A systematic report review of Ganser syndrome: 118 years of case studies. Eur Psychiatry; 2017;41(S1):S699–S699

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Ketamine: Should Such a Dissociative Agent Be Used for Anesthesia, Anti-­Depression/Suicidality, and Analgesia in DID Patients? Kristy A. Fisher and Thalia Adrian

Introduction

Ketamine

Ketamine, a nonbarbiturate dissociative anesthetic drug used since the 1970s, and its metabolites have many clinical uses within the medical field. These include both FDAapproved indications and off-label uses, as well as therapeutic potential in various areas still currently under investigation. Ketamine is a racemic mixture of (S)- and (R)-enantiomers with affinity for multiple receptor targets, thus providing anesthetic, analgesic, anti-inflammatory, and anti-depressant actions, as well as causing many somatic and neuropsychiatric side effects. Ketamine also offers a safe profile when used in certain health-compromised individuals, including the hemodynamically unstable and in those with severe pulmonary comorbidities, cyanotic heart disease, and neuromuscular disorders due to its sympathomimetic activity, broncho-dilatory properties, and maintenance of airway reflexes. Ketamine’s claim to fame however, is its potential to evoke dissociation [1–4]. Therefore, this chapter will discuss not only the mechanism of action, indications, off-label uses, and adverse effects of ketamine, but also its potentially controversial therapeutic use in particularly vulnerable populations, such as those patients diagnosed with DID. Being a very useful adjunct in various medical indications with a unique and safe use profile beneficial to some health-­compromised individuals, it is crucial to consider the risks vs. benefits with the incorporation of ketamine in treatment plans for DID patients.

History

K. A. Fisher (*) HCA Florida Aventura Hospital, Aventura, FL, USA T. Adrian Dr. Kiran C. Patel College of Allopathic Medicine NOVA Southeastern University, Fort Lauderdale, FL, USA e-mail: [email protected]

Since the initial discovery of general anesthesia in the nineteenth century, the need for a shorter-acting and safer agent eventually led to the discovery of ketamine and its use in human subjects (particularly with volunteer prisoners at the State Prison of Southern Michigan at Jackson, USA) as early as 1964. The drug was found to produce anesthesia and analgesia with effects of increased blood pressure, but minimal respiratory depression and no impact on blood count, nor functions of the liver and kidney. Ketamine gained FDA approval in 1970. Due to its effects of pain relief, along with its aid in blood loss and shock, ketamine was used in the field during the Vietnam War for severely wounded soldiers. First reports of recreational ketamine use appeared in the 1960s, with peak popularity in the 1990s as a component of ecstasy in Europe. Ketamine remains a drug of abuse available worldwide, with noted preference amongst the younger population of Hong Kong, China [5].

Ketamine: Indications Currently, there are many clinical indications for the use of ketamine, including FDA-approved indications, off-label uses, and areas of interest currently under investigation. Ketamine is currently FDA-approved for anesthesia and procedural sedation [4]. The S-enantiomer of ketamine, esketamine, gained FDA approval recently in 2019 for treatment-resistant depression in conjunction with oral anti-­ depressants or major depressive disorder (MDD) with suicidal ideation in adults [6]. Off-label uses include acute, chronic, and cancer pain management, along with post-­ surgical opioid sparing, as well as for acute aggression with or without concomitant benzodiazepine use, paramedic use for improved patient comfort en route to hospital (very limited authorized use, however), depression, suicidal ideation,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_5

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and postoperative sore throat as a complication of endotracheal intubation. Investigated areas of interest include its use in the treatment of post-traumatic stress disorder (PTSD); addiction, particularly with alcohol and opioid use disorders; asthma; and the prevention of cancer growth. Ketamine is also used as a drug of abuse for recreational purposes. Non-­ human uses include for purposes of sedation and anesthesia in veterinary medicine, as well as animal drug models of schizophrenia for research [1, 5].

 etamine: Pharmacokinetics, Dosage, K and Administration Ketamine hydrochloride is a derivative of cyclohexanone that is rapid-acting and extensively metabolized through the hepatic system via N-dealkylation, hydroxylation, conjugation, and dehydration, with an approximate half-life of 45 min [4]. Ketamine is metabolized into several clinically useful metabolites, which include norketamine, dehydronorketamine, hydroxyketamine, and hydroxynorketamine [2]. Norketamine has an elimination half-life of 1.13 h and thus, during prolonged infusions, can surpass the plasma concentration of ketamine [7]. Below the threshold dosing of 1–1.5 mg/kg intravenously and 3–4 mg/kg intramuscularly, ketamine produces effects of sedation and analgesia. Above this threshold dosing, ketamine can produce dissociative effects within 1–2  min post-administration [1, 4]. Peak plasma concentrations of ketamine of about 1200–2400 ng/ mL are required to induce dissociative anesthesia. Studies have shown that it can take 35–55 min for full recovery of appropriate orientation to person, place, and time at these dosages [2]. Routes of administration currently include intravenous, intramuscular, inhalation, and oral [8].

Ketamine: Mechanism of Action Ketamine acts via various receptors to exert its analgesic, anesthetic, anti-inflammatory, and anti-depressant effects. Overall, it acts predominantly as a noncompetitive antagonist of the N-methyl-d-aspartate (NMDA) receptor. NMDA receptor antagonism is responsible mainly for analgesia and anesthesia, along with anti-depression factors via an increase in glutamate, leading to synaptogenesis and increased brain-­ derived neurotropic factor (BDNF) [4]. Multiple hypotheses of the mechanism of action responsible specifically for the anti-depressant effects of ketamine have been proposed, which all encompass alterations in various pathways involved in synaptic plasticity, leading to enhanced excitatory synapses and homeostatic synaptic scaling. One such theory includes selective antagonism of NMDA receptors on gamma aminobutyric acid (GABA)

K. A. Fisher and T. Adrian

interneurons, leading to disinhibition of pyramidal neurons and enhanced glutamatergic firing. This then leads to an increase in activation of rapamycin complex 1 of the NMDA receptor with consequent protein synthesis. An alternative theory involves ketamine’s ability to inhibit NMDA receptors, leading to deactivation of calcium/calmodulin-­ dependent kinase eukaryotic elongation factor 2 kinase, thus resulting in dephosphorylation of eukaryotic elongation factor 2 and BDNF protein synthesis within the hippocampus, ultimately leading to synaptic AMPA receptor response [9]. The NMDA receptor antagonist properties of ketamine, particularly on those receptors located in the periphery, dorsal root ganglion, and central nervous system (CNS), are thought to be the key players involved in both acute and chronic pain alleviation, due to stimulation leading to phosphorylation and upregulation of NMDA and other glutamate receptors [7]. Ketamine also has low affinity and activity through GABA, dopamine, serotonin, sigma, opioid, and cholinergic receptors, along with voltage-gated sodium and hyperpolarization-activated cyclic nucleotide-gated channels [2]. Ketamine’s ability to interact with the sigma receptors leads to its use with chronic pain management, due to decreases in central sensitization, pain memory, and the wind-up phenomenon, which is the development of persistent, progressive, or chronic pain [4]. Chronic pain can be viewed in a multidimensional model, including the following three components: sensory-discriminative, affective-­ motivational, and cognitive-evaluative. Evidence supports ketamine’s ability to offer short-term modulation of the sensory-­discriminative component and long-term effects of the affective-motivational component via modulation of the psychological perception of pain [7]. The partial agonistic properties on the opiate mu-­receptors alleviate pain, while activity on the cholinergic, aminergic, and opioid receptor systems positively and negatively modulate analgesia and sedation [4]. Furthermore, it is important to note that the sedative/hypnotic effects of ketamine are significantly shorter than that of the chronic analgesic and anti-­ depressant effects. This suggests a secondary increase in synaptic connectivity is responsible [7].

 etamine: Mechanism of Action Responsible K for Dissociative Properties Dissociation describes a disturbance in the way the mind integrates consciousness, memory, identity, emotion, perception, motor control, and behavior, disorientation, numbness, and illusions [10, 11]. Ketamine can cause dissociation, albeit the exact biological and neurochemical origins of the dissociative effects are not fully understood. Historically, research has centered on the mechanism of ketamine’s rapid anti-depressant effects, while trying to minimize its psycho-

5  Ketamine: Should Such a Dissociative Agent Be Used for Anesthesia, Anti-Depression/Suicidality, and Analgesia in DID Patients?

active side effects, leaving the latter understudied. However, currently available literature does offer some promise in terms of potential avenues for future research. The neurobiological hypotheses behind the dissociative effects of ketamine include both NMDA/glutamate-dependent and independent mechanisms, as well as physiology similar to that of classical hallucinogens. Furthermore, EEG findings at the onset of dissociation with ketamine were compared to EEG readings in other anesthetics. These hypotheses and EEG findings are discussed further. The antagonism of the NMDA receptor is primarily responsible for the psycho-sensory effects of the dissociative hallucinogens (ketamine and PCP) [11, 12]. NMDA receptor antagonism leads to interference with the actions of glutamate, as discussed above. Glutamate is thought to be responsible for interactions and responses to the environment, emotional response, as well as learning and memory. Therefore, this interference is thought to lead to the distortions seen in ketamine-induced dissociation [13]. Ketamine primarily affects inhibitory interneurons, disrupting input to inhibitory interneurons and allowing increased activity of downstream excitatory neurons, and increased cerebral metabolism [14]. Cortical, hippocampi, and amygdala brain regions continue to communicate with less input and modulation from the inhibitory interneurons, leading to discordant information processing and producing dissociative states [14]. Independent of the NMDA receptor antagonism and subsequent glutamatergic neurotransmission interference, other postulations alluding to a combination of several pharmacologic properties have been proposed in the psychedelic effects of ketamine. These pathways include sigma, dopaminergic, and opioid receptors. Stimulation of sigma and D2 receptors is thought to contribute to the hallucinogenic effects, while activation of the μ-opioid receptor leads to analgesic and anxiolytic effects, as previously discussed. Furthermore, the blockade of the dopamine transporter in the prefrontal cortex potentiates the hallucinatory effects and produces stimulant and euphoric effects [11, 14]. In recent literature, ketamine has been compared to classical hallucinogens in order to investigate how these compounds impart their psychedelic effects. Classical hallucinogens, also referred to as serotonergic hallucinogens, which include psilocybin, lysergic acid diethylamide (LSD), and N,N-dimethyltryptamine (DMT), are hypothesized to produce their psychedelic effect primarily via the modulation of serotonin. More specifically, tryptamines (psilocybin and DMT) exhibit structural similarities with serotonin and are 5-HT2a receptor agonists/partial agonists [15]. The ergoline LSD has a high affinity for the 5-HT2a receptor and demonstrates partial agonism of the 5-HT2a receptor, leading to the desynchronization of the default mode network [16]. In contrast, ketamine is hypothesized to act primarily via the NMDA receptor antagonism and modulation of glu-

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tamate, as discussed above. The possibility of a common downstream metabolite has been an area of interest to investigators [16]. One study compared the changes in neurotransmitter metabolism during ketamine sessions to that of classical serotonin psychedelics, specifically LSD and psilocybin. This study design was implemented to investigate a possible correlation of the neurochemical actions with the hallucinogenic activity of the drugs. The findings showed increases in dopamine, ceruloplasmin, and B-endorphins, with decreases in MAO-A and MAO-B during ketamine sessions, which mirror conditions for hallucinogenic activity in the classic psychedelics. However, more in-depth research is necessary to draw conclusions between these similarities in the activities of these drugs [11]. Efforts to elucidate the central nervous system effects of ketamine employed EEG studies to assess the changes in wave patterns when using ketamine compared to other commonly used anesthetics. Of particular interest were the alterations noted upon the overlap of the loss of consciousness and the onset of dissociative amnesia. These changes included the abolition of the alpha rhythm, the dominance of theta activity, and the appearance of delta activity overlapping the loss of consciousness and onset of dissociative anesthesia [17]. The clinical significance of these findings remains uncertain at this time.

Ketamine: Adverse Effects The majority of adverse effects to both ketamine and esketamine are mild and transient [18] and can be categorized into the following categories: CNS (including neurologic and psychomimetic), cardiovascular, hepatic, urogenital, and gastrointestinal. Neurologic and psychomimetic effects tend to be dose-independent and apparent at all rates of infusion, which indicates a low threshold of occurrence, while the other categories tend to follow a more dose-dependent fashion. Both hepatic and renal impairment could induce a higher occurrence of those dose-dependent adverse effects [7]. Overall, the most common side effects include dissociation, anxiety, nausea, increased blood pressure, and headache [18]. The cardiovascular effects were deemed clinically insignificant when used at subanesthetic doses and are likely attributed to catecholamine release and norepinephrine reuptake inhibition at both peripheral nerves and the myocardium [19]. Cognitive side effects were also reported with IV infusions of ketamine, including impaired episodic and working memory, as well as slowed semantic processing, recognition memory, and procedural learning. However, most of the cognitive effects dissipated within 2  h of infusion [19]. Knowledge and understanding of the long-term effects of ketamine associated with chronic use are limited due to its association with mainly recreational abuse. However, some

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studies reveal chronic effects of neurotoxicity with higher doses, uropathology (including intermittent hematuria, nocturia, dysuria, pain in the bladder, and severe urgency and/or frequency, which is mostly due to direct toxicity on the ­bladder wall), gastrointestinal effects (abnormalities in liver function tests, common bile duct dilation, choledochal cysts, and ultimately, liver fibrosis), erectile dysfunction, and reduction in bladder function [19]. The following paragraph discusses adverse effects in regard specifically to esketamine. According to current literature, as well as the Spravato (brand name of esketamine) website, the second most common adverse effect (sedation being the most common) and the first most common psychological effect of esketamine is dissociative/perceptual changes, which require post dose monitoring for at least 2 h. Dissociation was described as a sense of disconnection from or distortion of self, feelings, thoughts, time, and space, as well as illusions, derealization, and depersonalization [6]. Contrary to data pertaining to ketamine, no cases of liver injury, interstitial colitis, or ulcerative colitis were reported with esketamine use. However, lower urinary tract events, including increased frequency and urgency, were reported with esketamine use, but resolved with either dose reduction or without any intervention [6]. Boxed warnings for esketamine include potential of abuse and/or misuse and sedation and dissociation warnings, as well as the anti-depressant class warning of heightened risk of suicidal thoughts and/or behaviors in both pediatric and younger populations [6].

 etamine: Dissociation and Other CNS K Adverse Effects The CNS adverse effects of ketamine thought to be most common fall within the psychomimetic category and include hallucinations (both auditory and visual), anxiety/panic attacks, paranoia, “high” feelings, euphoria or dysphoria, visual distortions, feelings of floating or melting, experiencing colors, and dissociation. Other CNS effects, which fall within the more neurological or cognitive domain, include altered vision (typically blurred), vertigo, numbness, dizziness, and nystagmus. Literature shows that these effects are typically most pronounced immediately upon administration, show significant reduction within 40 min post infusion, and disappear entirely within 4  h [7, 20]. Although not entirely understood, the mechanism of action responsible in producing the CNS effects is thought to be predominantly facilitated through the antagonistic properties exerted on the NMDA receptors. Current literature reveals common reportage of such adverse effects at anesthetic dosing, but incongruity within the subanesthetic dose range. Furthermore, literature has yet to establish any relationship between subanesthetic dose and effect. However, literature has revealed heightened occurrence of psychomimetic effects with S(+)

K. A. Fisher and T. Adrian

ketamine, potentially due to its higher potency. Premedication via benzodiazepines (i.e., midazolam) and alpha-2 agonists (i.e., clonidine) has been shown to mitigate, but not fully inhibit, psychomimetic effects [7]. Ketamine: Contraindications and Cautions Contraindications to ketamine use include active delirium, current substance abuse, allergy or prior hypersensitivity, aortic dissection, myocardial infarction, aneurysms, uncontrolled hypertension, unstable angina, severe liver disease. Controversial contraindications include active psychosis, acute alcohol intoxication (attributed to additive sedation), pregnancy, glaucoma, and increased intraocular pressure. Conditions considered to suggest cautionary use of ketamine include increased intracranial pressure (some studies indicate debatable increases of the CSF, while other studies reveal neuroprotective properties, including enhancement in cerebral perfusion), breast feeding (due to passage into breast milk), and use during obstetrics [4, 7, 21, 22].

 he Correlation Between Dissociation T and the Efficacy of Ketamine Dissociation and Anti-depression Current literature remains undefined in terms of whether or not dissociation leads to depression alleviation, with a mixture of study findings both suggesting and refuting dissociative influence over anti-depressant response of ketamine. However, multiple factors may account for this discrepancy. First, a concern of functional unblinding due to the side-­ effect profile of ketamine may account for the relationship existing between dissociation and anti-depression. Despite this concern, some studies that limited unblinding still determined that ketamine does possess actions of anti-depression. It is also worthy to note here that other side effects (i.e., increase in blood pressure) showed no correlation with anti-­ depression. Second, the timing of the treatment course has been consistent in multiple studies in various locations around the world. Additionally, the reduction in depressive symptoms is noted within and beyond the half-life of ketamine and its metabolite, norketamine. This suggests an actual effect that is biological in nature. Third, correlation inconsistencies may stem from the reported imprecision in the current dissociative symptoms measurement tools (i.e., CADSS), along with the implied complexity in the accurate evaluation of those considered to be in an altered state. Fourth, healthy patients compared to those with treatment-­ resistant depression may experience different effects, suggesting less of a likelihood of dissociation attributing to anti-depression. Lastly, dose-dependent studies revealed a relationship between dose and dissociation, but not between dose and anti-depression. Limitations of these studies did include the permittance of concurrent medication and small

5  Ketamine: Should Such a Dissociative Agent Be Used for Anesthesia, Anti-Depression/Suicidality, and Analgesia in DID Patients?

sample size. Altogether, these factors insinuate little support in acute anti-depression being due to dissociation, as well as the need for further investigation in the neurobiological effects of ketamine [9].

 se of Ketamine with Dissociative Identity U Disorder Dissociation in DID: Pathophysiology DID is marked by the existence of two or more distinct identities accompanied by dissociative symptoms causing significant disruptions in daily functioning [23]. Currently, the exact neurobiology responsible for dissociation with DID remains undetermined. This uncertainty is due in part to its lack of extensive study throughout the literature, as well as to both the rarity of the disorder and its commonly associated confounding comorbidities, most notably PTSD and depression [24]. Three separate, unintegrated hypotheses of the potentially responsible neurophysiological markers of dissociation in DID have been proposed and are supported by various imaging techniques. These three hypotheses include the orbitofrontal hypothesis, the corticolimbic hypothesis, and the temporal hypothesis [25]. The hypotheses are discussed further. The orbitofrontal hypothesis is supported by SPECT studies, revealing a decreased perfusion of the orbitofrontal region of the brain in DID patients in comparison to controls. The orbitofrontal cortex is an important regulator in the excitation and inhibition of the limbic system. The findings may support the hypothesis that early trauma affects the neurodevelopment of the orbitofrontal lobe [25]. This suggests early traumatization alters brain anatomy, particularly targeting the prefrontal cortex, thus affecting the maturation of the limbic system with subsequential effects on emotional regulation [26]. The corticolimbic hypothesis is supported by MRI, fMRI, and PET studies. One study established that DID patients had reduced hippocampi, amygdalae, and parahippocampal gyrus compared to controls. Additionally, there was a high correlation between psychoform/somatoform dissociations and decreased parahippocampal volume. Switching between identities demonstrated inhibition of the bilateral hippocampi, right parahippocampus, medial temporal lobe, and in minute regions of the substantia nigra and globus pallidus. Dissociation between different types of identities from an “emotional” identity attached to trauma memories and an “apparently normal” identity detached from trauma memories depicted elevations in blood flow to the amygdala, insular cortex, and somatosensory areas in the parietal cortex and basal ganglia and parts of the occipital, parietal cortex, anterior cingulate, and frontal areas. Of note, the same patterns were not reproducible in healthy controls simulating the change in identity states [25].

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The temporal hypothesis is supported by EEG and QEEg studies. These studies demonstrate mostly beta activity in the frontal and temporal lobes when transitioning between identity states. In addition, a lower average alpha coherence for “alter” identities is seen in the temporal, frontal, parietal, and central regions when compared to host identities [25].

 urrent Literature: Use of Ketamine in DID C Patients A paucity of literature addressing the use of ketamine amongst the DID patient population exists. Through an extensive literature review, only one relevant article was identified. This article depicts a case presentation of a patient suffering from refractory DID who underwent electroconvulsive therapy (ECT), where ketamine was utilized as the anesthetic. The patient was a 39-year-old female who presented with DID following severe physical, psychological, and sexual abuse beginning at the age of 2 and spanning into adulthood. This abuse was legitimized through extensive investigation, which ultimately led to the incarceration of her abuser. The patient developed four distinct alters and also suffered from longterm memory deficits, along with treatment-­resistant suicidal ideation, which was stable across the alters. A series of approved pharmacotherapy (including regimens of lithium, lamotrigine, ziprasidone, quetiapine, lurasidone, zolpidem, and prazosin) failed to produce results in her treatment, leading to a referral for weekly ECT treatments with the use of ketamine as the anesthetic agent. The report does not elucidate the reasoning in the choice of ketamine over alternative anesthetics. After initiating ECT treatments, the patient’s medications were consolidated to include doxepin, alprazolam, and lurasidone. ECT therapy (with ketamine as the anesthetic) was administered weekly for 2 years, culminating in the patient’s reporting of having “lost the other (alters).” The patient was able to integrate the four alters into one and recover her long-term memory. In addition to ECT treatment, psychodynamic psychotherapy, hypnotherapy, existentialhumanistic therapy, problem-centered therapy, and cognitive behavioral therapy were employed. The report notes ambiguity in whether frequent ECT aided in the integration of the alters or if different aspects of the treatment course, including the inclusion of ketamine with ECT treatment, were responsible for resolving her dissociative symptoms [27].

 ontroversy: Can Ketamine Be Safely Used C in DID Patients? Dissociation in both the context of DID and with ketamine-­ induction is a phenomenon that has yet to be extensively studied throughout literature. Therefore, the causative physiology in either context, as well as their impact on each other,

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is not well understood. Furthermore, although the dissociative dosage of ketamine has been roughly determined and multiple modalities of brain imaging have indicated physical changes upon dissociation while under the influence of ketamine, the actual correlation of dissociation to the efficacy of ketamine in regard to anesthesia, analgesia, and anti-­ depression has yet to be determined, with many current studies revealing mixed results. Therefore, at this point in time, it is impossible to determine the efficacy and safety of the use of ketamine in DID patients without more extensive research. The authors conducted an extensive literature review of the use of ketamine in DID patients. Unfortunately, a significant yield of relevant studies was unable to be produced and of the relevant entries identified, no definitive conclusions could be inferred. However, some interesting findings were uncovered that could potentially lead to future research. These findings are discussed below. Although the review did reveal a case presentation depicting the successful resolution of dissociative symptoms with the inclusion of ketamine in the treatment regime, many confounding variables exclude the possibility of correlation or causation based on this one report [27]. In 2015, the World Health Organization (WHO) conducted a review that suggested dissociation as a risk factor for the abuse of and dependence on ketamine [28]. One study investigated possible predictors of dissociation induced by ketamine and esketamine, with the consideration of the effects of trait dissociation. Trait dissociation is defined as the daily life frequency of dissociative experiences. The study found that trait dissociation could be considered a predictor of induced dissociation. The study also recommended screening for trait dissociation and providing patient counseling on its associated heightened risk prior to treatment [28]. The use of ketamine in DID patients remains an aenigma. The lack of research, rarity of the condition, vulnerability of subjects for study, undetermined physiology of DID and ketamine-induced dissociation, etc., all contribute to this mystery. As a very useful agent with its numerous established indications and abundant off-label uses, as well as its unique and safe use profile, which can be beneficial to some health-compromised individuals, it would be a disservice not to further investigate its safety and efficacy in treatment plans for DID patients. Therefore, authors highly recommend future research to establish safety and efficacy in such vulnerable populations.

References 1. Barrett W, Buxhoeveden M, Dhillon S. Ketamine: a versatile tool for anesthesia and analgesia. Curr Opin Anaesthesiol. 2020;33(5):633– 8. https://doi.org/10.1097/ACO.0000000000000916. 2. Zanos P, Moaddel R, Morris PJ, Riggs LM, Highland JN, Georgiou P, Pereira EFR, Albuquerque EX, Thomas CJ, Zarate CA Jr, Gould TD.  Ketamine and ketamine metabolite pharmacology: insights

K. A. Fisher and T. Adrian into therapeutic mechanisms [Erratum in: Pharmacol Rev. 2018 Oct;70(4):879.]. Pharmacol Rev. 2018;70(3):621–60. https://doi. org/10.1124/pr.117.015198. 3. Quirk K, Smith MA. Risk factors for the development of neuropsychiatric adverse effects in ketamine-treated pain. J Pain Palliat Care Pharmacother. 2022;36(2):88–94. https://doi.org/10.1080/1536028 8.2022.2066745. 4. Rosenbaum SB, Gupta V, Palacios JL.  Ketamine. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. 5. Nowacka A, Borczyk M.  Ketamine applications beyond anesthesia—a literature review. Eur J Pharmacol. 2019;860:172547. https://doi.org/10.1016/j.ejphar.2019.172547. 6. Bozymski KM, Crouse EL, Titus-Lay EN, Ott CA, Nofziger JL, Kirkwood CK. Esketamine: a novel option for treatment-resistant depression. Ann Pharmacother. 2020;54(6):567–76. https://doi. org/10.1177/1060028019892644. 7. Yang Y, Maher DP, Cohen SP.  Emerging concepts on the use of ketamine for chronic pain. Expert Rev Clin Pharmacol. 2020;13(2):135–46. https://doi.org/10.1080/17512433.2020.1717 947. 8. Rosenblat JD, Carvalho AF, Li M, Lee Y, Subramanieapillai M, McIntyre RS.  Oral ketamine for depression: a systematic review [Erratum in: J Clin Psychiatry. 2020 Apr 22;81(2)]. J Clin Psychiatry. 2019;80(3):18r12475. https://doi.org/10.4088/JCP.18r12475. 9. Ballard ED, Zarate CA Jr. The role of dissociation in ketamine’s antidepressant effects. Nat Commun. 2020;11(1):6431. https://doi. org/10.1038/s41467-­020-­20190-­4. 10. Sassano-Higgins S, Baron D, Juarez G, Esmaili N, Gold M.  A review of ketamine abuse and diversion. Depress Anxiety. 2016;33(8):718–27. https://doi.org/10.1002/da.22536. 11. Wolfson P, Hartelius G.  The ketamine papers: science, therapy, and transformation. Santa Cruz: Multidisciplinary Association for Psychedelic Studies; 2022. 12. Mion G, Villevieille T. Ketamine pharmacology: an update (pharmacodynamics and molecular aspects, recent findings). CNS Neurosci Ther. 2013;19(6):370–80. https://doi.org/10.1111/cns.12099. 13. National Institute on Drug Abuse. Hallucinogens Drug Facts. National Institute on Drug Abuse. 2019. 14. Purdon PL, Sampson A, Pavone KJ, Brown EN.  Clinical electroencephalography for anesthesiologists: part I background and basic signatures. Anesthesiology. 2015;123(4):937–60. https://doi. org/10.1097/aln.0000000000000841. 15. Rickli A, Moning OD, Hoener MC, Liechti ME.  Receptor interaction profiles of novel psychoactive tryptamines ­ compared  with  classic hallucinogens. Eur Neuropsychopharmacol. 2016;26(8):1327–37. https://doi. org/10.1016/j.euroneuro.2016.05.001. 16. Kojic M, Saelens J, Kadriu B, Zarate CA Jr, Kraus C.  Ketamine for depression: advances in clinical treatment, rapid antidepressant mechanisms of action, and a contrast with serotonergic psychedelics. Curr Top Behav Neurosci. 2022;56:141–67. https://doi. org/10.1007/7854_2022_313. 17. Mihaljević S, Pavlović M, Reiner K, Ćaćić M. Therapeutic mechanisms of ketamine. Psychiatr Danub. 2020;32(3–4):325–33. https:// doi.org/10.24869/psyd.2020.325. 18. Ceban F, Rosenblat JD, Kratiuk K, Lee Y, Rodrigues NB, Gill H, Subramaniapillai M, Nasri F, Lui LMW, Lipsitz O, Kumar A, Lee JG, Chau EH, Cao B, Lin K, Ho RC, Mansur RB, Swainson J, McIntyre RS. Prevention and management of common adverse effects of ketamine and esketamine in patients with mood disorders. CNS Drugs. 2021;35(9):925–34. https://doi.org/10.1007/ s40263-­021-­00846-­5. 19. Iqbal SZ, Mathew SJ.  Ketamine for depression clinical issues. Adv Pharmacol. 2020;89:131–62. https://doi.org/10.1016/ bs.apha.2020.02.005. 20. Acevedo-Diaz EE, Cavanaugh GW, Greenstein D, Kraus C, Kadriu B, Zarate CA, Park LT. Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-­

5  Ketamine: Should Such a Dissociative Agent Be Used for Anesthesia, Anti-Depression/Suicidality, and Analgesia in DID Patients? resistant depression. J Affect Disord. 2020;263:568–75. https://doi. org/10.1016/j.jad.2019.11.028. 21. Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan AD, Hurley RW, Viscusi ER, Narouze S, Davis FN, Ritchie EC, Lubenow TR, Hooten WM. Consensus guidelines on the use of intravenous ketamine infusions for chronic pain from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):521–46. https://doi.org/10.1097/ AAP.0000000000000808. 22. Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, Bhatia A, Davis FN, Hooten WM, Cohen SP. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):456–66. https://doi.org/10.1097/ AAP.0000000000000806. 23. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). 5th ed. American Psychiatric Association Publishing; 2013. 24. Roydeva MI, Reinders AATS. Biomarkers of pathological dissociation: a systematic review. Neurosci Biobehav Rev. 2021;123:120– 202. https://doi.org/10.1016/j.neubiorev.2020.11.019.

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25. Mitra P, Jain A. Dissociative identity disorder. Treasure Island (FL): StatPearls Publishing; 2022. 26. Reinders AATS, Chalavi S, Schlumpf YR, Vissia EM, Nijenhuis ERS, Jäncke L, Veltman DJ, Ecker C.  Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder. Acta Psychiatr Scand. 2018;137(2):157–70. https://doi. org/10.1111/acps.12839. 27. Webster KD, Michalowski S, Hranilovich TE.  Multimodal treatment with ECT for identity integration in a patient with dissociative identity disorder, complex post-traumatic stress disorder, and major depressive disorder: a rare case report. Front Psychiatry. 2018;9:275. https://doi.org/10.3389/fpsyt.2018.00275. 28. Correia-Melo FS, Leal GC, Carvalho MS, Jesus-Nunes AP, Ferreira CBN, Vieira F, Magnavita G, Vale LAS, Mello RP, Nakahira C, Argolo FC, Cardoso T, Souza CDS, Fontes ATC, Ferreira MB, Araújo-de-Freitas L, Tuena MA, Echegaray MVF, Cavalcanti DE, Lucchese AC, Bandeira ID, Telles M, Lima CS, Sampaio AS, Silva SS, Marback RF, Del-Porto JA, Abreu JN, Sarin LM, Paixão CS, Carvalho LP, Machado PRL, Turecki G, Lacerda ALT, Quarantini LC.  Comparative study of esketamine and racemic ketamine in treatment-resistant depression: protocol for a non-inferiority clinical trial. Medicine (Baltimore). 2018;97(38):e12414. https://doi. org/10.1097/MD.0000000000012414.

6

Culture and Dissociation Kristal C. Khan, Bilal Haider Malik, and Ian Hunter Rutkofsky

Introduction Culture encompasses the social behavior, institutions, and norms found in human societies, as well as the knowledge, beliefs, arts, laws, customs, capabilities, food, and habits of the individuals in these groups. Culture often originates from or is attributed to a specific region or location [1]. Race is sociological concept that seeks to segregate humans based on similar skin color and physical appearance. It is socially important because it supports racial ideologies, racism, discrimination, and social exclusion, which can have strong negative effects on mental health. There is evidence that racism can exacerbate many psychiatric disorders, contributing to poor outcome, and that racial biases can affect diagnostic assessment [2]. Ethnicity is the term used for the culture of people in a given geographic region or of people who descended from natives of that region. It includes their language, nationality, heritage, religion, dress, and customs. Examples of ethnicity include being labeled as Irish, Jewish, or Cambodian, regardless of race. Ethnicity is considered an anthropological term because it is based on learned behaviors, not biological factors. Many people have mixed cultural backgrounds and can share in more than one ethnicity [3]. Culture, race, and ethnicity contribute to economic inequities, racism, and discrimination that result in health disparities. Cultural, ethic, and racial identities can be sources K. C. Khan (*) St. Luke’s University Health Network, Geisinger Health System (Risant Health), Easton, PA, USA B. H. Malik California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA I. H. Rutkofsky Amen Clinics, Washington, DC, USA Convenient Psychiatry and Mental Health Services, Maryland, USA

of strength and group support that enhance resilience, but they may also lead to psychological, interpersonal, and intergeneration conflict or difficulties in adaptation that require diagnostic assessment [2].

Discussion Cultural diversity is a fact of life and respecting and understanding that diversity is an important and challenging goal. To be clinically competent, every clinician needs to be culturally competent, which includes cultural sensitivity, cultural knowledge, cultural empathy, cultural guidance, and flexible and culturally relevant doctor–patient relations and interactions. Culture has less influence on organic mental disorders and major psychiatric disorders (functional psychoses) than on minor psychiatric disorders (neuroses) or substance abuse. Culture has a profound influence on culture-­ related specific syndromes or epidemic mental disorders [4]. Culture must be taken into consideration when assessing and diagnosing a patient. Just as screening tools have validity limitations when used among culturally diverse populations, standard psychiatric diagnoses have limitations among these groups as well. Psychological expressions are, in part, culturally specific, and behavior that is abnormal or pathological in one culture can be the standard norm in another. For example, individuals who have migrated from countries with oppressive governments are expected to have paranoid thoughts. Culture plays a large role in understanding phenomena that might be construed as mental illnesses in Western medicine. These cultural concepts of distress may or may not be linked to particular diagnostic criteria in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) [5]. Increasing global migration and its associated trauma have resulted in an increasing awareness of the influence of culture on how people respond to traumatic events [6]. Dissociative disorders are heavily associated with a history of psychological trauma, which may lead to an uncon-

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scious defense mechanism involving the segregation of any group of mental or behavioral processes from the rest of the person’s psychic activity [7]. And for this reason, it is imperative that we recognize the influence of culture on how individuals respond to traumatic events. Dissociation has been linked as a protective factor in trauma patients. Auerbach, in 2009, examined 20 nonclinical Holocaust survivors, living in the United States, who had adjusted well after the war and suggested that dissociation of traumatic memories helped the survivors to create a “normal” life after the war [8]. However, the extent of dissociation’s protective effects varies among different cultures. In 2009, a study in Connecticut, USA, suggested dissociation as a protective factor, but more specifically among Black students [9]. They examined the racial differences in dissociation in 317 nonclinical students (190 whites, 127 ethnic minorities— Asian American, Black, Latino, biracial). All racial groups scored the same with respect to depression, anxiety, and stressful or traumatic life events. However, African and Asian American students recorded higher dissociation scores. For White and Latino students, higher dissociation scores were directly related to other increased psychological measures, while Black and Asian students showed an indirect relationship between dissociation and the other measures. In particular, Black students with higher dissociation scores were more likely to have less psychological distress. Similar, but weaker relationships were described for Asian American students. On the opposing end to syndromes that are unconsciously utilized for coping from trauma, it is also helpful to note syndromes utilized in a factitious manner. For example, Ganser’s syndrome is often defined as a dissociative disorder [7]. It is characterized as giving approximate answers (e.g., 2 + 2 = 5). This syndrome is usually preceded by extreme stress, with claims of amnesia for the period of psychosis, and recovery is most often sudden. The major contributory factor is the presence of a severe personality disorder. It is sometimes referred to as prison psychosis, since it mostly occurs in prison inmates and is sometimes believed to be a variant of malingering, with possible secondary gain (e.g., leniency with prison/court officials). Knowing these traits in varying populations can guide treatment more accurately. For the most part, standard international assessments used to evaluate cross-cultural dissociation results in similar psychometric properties across various cultural regions. However, certain regions may have different assessments for their region-specific pathologies. For example, lack of understanding dissociative psychosis (DP) in Turkey or dissociative hallucinosis among Latino communities may give a false diagnosis, leading to inaccurate and unnecessary treatment. Turkish psychiatrists consider DP qualitatively distinct from schizophrenia and other endogenous psychosis and refer to it as “pseudopsychosis” or “pseudopsychotic dissociation.” Common presentations of DP includes visual and

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auditory hallucinations; child-like, disorganized, or grossly unusual behavior; temporary disorientation of person, place or time; pseudo seizures; and altered states of consciousness. The diagnosis of DP is very prevalent in Turkish inpatient units (0.5–5.8% of admissions), and symptoms usually resolve a few days after admissions without medications [10]. A provider who is unaware of these symptoms among the Turkish population may inaccurately or unnecessarily choose a medication regimen for treatment. Psychotic disorders with acute onset and brief duration, usually in response to severe stress, show a higher prevalence in the developing world than in industrialized societies. There is also cross-cultural variation in the centrality of the type of trauma most connected to subsequent dissociative pathology. Whereas both childhood sexual and physical abuse have been implicated in most US and European research, Turkish and Puerto Rican studies suggest a larger link to emotional neglect and attachment difficulties in childhood (in Turkey) and physical but not sexual abuse (in Puerto Rico) [10]. Cultural concepts of distress (previously referred to as culture-bound syndromes) refer to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, and troubling thoughts and emotions [11]. They encompass folk illnesses, cultural syndromes, idioms of distress, and causal explanations. Individuals belonging to different cultural groups and subgroups experience, understand, and express mental distress and behavioral problems in unique ways that do not conform to standard classifications of psychiatric disorders as per the DSM. Many so-­ called culture-bound syndromes occur disproportionally among the poor and least educated, indicating that they are a socialized way of expressing distress among the most disenfranchised. Two of the most studied idioms, koro and ataques de nervous, provide excellent examples of how culture and social status shape distress [12]. It is important to understand cultural concepts to avoid misdiagnosis, build therapeutic alliance with a patient, and help with identifying vulnerable individuals/populations that may benefit from mental health promotion initiative or other public health activities. Table 6.1 lists some common culture-bound syndromes. The DSM-V [11] provides a systematic outline for incorporating culturally relevant information when conducting a multiaxial diagnostic assessment by utilizing their Cultural Formulation Interview (CFI). The CFI, listed below, is a 16-question tool that enables the wider use of cultural formulation in clinical cultural assessment [16]. It focuses on the individual’s experience and the social contexts of the clinical problem. The CFI follows a person-centered approach to cultural assessment by eliciting information from the individual about his or her own views and those of others in his or her social network. This approach is designed to avoid stereotyping and is available online: www.psychiatry.org/dsm5.

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Table 6.1  Culture-bound syndromes [12–15] Algonquin Indians

Uncontrollable craving to eat human flesh and the fear of turning into a cannibal Malaysia, Indonesia Amplified response to sudden shock, with symptoms of fearfulness, echolalia, echopraxia, and coprolalia Inuit Short periods of dissociation with increased sensation of sound or smell, followed by brief paralysis with anxiety and hallucinations. Believed to be caused by spirit activity Inuit Sudden dissociative periods of extreme excitement in which they tear off clothes, run naked through the snow, scream, throw things, and perform wild behaviors. Typically ends with convulsive seizures, followed by acute coma and amnesia for the event Kenya, Southern Africa (ZuluAnxiety state due to effects of magical potions given by a rejected love and Xhosa-­speaking interest, spirit, or demonic possession. Presents as trance-like states, loss of communities) consciousness, paralysis, shouting, pseudolalia, temporary blindness, and experiencing sexual nightmares Southeast Asian Austronesians Destructive or homicidal behavior exaggerated by brooding periods, followed by exhaustion and no memory of the event Taiwan, Southeast Asia Fearful beliefs of getting fatigued, impotent, or death precipitated by fear of getting cold Southeast Asia, India, China Acute anxiety reaction to a strong belief that their genitalia is retracting/ disappearing into the body possibly causing death Siberian women Compulsive mimicking of other people’s words or behaviors Filipino males Screaming/moaning during sleep, apparently experiencing a terrifying nightmare, followed by unexpected death China, Taiwan Trance-like state in which the individual is supposedly possessed by ancestral spirits. Accompanied by tremors, disorientation, delirium, and visual or auditory hallucinations Ainu and Sakhalin women of Extreme startle response involving automatic movements, imitative behavior, Japan infantile reactions, and obedience to command Lumberjacks of French-Canadian Extreme startle response involving yelling, imitative speech and behavior, descent living in Quebec and involuntary jumping, flying of arms and command behavior (resembles Maine Latah) Puerto Rico Period of brooding, followed by sudden violent attacks on others around them (similar to Amok) Siberia Indiscriminate, uncontrolled imitations of the actions of others (resembles Latah) Latinos in the United States, After a frightening event, they fear their soul has left their body. Symptoms Mexico, Central and South include weight loss, fatigue, myalgia, headache, diarrhea, insomnia, lack of America motivation, low self-esteem India Severe anxiety and hypochondriacal concerns associated with the discharge of semen, whitish discoloration of the urine, and feelings of weakness and exhaustion Haiti, Africa, Islands of the An individual who has disobeyed a ritual or taboo is hexed or cursed by a Pacific, Caribbean medicine man or sorcerer and dies within a few days. (Walter B. Cannon, one of the first researchers of voodoo death, suggested that the individual’s strong belief in the curse caused physiological reactions in the body resulting in death) Korea “Anger syndrome” including symptoms of insomnia, fatigue, panic, fear of impending death, anorexia, aches and pains, palpitations Chinese Acute, time-limited episode characterized by dissociative, paranoid, and other psychotic or non-psychotic symptoms, after participation in “qi-gong,” a Chinese health-enhancing practice Latin America (notably Puerto Uncontrollable shouting, acts of crying, trembling, seizure, or fainting-like Ricans) episodes, similar to panic attacks. Precipitated by stressful event related to family Philippines Disturbances of thoughts, motor behavior, and speech. Obedience to irrational commands, inappropriate and uncontrollable behaviors that result in physical exhaustion Africa, West Africa, Haiti Sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. May include hallucinations or paranoid ideation Portuguese population in Cape Pain, numbness, tremors, paralysis, convulsions, stroke, blindness, heart Verde, and their immigrants in attack, infection, and miscarriage the United States

Wendigo psychosis Latah Uqamairineq Piblokto, Arctic hysteria

Ufufunyane

Amok Pa-leng “Frigophobia” Koro Amurakh Bangungut Hsieh-ping Imu Jumping Frenchmen of Maine Syndrome Mal de pelea Myriachit Susto Dhat syndrome Voodoo death

Hwa-byung Qi-gong deviation Ataque de nervious Mali-Mali Boufee delirante Sangue dormindo or “sleeping blood”

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Conclusion Culture has less influence on organic mental disorders but has a profound influence on culture-related specific syndromes. Understanding an individual’s culture plays an important role in accurately assessing, diagnosing, and treating them. As global migration increases, it is important to be more aware of the trauma that incurs and people’s response and coping mechanisms to that trauma. Many culture-bound syndromes are more prevalent among lesser industrialized societies with lower socioeconomic status and can be that population’s way of expressing and coping

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with distress. What may be considered psychosis in one area may be seen as a normal and common response to distress in another, for example, DP in Turkey, which is very prevalent and resolves a few days after admission without medication. The DSM-V CFI is a helpful tool to utilize in assessing individuals of different cultural backgrounds, since it focuses on the individual’s experience and the social contexts of the clinical problem. As migration and cultural diversity continue to grow, it is crucial that we remain aware of culture-bound syndromes, in an effort to alleviate inequities, racism, and discrimination and ultimately provide improved patient care.

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References 1. Wikipedia. Culture 2022. https://en.wikipedia.org/wiki/ culture#cite_note-­tyor1871-­1. 2. Influential Publications. Cultural formulation. Focus. 2015;13(4):478–84. 3. Nittle NK. Understanding the difference between race and ethnicity. 2021. https://www.thoughtco.com/difference-­between-­race-­and-­ ethnicity-­2834950#:~:text=Ethnicity%20is%20the%20term%20 used%20for%20the%20culture,their%20language%2C%20 nationality%2C%20heritage%2C%20religion%2C%20 dress%2C%20and%20customs. 4. Tseng WS, Streltzer J. Introduction: culture and psychiatry. Focus. 2006;4(1):81–90. 5. Center for Substance Abuse Treatment (US). Cultural formulation in diagnosis and cultural concepts of distress. Rockville: Substance Abuse and Mental Health Services Administration; 2014. 6. Kruger C. Culture, trauma and dissociation: a broadening perspective for our field. J Trauma Dissoc. 2020;21(1):1–13. 7. Sadock BJ, Sadock VA Ruiz P Kaplan and Sadock’s synopsis of psychiatry. 11 Lippincott Williams & Wilkins; 2015. 451–464 8. Auerbach CF, Mirvis S, Stern S, Schwartz J. Structural dissociation and its resolution among Holocaust survivors: a qualitative research study. J Trauma Dissoc. 2009;10(4):385–404.

K. C. Khan et al. 9. Douglas AN.  Racial and ethnic differences in dissociation: an examination of the dissociative experiences scale in a nonclinical population. J Trauma Dissoc. 2009;10(1):24–37. 10. Lewis-Fernández R, Martínez-Taboas A, Sar V, Patel S, Boatin A.  The cross-cultural assessment of dissociation. In: Wilson JP, Tang CS-K, editors. Cross-cultural assessment of psychological trauma and PTSD. Boston: Springer US; 2007. p. 279–317. 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association Publishing; 2013. p. 749–59. 12. Lopez I, Avril H. Culture-bound (or culturally salient?): the role of culture in disorder. In: Keith KD, editor. The encyclopedia of cross-­ cultural psychology. Hoboken: Wiley-Blackwell; 2013. 13. Association AP.  Culture-bound syndrome in APA Dictionary of Psychology. Washington, DC. 2022. https://dictionary.apa.org/ culture-­bound-­syndrome. 14. Wiki P. Ethnospecific disorders. 2022. https://psychology.fandom. com/wiki/Category:Ethnospecific_disorders. 15. Mampatta J.  Cultural concepts of distress and assessment. 2019. https://www.slideshare.net/jithinmampatta/ cultural-­concepts-­of-­distress-­and-­assessment. 16. DSM5 APA.  Cultural Formulation Interview (CFI). 2013. https:// www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/ APA_DSM5_Cultural-­Formulation-­Interview.pdf.

7

Epidemiology of Dissociative Identity Disorder José Hawayek

Introduction

Epidemiology

I stepped into the room and called for “Coraline,” as instructed. A young, tall, slender man walks up and answers me in a childish female voice: “That is me, doctor!” After taking “Coraline into a separate room for an interview, we begin to talk about what brought “her” to the hospital and how we could help her. Part way through the questions, “Coraline” shakes her head, closes her eyes, and then begins to talk in a deep, manly voice: “This is Steven. Who are you? Why am I at a hospital?” This was the first time I had ever encountered a patient diagnosed with dissociative identity disorder. Dissociative identity disorder or DID is a mental health condition that has garnered more recognition in the past few years primarily due to sources such as television, comic books, and social media. As a result, its diagnosis has increased, and symptoms are observed more frequently among teenagers and young adults than before. DID has a diagnosis rate of approximately 1.5% in the world. However, local studies within the United States have placed the estimate close to 1% of the population [1–5]. Direct studies documenting the actual prevalence and incidence of the condition have not been done on a large scale. They remain elusive as the condition was formerly believed to be a “hoax.” Most individuals with DID are encouraged to downplay their symptoms or feel a public shame to come forward with their experiences, given this past stigma. Currently, studies are underway to identify predisposing factors, possible etiologies, and comorbidities to the condition.

Incidence and Prevalence

J. Hawayek (*) Larkin Community Hospital, General Psychiatry Residency Program, South Miami, FL, USA

According to the American Psychiatric Association, the 12-month prevalence of DID among adults in the United States is 1.5%, without statistically significant differences between male and female patients [4–6]. Population prevalence estimates widely vary. Specific estimates of DID within psychiatric patient populations place the incidence of DID within inpatient settings between 1 and 10% [5, 7–9]. Rates within the outpatient community place the incidence between 1 and 3%; however, these reports are based on individual practices [7–9]. Current evidence suggests a 2–5% prevalence among psychiatric inpatients, 2–3% among outpatients, and a 1% prevalence in the general population [10–12]. Teenagers in the psychiatric outpatient population appear to have the highest prevalence rate, with rates reported to be as high as 16.4%. Most dissociative disorders carry a prevalence of 12.0–13.8% within the psychiatric outpatient population. Currently, DID is diagnosed more commonly in females than males, from 5 to 9 times more often in young female adulthood [6, 10–13]. Currently, diagnosis of DID in children is infrequent due to a lack of recent research and address to the current controversies surrounding the condition. DID occurs more commonly in young female adults, and its prevalence declines with age.

Comorbidities Various psychiatric diagnoses and disorders are comorbid with a dissociative identity disorder. The most observed comorbid disorder of DID is depression, with over 80% of diagnosed cases also meeting the criteria for major depressive disorder [10–12]. Other comorbid disorders include substance abuse disorders, eating disorders, anxiety disorders, bipolar disorders, and personality disorders. In addition, a sizable portion of patients diagnosed with DID has histories of borderline personality disorder and post-­ traumatic stress disorder (PTSD) [13–15]. Although there is

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a strong correlation between the development of DID and trauma, there exists enough evidence to place DID as a separate diagnosis from other conditions such as PTSD [10–15]. Patients diagnosed with DID have a prevalence estimate of comorbidity with PTSD of 79–100%. Prevalence with a diagnosis of major depressive disorder range from 83 to 96% [16]. Substance abuse shows similar comorbidity, including past and present, ranging between 83 and 96% [16, 17]. The somatoform disorder has prevalent comorbidity of 35–61% [16, 17]. Headaches have been commonly associated with DID, and studies show a prevalence between 79 and 91% [16–18]. Personality disorders most prevalent with DID include avoidant personality disorder and borderline ­personality disorder, with the former having an estimated prevalence of 76% and the latter 31–83% [16–19]. Of note, presentations of dissociation in people with schizophrenia differ from those with DID as their base is not rooted in trauma, which can be evaluated. However, both conditions share a high rate of dissociative auditory hallucinations and other perceptual disturbances. In addition, a patient diagnosed with DID demonstrate the highest potential for hypnosis of any clinical population [18–22].

Risk Factors Risk factors associated with the development of DID include various possible causes. No one such cause has been identified as a definitive source of DID. Retrospective studies have formulated an association between patients diagnosed with DID and a history of severe, chronic childhood trauma (usually physical or sexual abuse), in most cases beginning before age 6. Studies have shown that of patients diagnosed with DID, between 60 and 100% have experienced some form of sexual, physical, or general trauma before age 6, with an average median of 86% [8, 23–26]. For reference, rates of childhood abuse reported by adults in the United States range between 8 and 17% [27]. There are no studies detailing the proportion of adults who suffered from childhood abuse who subsequently developed symptoms of DID. Some theories postulate that symptoms of DID can be induced by therapy. This is a highly contested and a factor of much dispute. Hypotheses suggest that symptoms of DID can be “created” by therapists using techniques such as hypnosis, age regression, or memory retrieval on suggestible individuals. The Sociocognitive Model (SCM) proposes that DID is derived from a person either consciously or unconsciously behaving in a certain way as dictated by cultural stereotypes with others, primarily therapists, providing cues as to such behaviors [25–27]. This model refers then that behavior is affected by external portrayals of DID [23, 26– 28]. Proponents of this model argue that the bizarre dissociative symptoms characteristic of DID are rarely present before therapeutic intervention. Proponents of SCM agree that DID is accompanied by genuine distress and symptomatology as

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well as its diagnostic criteria, but they remain skeptical over the traumatic etiology; this is due to the characteristics of people diagnosed with DID, which include hypnotizability, suggestibility, mental absorption, and fantasization [27–30]. Proponents of SCM also note that a small cohort makes most DID diagnoses of doctors. Hypotheses to justify this propose that in addition to therapeutic provocation, DID can result from role-playing; many disagree with this model, given a lack of incentive to maintain or manufacture the alternate identities. Other arguments against DID include the lack of diagnosis of DID in children, the augmentation of diagnosis after 1980 without evidence of increased rates of child abuse, the appearance of the disorder predominantly present in patients partaking of psychotherapy with hypnosis, the presence of alternate identities comprised of animals or mythological beings, and an increase in the number of identities over time [28, 29]. There is little agreement between those who see therapy versus trauma as a cause. Currently, the rarity of the diagnosis of DID in children is cited as a reason to doubt the existence of the condition, with proponents of both the traumatic model and SCM citing that discovery of DID in a child who has not undergone psychotherapy would undermine the SCM; on the other hand, if children are found to be diagnosed with DID only after incurring treatment would challenge the traumagenic model. As of 2011, over 250 cases of DID have been diagnosed in children; however, the data do not favor or disprove either model [17, 20, 25]. It is of note that many of these patients were presented to clinicians by parents who had a diagnosis of DID; others admitted to being influenced by the appearance of DID within media or a diagnosis of psychosis primarily with auditory perceptual disturbances [26–28]. No studies have been published focusing on finding children with DID in the general population.

Conclusion Dissociative identity disorder is a rare and uncommon syndrome that has recently come to light due to media exposure and knowledge of the condition. DID is still rarely seen within the general adult community and even more seldom found within pediatrics, although recent data point to an increase in diagnosis within the teenage years. The disorder is more often observed in females than males and more frequently diagnosed in individuals with comorbid conditions such as major depressive disorder and borderline personality disorder. More and more, we can see the association between childhood trauma and the development of DID.  Current debate exists over whether dissociative identity disorder exists as a standalone diagnosis or as separate from trauma and PTSD. Current areas of debate also include the origin of the disease. More focus has been brought to previous studies

7  Epidemiology of Dissociative Identity Disorder

regarding the pathogenesis and origin of the syndromes, and it has been postulated that the disease may be born out of therapeutic focus. Currently, much debate and further studies are required for the epidemiology and statistical effect of the syndrome to be fully comprehended. Several factors limit the current data, most of which stem from small studies and ample time between studies. Further epidemiological studies should focus on the acquisition of data regarding the general prevalence of the disease in the general population and within subsets such as children and people with comorbid disorders, the increase in diagnosis after media exposure, and the presence of the diagnosis prior to exposure to knowledge or therapy for a ­condition. Currently, insufficient empirical evidence exists to support epidemiological data regarding dissociative identity disorder within most populations, and current conclusions are drawn from estimates and resources compiling. DID is a condition that will require further studies and will likely continue to develop within the following years as more clinicians and people are aware of the symptoms, diagnosis, and treatment. “There are no uncommon presentations of uncommon diseases but rather atypical presentations of common diseases”—a common medical saying.

References 1. Reategui A.  Dissociative identity disorder: a literature review. Brigham Young Univ Undergrad J Psychol. 2019;31:22–7. 2. Lynn SJ, Berg J, Lilienfeld SO, Merckelbach H, Giesbrecht T, Accardi M, Cleere C.  Chapter 14. Dissociative disorders. In: Hersen M, Beidel DC, editors. Adult psychopathology and diagnosis. Hoboken: Wiley; 2012. p. 497–538. 3. International Society for the Study of Trauma Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision. J Trauma Dissociation. 2011;12(2):188–212. 4. Sar V, Önder C, Kilincaslan A, Zoroglu SS, Alyanak B. Dissociative identity disorder among adolescents: prevalence in a University Psychiatric Outpatient Unit. J Trauma Dissociation. 2014;15(4):402–19. 5. Maldonado JR, Spiegel D.  Dissociative disorders—dissociative identity disorder (multiple personality disorder). In: Hales RE, Yudofsky SC, Gabbard GO, editors. The American Psychiatric Publishing textbook of psychiatry. 5th ed. Washington: American Psychiatric Association Publishing; 2008. p. 681–710. 6. Boysen GA. The scientific status of childhood dissociative identity disorder: a review of published research. Psychother Psychosom. 2011;80(6):329–34. 7. Sadock BJ, Sadock VA. Dissociative disorders—dissociative identity disorder. In: Kaplan & Sadock’s concise textbook of clinical psychiatry. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 299–300. 8. Thornhill JT.  Psychiatry. 6th ed. Philadelphia: Wolters Kluwer Health; 2011. p. 169. 9. Kihlstrom JF.  Dissociative disorders. Annu Rev Clin Psychol. 2005;1(1):227–53. 10. Ducharme EL. Best practices in working with complex trauma and dissociative identity disorder. Pract Innov. 2017;2(3):150–61.

51 11. Spiegel D, Loewenstein RJ, Lewis-Fernández R, et al. Dissociative disorders in DSM-5. Depress Anxiety. 2011;28:824. 12. Ross CA. Epidemiology of multiple personality disorder and dissociation. Psychiatr Clin North Am. 1991;14:503. 13. Sar V, Akyüz G, Doğan O.  Prevalence of dissociative disorders among women in the general population. Psychiatry Res. 2007;149:169. 14. Knudsen SA, Draijer N, Haslerud J, et al. Prevalence of dissociative disorders in a Norwegian general psychiatric department. In: Van der Hart O, Boon S, Draijer N, editors. Fifth annual spring conference of the International Society for the Study of Dissociation. International Society for the Study of Dissociation, Amsterdam; 1995. 15. Lipsanen T, Korkeila J, Peltola P, et  al. Dissociative disorders among psychiatric patients. Eur Psychiatry. 2004;19:53. 16. Tutkun H, Sar V, Yargiç LI, et al. Frequency of dissociative disorders among psychiatric inpatients in a Turkish University Clinic. Am J Psychiatry. 1998;155:800. 17. Gast U, Rodewald F, Nickel V, Emrich HM. Prevalence of dissociative disorders among psychiatric inpatients in a German University Clinic. J Nerv Ment Dis. 2001;189:249. 18. Friedl MC, Draijer N. Dissociative disorders in Dutch psychiatric inpatients. Am J Psychiatry. 2000;157:1012. 19. Horen SA, Leichner PP, Lawson JS.  Prevalence of dissociative symptoms and disorders in an adult psychiatric inpatient population in Canada. Can J Psychiatry. 1995;40:185. 20. Spiegel D, Loewenstein RJ, Lewis-Fernández R, Sar V, Simeon D, Vermetten E, Cardeña E, Dell PF. Dissociative disorders in DSM-5 (PDF). Depress Anxiety. 2011;28(9):824–52. 21. Ross CA. History, phenomenology, and epidemiology of dissociation. In: Michelson LK, Ray WJ, editors. Handbook of dissociation. New York: Plenum Press; 1996. 22. Saxe GN, van der Kolk BA, Berkowitz R, et al. Dissociative disorders in psychiatric inpatients. Am J Psychiatry. 1993;150:1037. 23. Rifkin A, Ghisalbert D, Dimatou S, et al. Dissociative identity disorder in psychiatric inpatients. Am J Psychiatry. 1998;155:844. 24. Latz TT, Kramer SI, Hughes DL.  Multiple personality disorder among female inpatients in a state hospital. Am J Psychiatry. 1995;152:1343. 25. Yu J, Ross CA, Keyes BB, et  al. Dissociative disorders among Chinese inpatients diagnosed with schizophrenia. J Trauma Dissociation. 2010;11:358. 26. Graves SM. Dissociative disorders and dissociative symptoms at a community mental health center. Dissociation. 1989;2:119. 27. Reinders AATS, Veltman DJ. Dissociative identity disorder: out of the shadows at last? Br J Psychiatry. 2021;219(2):413–4. https:// doi.org/10.1192/bjp.2020.168. 28. Dorahy MJ, Brand BL, Sar V, Krüger C, Stavropoulos P, Martínez-­ Taboas A, Lewis-Fernández R, Middleton W.  Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. 29. Thompson PM, Jahanshad N, Ching CRK, Salminen LE, Thomopoulos SI, Bright J, Baune BT, Bertolín S, Bralten J, Bruin WB, Bülow R, Chen J, Chye Y, Dannlowski U, de Kovel CGF, Donohoe G, Eyler LT, Faraone SV, Favre P, Filippi CA, Frodl T, Garijo D, Gil Y, Grabe HJ, Grasby KL, Hajek T, Han LKM, Hatton SN, Hilbert K, Ho TC, Holleran L, Homuth G, Hosten N, Houenou J, Ivanov I, Jia T, Kelly S, Klein M, Kwon JS, Laansma MA, Leerssen J, Lueken U, Nunes A, Neill JO, Opel N, Piras F, Piras F, Postema MC, Pozzi E, Shatokhina N, Soriano-Mas C, Spalletta G, Sun D, Teumer A, Tilot AK, Tozzi L, van der Merwe C, Van Someren EJW, van Wingen GA, Völzke H, Walton E, Wang L, Winkler AM, Wittfeld K, Wright MJ, Yun JY, Zhang G, Zhang-James Y, Adhikari BM, Agartz I, Aghajani M, Aleman A, Althoff RR, Altmann A, Andreassen OA, Baron DA, Bartnik-Olson BL, Marie Bas-Hoogendam J, Baskin-Sommers AR, Bearden CE, Berner LA,

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J. Hawayek Boedhoe PSW, Brouwer RM, Buitelaar JK, Caeyenberghs K, Cecil CAM, Cohen RA, Cole JH, Conrod PJ, De Brito SA, de Zwarte SMC, Dennis EL, Desrivieres S, Dima D, Ehrlich S, Esopenko C, Fairchild G, Fisher SE, Fouche JP, Francks C, Frangou S, Franke B, Garavan HP, Glahn DC, Groenewold NA, Gurholt TP, Gutman BA, Hahn T, Harding IH, Hernaus D, Hibar DP, Hillary FG, Hoogman M, Hulshoff Pol HE, Jalbrzikowski M, Karkashadze GA, Klapwijk ET, Knickmeyer RC, Kochunov P, Koerte IK, Kong XZ, Liew SL, Lin AP, Logue MW, Luders E, Macciardi F, Mackey S, Mayer AR, McDonald CR, McMahon AB, Medland SE, Modinos G, Morey RA, Mueller SC, Mukherjee P, Namazova-Baranova L, Nir TM, Olsen A, Paschou P, Pine DS, Pizzagalli F, Rentería ME, Rohrer JD, Sämann PG, Schmaal L, Schumann G, Shiroishi MS, Sisodiya SM,

Smit DJA, Sønderby IE, Stein DJ, Stein JL, Tahmasian M, Tate DF, Turner JA, van den Heuvel OA, van der Wee NJA, van der Werf YD, van Erp TGM, van Haren NEM, van Rooij D, van Velzen LS, Veer IM, Veltman DJ, Villalon-Reina JE, Walter H, Whelan CD, Wilde EA, Zarei M, Zelman V, ENIGMA Consortium. ENIGMA and global neuroscience: a decade of large-scale studies of the brain in health and disease across more than 40 countries. Transl Psychiatry. 2020;10(1):100. 30. Brand BL, Lanius RA.  Chronic complex dissociative disorders and borderline personality disorder: disorders of emotion dysregulation? Borderline Personal Disord Emot Dysregul. 2014;1:13.

8

Multiple Personality in Popular Culture Amir Arad and Bilal Haider Malik

If someone with multiple personalities threatens to kill himself, is it considered a hostage situation? ―George Carlin

Introduction Multiple personality is reflected throughout varying forms of popular culture from language, literature, and television. We will uncover several that exist across a variety of popular culture mediums.

The next expression is often used in situations where there is uncertainty: “I’m debating with myself whether to…” In this situation, there must be at least two conflicting viewpoints in order for there to be a debate. So one must ask, who is “Myself” such that “I” can have a difference of opinion? [2]

Additionally, Jay Noricks writes: We recognize our natural multiplicity in the ordinary language we use to express ourselves. A frustrated employee might say, “A part of me wants to tell my boss to go to hell, but the rational part of me says I need this job.” Someone with marital issues might say, “A part of me wants to leave, but another part is afraid to be alone.” A friend with an addiction might say, “I can go for a few days without using, but then a part of me takes over and I find myself getting high all over again” [3].

Discussion Language The word is dissociate. There is no ‘a’ before the ‘ss’. People invariably say dis-a-ssociate, which, if you’re suffering Disso-ciative Identity Disorder/Multiple Personality Disorder, can be irritating. ―Alice Jamieson, Today I'm Alice: Nine Personalities, One Tortured Mind

Language is ripe with many common expressions that point to examples of multiple personality. When people use common expressions such as “I was beside myself”, “I don’t know what got into me”, “I am ashamed of myself” or “I am just arguing with myself,” these are all examples of language ripe with elements of multiple personality [1]. Celia Ramos in her graduate thesis writes: The statement “I was beside myself” is usually said in times of anguish or worry. But how does one answer the question of the location of “I” in terms of “myself”? Another expression, “I don’t know what got into me” is uttered when a person does not understand his/her own actions. What can get “into” a person such that the “I” would not know?

A. Arad (*) · B. H. Malik California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA

The multiplicitous nature of our understanding of ourselves extends across to other languages and cultures too. In German ich stehe neben mir means I stand next to myself related to anger. French je ne me reconnais pas is translated to “I do not recognize myself.” Russian, взять себя в руки—to pull oneself together [1, 4] In Spanish, Soy yo mismo o me parezco means “Did I do this or is it someone like me?” In Japanese pronunciation: Ware o ushinau translates, “to lose yourself” and is used to describe what happens after someone is overcome by rage and does something terrible, afterward they might say I just lost myself [1]. These expressions demonstrate a more common side of multiple personality for who is the “I” that is arguing with “myself”? Renowned author and teacher Eckhart Tolle embarked on his journey of self-exploration when he grappled with the thought, “I cannot live with myself any longer,” a thought that persistently echoed in his mind. “Then suddenly I became aware of what a peculiar thought it was, Am I one or two? If I cannot live with myself, there must be two of me: the ‘I’ and the ‘self’ that ‘I’ cannot live with” [5].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_8

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There are other common expressions such as “The devil made me do it” that illustrate other voices outside the individual that communicate instructions. The common devil on one shoulder or angel on the other shoulder giving directions is a more common cultural example of multiple personality [1].

Literature Literary Doubles Literary Doubles also known as the “Gothic double” is a literary device used to divide the personality of a character [6]. A major shift in literature occurred in the late eighteenth and early nineteenth centuries, where evil was no longer situated within a physical location such as a haunted castle, but expanded to inhabit the mind of characters, often referred to as “the haunted individual.” [7] There are many stories and novels that fall into the “literary doubles” category. As psychiatrist James Grotstein explains, “In nineteenth-century literature the awareness of the ‘stranger within’ came even more to the fore, and many literary themes around the ‘double’ emerged…. Generally, the double seemed to connote one’s darker, more sensuous, and less socially consonant self.” [8] The quintessential example of literary doubling can be found in “The Strange Case of Dr Jekyll and Mr Hyde” (1886) by Robert Louis Stevenson, where the main character physically changes into an evil, carnal and savage version of himself. By doing so, Stevenson is able to examine the question of the presence of good and evil in an individual [9]. Additionally, Dr. Jekyl and Mr. Hyde is also the quintessential example of the popular perception of DiD. Stevenson’s narrative about the duplicity of human nature depicts Dr. Jekyll as an intelligent scientist and Mr. Hyde, his alter ego, as someone who does not repent or accept responsibility for his evil crimes. Grotstein lists a number of “literary double” works by notable authors [1]. Herman Melville, Pierre; or, The ambiguities and Bartleby the Scrivener” E.T.A Hoffman, “The story of the Lost Reflection” and “The Doubles” Charles Dickens, The mystery of Edwin Drood and A Christmas Carol Dostoyevsky, The Double, The idiot, Crime and punishment, the possessed, and The Brothers Karamozov Robert Louis Stevenson, The Strange Case of Dr Jekyll and Mr Hyde

Joseph Conrad, The heart of Darkness and “The Secret Sharer” Vladimir Nabokov, Pale Fire Edgar Allen Poe, “The Story of William Wilson” Henry James, “The Jolly Corner” Honore de Balzac, Peau de Chargin Johann Wolfgang von Goethe, Faust Mary Shelley Frankenstein Oscar Wilde, The picture of Diarian Gray Thomas Mann, Doctor Faustus Flannery O’Conner, The violent Bear It Away William Faulkner, Sartoris, Go down Moses, and Absalom, Absalom! Jorge Luis Borges, Borges and I and the Other

Comic Books The Marvel comic books, television series, and films portray many characters both heroes and villains thought to have dissociative identity disorder [1]. Heroes sometimes have a secret identity like superman or batman, but in some cases they completely transform into someone else who is not necessarily even human and who may not share any memories with them. For example, in Stan Lee’s “The Incredible Hulk,” Dr. Bruce Banner is a different person when transformed into the “Savage Hulk.” It is suggested that the Hulk is an embodiment of all the pent-up rage and aggression that Banner felt throughout his life having suffered severe trauma as a child inflicted by his father. This abuse resulted in the young Bruce Banner developing dissociative identity disorder and the early emergence of several alternate personalities. Banner even emerged additional personalities as well as the Hulk: The amoral version called “Joe Fixit”, the integrated personality “Merged Hulk”, “Professor Hulk”, “Devil Hulk”, and the “Green Scar” were all additional personalities of Banner [10]. Villains such as Batman’s foe Two-Face tend to have fully incohesive pathological multiplicity sometimes with an awareness of their normal selves, and sometimes not, often mixed in with elements of schizophrenia and other mental illnesses [1].

Television Is a television series created by Steven Spielberg that started running on Showtime between 2009 and 2011. In it, actress Toni Collette is a mother of two in her mid-30s with dissociative identity disorder struggles with four wildly

8  Multiple Personality in Popular Culture

divergent selves after trying to take a break from her meds to discover the cause. In the show Tara abruptly switches from one sub personality into another, and the series explores the effects DID can have on family members and her ability to function productively in society. United States of Tara is a television series that aired on Showtime from 2009 to 2011. Created by Steven Spielberg, the show features actress Toni Collette as a mother in her mid-30s who grapples with Dissociative Identity Disorder (DID). Her character attempts to uncover the underlying cause of her condition by discontinuing her medication. Throughout the series, Tara experiences abrupt shifts between four distinct sub-personalities, shedding light on the profound impact of DID on both family members and her ability to function effectively in society. Helpful in many ways, Tara’s alters sometimes came in handy, but they often disrupted her ability to live her life normally. In United States of Tara, the series provides an insightful portrayal of Tara’s journey with mental illness, offering a comprehensive depiction of its impact on her, her family, and her social circle. The show highlights Tara’s tendency to transition into one of her distinct alters in response to stressors, such as confrontations, surprises, or moments of unease. While these alters occasionally prove beneficial by assisting her in coping with challenging situations, they frequently hinder her ability to lead a conventional and stable life [11]. The character Tara offers viewers a realistic portrayal of how a person with DID might behave. For many audience members who have never had personal interactions with individuals living with DID, this series serves as a crucial source of exposure and insight into the condition. Tara’s DID, rooted in severe sexual abuse, led to her dissociation from the traumatic experiences. Her actions and experiences depicted in the show play a pivotal role in shaping the audience’s understanding of DID and its complexities, shedding light on the condition’s real-world manifestations [11].

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Conclusion The concept of multiple personality is deeply ingrained in our popular culture, captivating individuals from diverse backgrounds who are fascinated by the notion of having multiple selves. The significance of multiple personality in shaping our cultural psyche is undeniable. In the upcoming chapter, we will narrow our focus to explore its portrayal in Hollywood films.

References 1. Fadiman J, Grueber J. Your symphony of selves. Park Street Press; 2020. 2. Ramos C. Dissociation: potential key to optimal mental function. Master’s thesis, University of Houston-Clear Lake, Texas; 1993. 3. Noricks J. Parts psychology: a trauma based- self-state therapy for emotional healing. Los Angeles: New University Press; 2011. 4. https://ling-­app.com/ru/russian-­idioms-­2/. 5. Tolle E. The power of now. 2004. 6. https://en.wikipedia.org/wiki/Gothic_double. 7. Aguirre M. In: Bloom C, editor. On Victorian horror. Gothic horror: a reader’s guide from Poe to King and beyond. 1998. p. 214. 8. Grotstein JS.  The Alter Ego and Deja vu phenomena: notes and reflections. In: Rowan and Cooper, The plural self. 9. https://www.reference.com/world-­v iew/literary-­d oubling-­ 8ce4351b9e4d5203. 10. https://marvel.fandom.com/wiki/Glossary:Dissociative_Identity_ Disorder. 11. Unleashed from the shackles: modern media’s portrayal of mental illness: United States of Tara. Kayla Brown Columbus State University.

Cultural References to Multiplicity Literature Fictional characters. https://en.wikipedia.org/w/index.php?search=Fic tional+characters+with+multiple+personalities&title=Special:Sear ch&profile=advanced&fulltext=1&ns0=1 Books—Good reads shows hundreds of fiction and non fiction multiple personality books. https://www.goodreads.com/shelf/show/ multiple-­personalities.

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Dissociative Identity Disorder in Hollywood and Other Movies Amir Arad and Bilal Haider Malik

Introduction

Discussion: Films

It is easy to see the appeal of cinema portraying characters with DID. DID is a condition that lends itself to extremes of behavior, conflict, torment, secrets, and mysteries everything a juicy drama requires in one character. Unfortunately, those dramas have tended to be horror movies and psychological thrillers, which have not really helped our understanding of the condition [1]. It is apparent that most of the misconceptions about DID are portrayed in films and characters are shown as perpetrators of violence [2]. In films, 46% of characters with mental health conditions are shown as perpetrators of violence. This erroneous belief that individuals suffering from mental illnesses are largely dangerous criminals to society is one that is continually reinforced by depictions in film [3]. In films, mental illness may be used to vilify a character, or inappropriately and inaccurately link them to violence [4]. Representing mental illness in this way may be one reason experts have argued that mass media contributes to the stereotypes and stigma surrounding mental health [5]. In fact, despite the stereotypes and misconceptions about the disorders in films, research has found that very few DID patients commit acts of crime [6] or acts of violence or aggression toward others [7]. There is no link between increased criminal activity and dissociative identity disorder. People with DID are no more likely to be violent than anyone else. To the contrary, people with DID are more likely than the general population to be re-traumatized and experience further abuse and violence [6].

Multiple personality disorder was first introduced to the big screen in 1920, with the release of Dr. Jekyll and Mr. Hyde. Since then, there have been over 75 films featuring a character suffering from DID symptoms (IMDb.). Hollywood has become proficient at multiple personalities to create a new genre of films shaped around multiple realities or identities [8].

Shutter Island Martin Scorsese’s 2010 film, Shutter Island, follows the story of US Marshal Teddy Daniels, portrayed by Leonardo DiCaprio, as he investigates a missing person case at the Ashecliffe Hospital for the criminally insane on Shutter Island in Boston Harbor. Unbeknownst to Daniels, the hospital’s chief of staff, Dr. Cawley, engages him in therapeutic role-playing to reveal that Daniels is suffering from Dissociative Identity Disorder (DID) and is, in fact, Andrew Landis. Andrew Landis, a violent patient at the hospital, murdered his wife after discovering she had drowned their children in a lake. The trauma and guilt from failing to save his children led Landis to create a new identity. Dr. Cawley’s therapy aims to help Teddy play out his fantasy to its conclusion, ultimately helping him accept reality. The film highlights the danger and violence associated with mental illness, particularly in patients with DID. However, it’s important to note that this portrayal may perpetuate a misleading association between DID and violence.

A. Arad (*) · B. H. Malik California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_9

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Fight Club

Sybil

Fight Club is a 1999 American film, based on the Chuck Palahniuk novel, featuring Ed Norton as the “Narrator,” who suffers from Dissociative Identity Disorder (DID). Norton’s character manifests a chaotic alter ego named Tyler Durden, portrayed by Brad Pitt. The story begins with the “Narrator” encountering Tyler Durden after returning home to find his apartment and belongings destroyed. They engage in a cathartic fistfight and decide to continue these confrontations. These fights evolve into organized brawls outside a bar, eventually leading to the establishment of the “Fight Club” in a warehouse. As new members join the club, they engage in acts of vandalism, causing increasing concern for the “Narrator.” The plot takes a dramatic turn when Tyler reveals that he was responsible for the apartment explosion and, shockingly, that Tyler is a dissociated personality of the “Narrator.” The “Narrator” had assumed the identity of Tyler during periods of what he believed to be sleep. This film serves as a violent portrayal of Dissociative Identity Disorder in a Hollywood context, exploring the complex dynamics of the condition through the characters of the “Narrator” and Tyler Durden.

Sybil, based on Flora Rheta Schreiber’s novel, is a 1976 television film starring Sally Field, is perhaps the most complex and powerful portrayal of DID that cinema has to offer [13]. Sybil is the story of a young woman and her set of 16 alternate personalities developed as a means of coping with a childhood sexual trauma (she was mentally abused by her mentally unstable mother). Sybil’s alters ranged in age from Peggy who represented Sybil at the age when the trauma happened to Vicky who was Sybil’s current age. Sybil’s therapist Dr. Cornelia Wilbur hypothesized that Sybil invented the other alters in order to preserve a characteristic or skills that she cared for that were repressed as a result of the trauma. For example, one alter played the piano, another was a sophisticated young lady, a third was a free spirited romantic young woman, and so on [8]. Dr. Wilbur hypnotizes Sybil to introduce her to all the other personalities and explains that Sybil recovered her memories and went on to live a full and happy life as an academic. The ending celebrates the reintegration of Sybil’s alters as a way of enriching her personality rather than being an obstacle to her personal development.

Psycho

Split

Psycho, the 1960 film by Alfred Hitchcock, is considered to be, “the first psychoanalytical thriller” [9] and was nominated for four Academy Awards. Here, Marion Crane, played by Janet Leigh, stops for the night at the Bates Motel where she meets proprietor Norman Bates, portrayed by Antony Pernkins. When Marion showers, in one of the best-known scenes in all of cinema [10], a shadowy figure appears and stabs her to death. Soon afterward, Norman’s anguished voice is heard from the house yelling “Mother! Oh God, Mother! Blood! Blood!” In the film, a psychiatrist later explains that jealousy drove Norman to murder his mother and her lover 10 years earlier. He recreated his mother in his mind as an alternate personality as jealous and possessive toward Norman as he felt about his mother. Whenever Norman is attracted to a woman, “Mother” takes over and had already murdered two other young women before Marion. The psychiatrist concludes “Mother” has now completely taken over Norman’s personality. Psycho is a horror masterpiece but as a portrayal of a real-­ life mental-health condition, it is nonsense. Just as autism in the movies makes you a math genius, so DID makes you a “psycho” [1].

Split is a 2016 psychological thriller film written, directed and produced by M. Night Shyamalan. In it, three girls are kidnapped by a man named Kevin Wendell Crumb, who is diagnosed with 23 distinct personalities. They must try and escape before the emergence of a frightful new 24th alter with animalistic tendencies referred to as “The Beast.” Split is the latest example of movies, portraying a highly stigmatizing inaccurate version of DID [6]. The movie directly links DID patients with kidnap, murders, and violent actions furthering the negative association between DID and violent behaviors. Movies such as Split can be extremely damaging, argues Dr. Simone Reinders, a neuroscientist studying DID at King’s College London in collaboration with universities in the Netherlands. “They make it seem as if patients with DID are extremely violent and prone to doing bad things. This is actually not true and it very badly misrepresents the psychiatric disorder. Individuals with DID definitely do not have a tendency to be violent; more a tendency to hide their mental health problems. I’m very concerned about the effects that the movie will have for patients with DID, and how the general public will now see these patients. There’s already a lot of stigma and skepticism concerning this specific disorder” [1].

9  Dissociative Identity Disorder in Hollywood and Other Movies

Monsters Inside: The 24 Faces of Billy Milligan The 2021 Netflix docuseries Monsters Inside: The 24 Faces of Billy Milligan is about Billy Milligan, who was arrested in 1977 for rape, kidnap, and aggravated assault. Although the evidence confirmed that he had committed the crimes, Milligan had no recollection of any of these crimes. He was later found innocent for reasons of insanity. Psychiatrists identified different sets of personalities and diagnosed him as having dissociative identity disorder. Each character had a different characteristic of how they spoke or walked. Psychiatrists said that due to trauma (Milligan claimed to be molested by his step father) aspects of his personality splintered out to and became independent personalities that the core self may not have even known about. The docuseries shows Milligans life and history including the 10  years in mental hospitals, where he was diagnosed with a total of 24 personalities. He was released in 1988, and then discharged from the Ohio mental health system and Ohio courts in 1991. His life outside the system and trying to lead a normal life is also discussed.

Conclusion The portrayal of DID in films and in Hollywood perpetuates a negative stereotype and misconceptions predominantly of DID’s association with violent behaviors for entertainment purposes. This was most prevalent in the top films concerning DID.

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This distorted impression of DID undermines viewers’ ability to formulate factual understanding of a mysterious mental illness and furthermore reduces the likelihood that those with mental illness seek out help.

References 1. Rose S.  From Split to psycho: why cinema fails dissociative identity disorder. The Guardian. 2017. h t t p s : / / w w w. t h e g u a r d i a n . c o m / f i l m / 2 0 1 7 / j a n / 1 2 / cinema-­dissociative-­personality-­disorder-­split-­james-­mcavoy. 2. Sampson V.  The portrayal of dissociative identity disorder in films. 2020. https://www.elon.edu/u/academics/communications/ journal/wp-­content/uploads/sites/153/2020/12/Fall2020Journal. pdf#page=79. 3. Smith SL, Choueiti M, Choi A, Pieper K, Moutier C. Mental health conditions in film & TV: portrayals that dehumanize and trivialize characters. 2019. http://assets.uscannenberg.org/docs/aii-­study-­ mental-­health-­media_052019.pdf. 4. Lawson A, Fouts G. Mental illness in Disney animated films. Can J Psychiatry. 2004;49:310. 5. Davey GCL. Mental health & stigma: mental health symptoms are still viewed as threatening and uncomfortable. Psychol Today. 2013. https://www.psychologytoday.com/blog/why-­we-­worry/201308/ mental-­health-­stigma. 6. Chen S. Analysis of dissociative identity disorder presented in popular movies and the possible impacts on public stereotypes. 2021. 7. h t t p s : / / w w w. t h e r e c o v e r y v i l l a g e . c o m / m e n t a l -­h e a l t h / dissociative-­identity-­disorder/related/did-­myths/. 8. Trifonova T. Multiple personality and the discourse of the multiple in Hollywood cinema. Eur J Am Cult. 2010;29(2):145. https://doi. org/10.1386/ejac.29.2.145_1. 9. https://psychology2.wordpress.com/2010/04/27/sybil-­summary/. 10. https://www.independent.co.uk/arts-­entertainment/films/features/ the-­s hower-­s cene-­w hy-­4 5seconds-­o f-­h itchcock-­s -­p sycho-­s till-­ haunt-­us-­a7967676.html.

An Effective Approach to Treatment of PTSD and Other Dissociative Disorders: One Practitioner’s Experience

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Dody J. Reustle

Introduction From the moment we make our way out of the womb our instinctual drive to survive takes hold. Survival is a primary focus, and anything new may be frightening at first. Our brains are not fully developed at birth. The brain begins to expand awareness by taking in information from the external and internal worlds. A sensory feedback loop collects nonverbal and feeling sensations to understand what is pleasant and unpleasant. Language understanding does not exist for about the first year. Nonverbal experiences and sensory feelings are noted by the patient, and a perception of the positive and negative associations become internalized and is identified by the person as a part of the self. In addition to the overwhelming drive to survive, newborns are equipped with mirror neurons in the brain. These neurons enable the baby to learn how to connect, understand, and imitate the mother’s smile and other cues. The continued development of empathy, vocalizations, and communication brings understanding and continues to provide communication with others throughout life. In an article by Sammy Ahmed, he reports that people with autism lack these mirror neurons and suggests that this could be why these people have little to no communication skills, there is a lack of empathy for others, and they are unable to connect emotionally with others because they do not understand social cues [1]. What is structural neuroplasticity? According to Moheb Costandi, “Neuroplasticity, is the nervous system in the brain that continues to change and evolve throughout our life. It adjusts to changes in the environment, learns new things, and when induced “willfully it reshapes and improves oneself.” When considering the brains’ ability to adapt and learn new things, this fact explains how the psychotherapeutic process can assist and guide the person through the psychological trauma [2].

D. J. Reustle (*) Dr. Dody Reustle, Private Practice, Fairfield, CA, USA

Arielle Schwartz writes, “Neuroplasticity is the brain’s ability to modify, change, and adapt both the structure and function throughout life in response to experience” [3]. Some traumatic experiences are subliminally activated and sit in the unconscious and go unrecognized but causing stress and increased hypervigilance. The anxiety can build up or remain distressful and fearful of the unknown. During a major flashback the person may dissociate to avoid feeling anything. Patients have reported flashbacks when driving, or jogging. Then, out of the blue, they see a horrendous image and they panic and struggle to get rid of it [4]. The treatment of choice for PTSD and DID is to first focus on psychoeducation and CBT coping skills. The focus is to teach calming breathing, grounding techniques, and emotional regulation. Self-soothing, mindfulness and relaxation skills provide relief from panic. Relaxation and art therapy exercises enhance preparation for EMDR. Use of the different self-care techniques and coping strategies empowers the person and reinforces emotional stabilization. Positive strengths are validated, and accomplishments thus far are reviewed. The bilateral stimulation of EMDR is the final step that activates the internal dialogue for reprocessing the traumatic image and replacing the false cognition with a positive cognition. This chapter aims to discuss meaningful and effective treatments available to help even the most intractable cases of PTSD and dissociative identity disorder [5–8].

Modalities The psychotherapeutic modalities are an interweaving of CBT, EMDR, Art Therapy, Positive Psychology, Mindfulness, and a variety of calming breathing, grounding, and relaxation skills [9–11]. Cognitive Behavioral therapy (CBT) teaches healthy coping strategies and positive self-awareness. CBT helps reduce dysfunctional behaviors and aids in recognizing distorted thinking styles. This technique allows reframing of negative and dysfunctional assumptions [12].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_10

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Mindfulness is a process of focusing one’s awareness on the present moment. It is a slowing down and acknowledging of sensorial information and body sensations. Being mindful of the moment in the body enhances the sense of peaceful relaxation [13, 14]. Art therapy is a form of creative expression that allows the creative process to bring internal imagery and nonverbal symbolism out into the physical realm for understanding and healing [15]. Positive psychology is the focus and validation of the person’s strengths and talents instead of weaknesses. It empowers positive experiences such as happiness, inspiration, love, resilience, compassion, and other individual traits that promote well-being and self-esteem [16]. Psychoeducation explains how the brain’s response to panic, and stress hormones and how the most primitive part of the brain reacts to threats of danger and reduced levels of oxygen. A discussion will occur on how our perceptions are based on the physical, mental, emotional, and spiritual sense of self. Eye Movement Desensitization Reprocessing (EMDR) is a form of psychotherapy that reduces or eliminates the distress associated with traumatic memories. Traumatic negative thoughts, images, emotions, and bodily sensations remain as unprocessed memories. It is the use of bilateral stimulation “repeated eye movements” stimulates the processing and resolution of the memory [10].

oping a treatment plan. This information also establishes a baseline of symptoms, the level of severity, and frequency of symptoms. The patient is also encouraged to have a medical evaluation done to rule out any medical causes for the distressing symptoms [17, 18]. Psychosocial education is provided concurrently with calming breathing and grounding techniques. The individual practices the breathing/grounding strategies along with the therapist. This response empowers the person with techniques and knowledge to take control over and reduce panic attacks. Gathering personal history enables development of a treatment plan. Then the focus of therapy may be discussed with the individual. The person is also reminded that they are the one in control of their treatment and can stop the process at any time.

Clinical Interviews and Assessments

Case Study 1: Ms. S

This psychologist assesses every person that enters into therapy for levels of anxiety, depression, PTSD, and alcohol/substance abuse. Referral to medical support is appropriate when danger to self or others, or medication needs, or physical evaluation was indicated. The clinical interview includes a family genogram, history of childhood, and family relationships, divorces, drugs and alcohol use, mental health problems, strengths and weakness, hobbies, current social relationships, schooling, and employment and military career. The assessments utilized include the following: The Standardized Mini Mental State Exam (SMMSE), Beck Depression Inventory(BDI-II), Beck Anxiety Inventory (BAI), the PTSD checklist of trauma symptoms (PCL-S), the Michigan Alcoholism Screening Test (MAST) and when appropriate a Multidimensional Inventory of Dissociation, (MID). Overwhelming panic attacks must be treated in the first session with psychoeducation and coping strategies for calming breathing and grounding. Patients can learn how distorted perceptions occur, how to recognize them, and how to overcome them by calming techniques and awareness. Assessments and screenings provide information for devel-

F43.10 PTSD F44.81 Dissociative Disorder F41.0 Panic Disorder F33.1 Major Depression Disorder with anxious ­distress [19]. Ms. S. entered therapy to address major symptoms of depression, overwhelming anxiety, panic attacks, sleep disorders, and lost time. Ms. S. is a 35-year-old married woman who has a successful career working from home for a corporation. She is tall, slender, and dresses in layers of loose fitting clothes that hide her feminine frame. Ms. S. has long curly red hair pulled up in back with a single clip. She is very friendly and respectful and sits down in the chair with a giggle. Ms. S. is well spoken and makes good eye contact accompanied by her warm smile. She openly shares that her life had become increasingly dysfunctional due to frequent panic attacks, and the inability to complete things and manage her time. She went on to say that her relationship with her husband had become progressively more strained due to household mismanagement, her scattered thinking, distracted thinking and inability to completing projects for her employer in a timely fashion.

Two Case Studies Two case studies demonstrate the similarities and differences that existed for each individual. We will discuss the process they underwent to gain freedom from the horrible cycle of PTSD and DID. The emphasis of this work is to stay with and follow the person throughout their process. Do not go too fast, or too slow by following the person’s lead ensures that self-empowerment needs are not overlooked, and natural healing and learning processes in the brain are completed.

10  An Effective Approach to Treatment of PTSD and Other Dissociative Disorders: One Practitioner’s Experience

The patient reported a lifelong fear of sleeping due to recurrent and terrifying nightmares since childhood that occurs three to four times a week. Ms. S. said that her husband is extremely frustrated with her growing dysfunction. Ms. S. reported she had become more unfocused and unable to cope with everyday life over time. She shared that it takes all day to empty the dishwasher. “I would start in the morning emptying the dishwasher and would find myself three hours later confused and wandering in another part of the house. The loss of time has been frightening and lead to panic attacks.” Ms. S. said all of these stressors have put an enormous strain on her life, her marriage, and her career, and she needs to reduce the emotional distress. She reported that she has felt like a worthless failure all her life: “I’m a disappointment to my dad’s parents and relatives, I’m a disappointment to my dad and a disappointment to my mom. She said she has been taking an antidepressant and anxiolytic medication for approximately 10 years. This psychologist recommended Ms. S. have a physical to rule out any medical causes that could mimic mental health problems. In addition, an evaluation of her medications might also be helpful since her current symptoms may need a medication adjustment. Completion of the clinical interview, genogram, and data gathering provided a baseline of symptom distress allowing development of a treatment plan. Moreover, psychoeducation and a panic attack strategy was taught and practiced during several sessions. The panic strategy offers breathing techniques and grounding methods to help Ms. S. gain some control over the panic attacks and negative self-talk. During sessions, CBT coping skills, narrative relaxation, mindfulness, and EMDR self-care techniques (Safe Place, Light Stream, and Container) were provided and practiced reinforcing healthy self-care skills. Ms. S. came in distressed and shared, “My life is crumbling all around me.” She was tearful and very frightened. She shared that her husband had driven her due to the severity of her mental health. After discussing this decision, she left with her husband and went to the hospital for emotional stabilization. While she was in the hospital, the doctors adjusted her medication. No health concerns were found to contribute to the level of distress. Once at home, she said the medication adjustment help her feel somewhat better. Art therapy creates a safe way to gain awareness and connect with the nonverbal and symbolic inner world. It is the unseen inner-world of feelings, emotions, imagery, beliefs, and symbolism. Ms. S. was able to tap into her internal imagery throughout her therapy. At times, art therapy would allow a better understanding by creating an image of the feeling. This idea was then discussed, and personal meaning would then emerge as insights. Imagery was honored for the understanding Ms. S. would gain from a color, shape, or pattern. As she explored her emotions, she was able to see the differ-

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ences between each emotion (anger, self-confidence, guilt, love, fear, and happiness). Identifying feelings of each emotion established the foundation for future EMDR work when integrating different emotional parts of the self. As light is put on the foundation of beliefs and experiences, discussion of her nightmares became more accessible for Ms. S. as she gained a new understanding of herself and how everything fits together. In-between sessions, she utilized journal work to reduce the constant flooding of confusing thoughts, beliefs, and ideas. This action empowered her by decluttering her freeway of thoughts. Sometimes a color was used, or phrases would give focus to her anxiety. At the next session, Ms. S. came to therapy with her journal and was able to reflect on the images or phrases with better awareness, resulting in her feeling more confident and less chaotic. Ms. S. made significant progress utilizing art therapy, mostly because there is no right or wrong when learning about one’s inner self. Journaling helped Ms. S. organize and gain conscious awareness of her internal chaos. The symbolism, disconnected thoughts, and imagery provided meaning and new insights. She felt empowered by tracking the confusion as it redirected the anxiety and confusion into the journal with the intention of discussing it later. Thus, giving hope to understanding things later. Bilateral stimulation processed these feelings and beliefs. She then felt tension in her chest and a buzzing in her head. She felt a heavy weight on her shoulders and in her diaphragm, “I’m a burden”. Ms. S. described an event when she was emptying the dishwasher, and 3  h later she found herself wandering in another part of the house, confused, and panicky with no recollection of the last 3 h. This loss of time was very distressing for her as she experienced a lot of confusion and panic attacks resulting from that time. Ms. S. has reported that she still finds she will dissociate to avoid uncomfortable situations or pain. She has learned to breathe, ground, and bring herself back into her body in the moment. Ms. S. reports that EMDR has released her from old beliefs and taught her awareness and recognition of the dissociated sensation, and she can now bring herself back into her body by breathing and grounding herself. She has shared that she previously used dissociation to avoid feeling uncomfortable in her skin, when feeling emotional pain, fear, and worthlessness. During another session, Ms. S. came in and reported she has had recurrent nightmares since she was a young child, about 5  years old. She said, “I call them terrifying nightmares, that occurred 3–4 times a week.” Bilateral stimulation eliminated nightmares. Once Ms. S. was prepared with calming skills, self-care, and coping strategies, the target image, negative self-beliefs, and positive replacement beliefs were decided upon, bilateral stimulation began. Ms. S. worked through the painful mem-

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ory of her father yelling and screaming, berating, and ridiculing her. Through repetitive bilateral stimulation, she was able to internally watch as the emotional and logical hemispheres came to an understanding. She watched memories of trying to please everyone, “My dad, his parents, all his relatives, my mom, I was never good enough.” She then reported feeling a buzzing in her head, and she recalled never flunking an exam, never getting fired from a job. Suddenly, thoughts of painful hopelessness, and overwhelming fears of failure, being unlovable, homeless, jobless, and alone all faded into the background. She said, “I do deserve to exist!” and all the pain felt distant and vague. Ms. S. had integrated her belief that she did not deserve to exist. During the body scan and closure process of the EMDR, she had reported a painful tightness and tension in her chest and diaphragm. She also felt a heavy weight on her shoulders and in her tightly clenched fists. After another round of bilateral stimulation, Ms. S. reported having a sudden rush of tension, weight, and distress flow down her body and out through her feet. She quietly turned and said, “I could never trust my own judgement or my perception of reality: This feels so different”. Over time, Ms. S. attended weekly sessions for a year gaining awareness and understanding of her spiritual, mental, emotional, and physical self. She learned CBT coping skills, participated in Art therapy, EMDR, and practiced Relaxation and Mindfulness techniques. Ms. S. is now aware of the difference between her past, present, and future. She reports feeling more self-assured and functional. She is able to focus on things and can get things done. Episodes of dissociation have reduced, and panic attacks are fewer. She copes better with life, and stressful anxiety no longer controls her. She reports social interactions are healthier, and her relationships with her husband has changed significantly. Ms. S. practices setting limits with intrusive people, and with those who take advantage of her. She has identified and is learning about her emotions; for example, she has recently learned that she can get angry about a belief that was once taboo. Now, she accepts her anger as a normal response to frustrating life experiences. One of her biggest accomplishments in her therapy is recognizing when she dissociates. She shared that she is sleeping much better and finally, she continues to work on communication skills and improving the quality of her life and her relationship with her husband. Therapy with Ms. S. continues to focus on reducing the chaos of negative thoughts and beliefs, and resentments, to improve relationships and integrate more clarity into her life.

Case Study 2: Mr. R F41.0 Panic Attacks F48.1 PTSD F34.1 Dysthymia [19].

D. J. Reustle

Mr. R. was referred to this psychologist to address the increasing anxiety, flashbacks, and panic attacks that were intruding into his life. Mr. R. was seen by this psychologist for a total of 12 sessions over a 5 month period. Mr. R. presented as a polished 45-year old military man who has seen a lot in his young life. He is well-groomed, easily engaged, and well spoken. He is a married father of three minor children. He and his wife have been together for almost 20 years. His thought process was coherent, and goal directed. His mood was anxious with a depressed affect. Mr. R. came into therapy ready to focus on feelings of emotional emptiness, panic attacks, and trauma-related flashbacks from military deployment. He reported that the intrusive panic attacks, flashbacks, and recurrent nightmares have recently increased in frequency and intensity. Throughout our work together he was receptive to, and utilized, the various coping, breathing, and relaxation strategies practiced in his session to reduce panic attacks and improve his coping skills in his everyday life. Therapy began with Mr. R’s openness and participation in self-report assessments, clinical interview, and family history genogram. The first sessions focus on data gathering and help to create a base line for Mr. R’s emotional, mental, physical, and spiritual information. It is important to figure out where one is for the creation of an individualized treatment plan. He appeared younger than his chronological age, however, despite that it was apparent that he had a deep concern that has been with him for a while. He reported he is in good health. In addition, he has no medical concerns and is not taking any medication. During the clinical interview, Mr. R. provided a family history and completed assessments to identify any symptoms of anxiety, depression, and trauma. The results of these tests revealed that Mr. R. has mild to moderate symptoms of depression and anxiety, and his trauma symptoms were in the severe range. The Mental State exam was unremarkable with no cognitive, spatial, location, or memory deficits indicated. The drug and alcohol assessments did not reveal any substance abuse concerns. When asked what led him to seek therapy, he reported the following, “At times I feel disconnected emotionally from my wife and kids. It’s like being on auto pilot I feel numb, like I’ve lost part of myself.” He also shared,” Most of the time when asked what I’m feeling I do not know what I’m feeling emotionally, or I just feel isolated and shut down.” Mr. R. stated that he currently works as a medical staff member in military Trauma Bays. He shared that he deployed to war zones over a 5 year span of time. He added that he has seen a lot of death and loss. He shared one case that still haunts him to this day. It involved a 4-year-old boy who died from a random gunshot wound to the head and chest Mr. R. choked up stating, “This was a little boy innocently playing outside his home. He didn’t do anything wrong. At one point I glanced at this dark haired boy, and he could have been my own son.” This realization was deeply personalized for him

10  An Effective Approach to Treatment of PTSD and Other Dissociative Disorders: One Practitioner’s Experience

and has haunted him for years since. He reported that he is mostly triggered by this memory when off duty, driving in the car, running, and relaxing with his family. Mr. R. has not shared this memory with his wife even though he has nightmares and panic attacks from the flashbacks. He explained when at work he can block everything out and focus solely on the medical needs of his patients in the moment. Compartmentalization to remove emotional distractions is a defensive mechanism in which people mentally separate thoughts, emotions, or experiences to allow functioning in the moment. (psychologytoday.com). The panic attacks were addressed immediately by educating him on the levels of anxiety, breathing and grounding strategies, recognizing body sensations, and practicing positive self-talk. Mr. R. practiced the breathing and other coping techniques in the session, so he was able to better cope and take control of the panic attacks. During the next session, Mr. R. shared that he was troubled by feeling disconnected and isolated from his family and children. He feels he is in survival mode, guarded and closed off from others. He wants to feel closer to his wife and kids but does not know how. He shared feelings of anhedonia and has difficulty concentrating on things. Mr. R. was assessed and found to be a good candidate for Eye Movement Desensitization Reprocessing (EMDR). This psychologist began the preparation work getting him ready for EMDR.  Before doing any bilateral stimulation, Mr. R. was taught numerous EMDR coping skills as well as Cognitive Behavioral self-care techniques. Some of the techniques include the container, light stream, the Calm Place, the remote button, and more. The light stream relaxation was the first narrative and visualization coping strategy. During the light stream relaxation, Mr. R. walked through the relaxation. The narrative includes sensorial questions to help him learn how to locate and visualize specific sensory information such as size, shape, color, and texture. During the process, Mr. R. discovered his emotions were outside of his body, all safely held in front of him in a protective round ball shape. On finding his emotions, he was then able to access his emotions again, whenever he desired. After that narrative, Mr. R. realized that his emotions had become too difficult to manage, so he pushed them out of his conscious awareness, which resulted in him feeling numb, isolated, and disconnected from his family. The Calm Place is a structured relaxation that the patient identifies as an image of safety associated with being calm. This brings internal peace, focus, and security. The Container is a strongly created image of a trunk or container that will hold unwanted or distressful thoughts, images, and feelings. The Remote Button is an imaginary tool: you can change the channel or push the mute button when you are feeling emotionally distressed and distracted. All of these tools promote self-soothing and healthy coping [20–22].

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Now that Mr. R. had reconnected with his feelings, he needed more psychoeducation and skill building to enable him to learn how to adjust to his emotions and prevent emotional flooding. This fact meant that more psychoeducation, coping skills grounding, and mindfulness techniques were added to his self-care strategies. Soon, the container, the calm place and more relaxation, grounding, and breathing practices were incorporated into the sessions. The goal of Art therapy involves the identification of a person’s personal nonverbal and symbolic imagery. Access to nonverbal information is obtained through relaxation and sensorial awareness on a preconscious and or unconscious level. Everyone has their own meaning for sensory information. Nonverbal work speaks to that part of our being that only holds visual and sensory knowledge. Art therapy helps the unconscious become conscious and understood. An example of nonverbal and sensory imagery would be to think of your favorite color. Then, one may ask, why do I like that color or how does it make me feel? A sense of smell brings images to one’s mind, the smell of fresh popcorn, the image of a beautiful pool on a hot day, all these sensory images create a picture in the mind. Mr. R. later reported that the panic attacks and flashbacks were not as overwhelming, but the nightmares were still problematic. The decision to work on the traumatic memory of this little boy in the trauma bay was the most disturbing problem for Mr. R.  We will focus on reducing/eliminating this distress. Psychological strategies being used include Cognitive Behavioral Therapy CBT, Eye Movement Desensitization Reprocessing EMDR, and nonverbal imagery and art therapy. The event that had the most traumatic impact occurred when a four-year-old boy was fatally shot outside his home and brought into the trauma bay by his father. Mr. R. described his attempts to save this boy. There was a trauma team working to save this boy, but nothing worked. Mr. R. felt responsible and internalized feelings of failure and guilt. Mr. R. prepared the boy’s body for his loved ones to say goodbyes. In the process, Mr. R. realized the similarities of this boy to his own 5-year-old son. Mr. R. took note of the boy’s dark hair, curly eyelashes, and bloodstained fingers. EMDR began with Mr. R. visualizing standing in the Trauma Bay, with all the staff trying to save the injured boy. He was then able to experience the joy of being a father and a responsive husband.

Summary An integrated approach including EMDR is an effective method of dealing with intractable PTSD and/or DID allowing persons who have historically been unable to find relief to find some solace. Previous models of medication only have failed miserably.

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A treatment plan designed for an individual’s needs is vital to the success of the therapy. The modern understanding of Neural Plasticity has led to a whole new era of treatment through the EMDR process, which is taking on and disposing of old beliefs and theories.

attacks, isolation, and hypervigilance, guilt, shame, feelings of emotional worthlessness, and disconnection from family, no longer control them.

Conclusion

1. Ahmed S.  Mirror neurons and autism: a social perspective. New York: NYU Steinhardt, Applied Psychology. 2011: 2–3. 2. Costandi M. Neuroplasticity. In: Essential knowledge series neuroscience. MIT Press. 2017. p. 2. 3. Schwartz A.  The complex PTSD treatment manual. Eau Claire: PESI Publishing; 2021. p. 33–42. 4. Schwartz A.  The complex PTSD treatment manual. Eau Claire: PESI Publishing; 2021. p. 23–9. 5. Shapiro F.  Eye movement desensitization and reprocessing. New York, London: Guilford Press; 2001. p. 243. 6. White Bison. The red road to wellbriety. Colorado Springs: White Bison; 2002. p. 10–6. 7. Dubi M, Powell P, Gentry JE. Trauma, PTSD, grief and loss, vol. 35. Eau Claire: PESI Publishing and Media; 2017. p. 59. 8. Marich J. EMDR made simple. Eau Claire: Premier Publishing and Media; 2011. p. 68–9. 9. Marich J. Trauma made simple. Eau Claire: PESI Publishing and Media; 2014. p. 121–9. 10. Leeds A. A guide to the standard EMDR therapy protocols for clinicians, supervisors, and consultants, vol. 5–8. New York: Springer Publishing Company; 2016. p. 126. 11. Dubi M, Powell P, Gentry JE. Trauma, PTSD, grief and loss. Eau Claire: PESI Publishing and Media; 2017. p. 67–71. 12. Van Der Kolk B. The body keeps score. New York: Viking Press; 2014. p. 259–62. 13. Shapiro F.  Eye movement desensitization and reprocessing. New York: Guilford Press; 2001. p. 333–4. 14. Schwartz A.  The complex PTSD treatment manual. Eau Claire: PESI Publishing; 2021. p. 65–74. 15. McNiff S. Art heals, how creativity cures the soul, vol. 3–5. Boston: Shambhala Publications; 2004. p. 105–10. 16. Sieber W. Understanding and practicing positive psychology. 17. Van Der Kolk B. The body keeps score. New York: Viking Press; 2014. p. 96–8. 18. Schwartz A.  The complex PTSD treatment manual. Eau Claire: PESI Publishing; 2021. p. 77–91. 19. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. 20. Shapiro F.  Eye movement desensitization and reprocessing. New York: Guilford Press; 2001. p. 125–7. 21. Leeds A. A guide to the standard EMDR therapy protocols for clinicians, supervisors, and consultants. New York: Springer Publishing Company; 2016. p. 123. 22. Marich J.  Process not perfection, expressive arts solutions for trauma recovery. Warren: Creative Mindfulness Media; 2019. p. 87–93.

Once the traumatic experience has been resolved, some people are fine to move on with their lives, while others continue in therapy and their healing process. Those who remain in therapy often continue to work on distress and chronic PTSD and DID from early childhood and more support and work might be wise. Those with chronic early childhood trauma may need extra psychoeducation and guidance after EMDR has eliminated the symptoms of PTSD. For example, one person prior to EMDR work had never allowed herself to feel any negative emotional reactions toward others because she believed she was a worthless and heartless person with no feelings. After resolving several childhood traumas, she called the office in crisis and in need of support. She shared the following, “While driving to a meeting I suddenly realized I had become extremely enraged and angry towards another driver. This was so scary that I pulled off the road to recompose myself. I felt like I had gone crazy and something terrible had just happened.” We discussed the incident and soon without any input on this therapist’s part, she realized what had happened. She shared, “For the first time I was feeling my own anger at another driver.” She shared how strong her feelings were, and she wondered if her feelings of anger were healthy. We talked about this new awareness and that she will continue to go through the psychological healing she has worked hard to accomplish. Psychoeducation and positive psychology provide a moment of reflection, acknowledging, and understanding of the hard work accomplished. It is nice to take a breather and focus on the strengths that have surfaced, self-awareness, and the weaknesses that have been overcome. Both people expressed so much happiness at the relief they were feeling. Symptoms of DID and PTSD were no longer occurring without warning: The paralyzing emotional pain, haunting flashbacks, horrendous nightmares, panic

References

DID and Depression

11

Diana Diaz, Clara Alvarez, Zerimar Ramirez, and Shivani Kaushal

Introduction Dissociative identity disorder (DID) has been a long-debated condition in the field of psychiatry, with controversy partially driven by ambiguity surrounding its diagnosis. In addition to the ambiguity and skepticism surrounding this psychopathology, dissociative identity disorders are also characterized by intricate complexities in terms of associated symptoms and psychiatric comorbidities, which might explain some of the existing diagnostic challenges surrounding it. Putnam’s “discrete behavioral states” model of dissociative identity disorder [1] proposes three levels of psychopathology that are inherent to dissociative states. The first is inherent in the pathological conditions themselves, such as anxiety and depression. The second level occurs if the individual is incapable of self-regulating the expression of these dysfunctional states or of better integrating them into their lives. The third and final level arises from maladaptive responses to block the D. Diaz (*) Department of Psychiatry, Aventura Hospital and Medical Center, Aventura, FL, USA Dr. Kiran C. Patel College of Allopathic Medicine Nova Southeastern University, Davie, FL, USA e-mail: [email protected] C. Alvarez Department of Psychiatry, Aventura Hospital and Medical Center, Aventura, FL, USA Dr. Kiran C. Patel College of Allopathic Medicine Nova Southeastern University, Davie, FL, USA Medical Education Department, Dr. Kiran C. Patel College of Allopathic Medicine Nova Southeastern University, Davie, FL, USA e-mail: [email protected] Z. Ramirez St George University School of Medicine, Florida, USA S. Kaushal Kiran C. Patel College of Osteopathic Medicine, Florida, USA

painful experiences of these pathological states (e.g., attempts to self-medicate depression). Suggesting there is a higher comorbidity of mental illness in this population as a consequence of the second and third levels of psychopathology [2]. Furthermore, the high rate of comorbidity observed in DID is not merely a result of inadequate or over inclusive diagnostic criteria. Instead, it reflects a composite etiology of psychiatric disorders and the need for a multimodal management approach [3, 4]. In particular, the DID patient population has a pattern of comorbid disorders that is similar to that of other severely traumatized individuals, such as anxiety disorders, PTSD, and substance abuse [5]. In addition, research indicates that patients diagnosed with DID also have high rates of depression, with self-harm and suicide attempts associated with the depressive symptomatology [6]. Given that dissociative identity disorders usually stem from traumatic experiences, which can impact social and emotional functioning, it is no surprise that depression is frequently found in combination with them. Multiple studies have shown that 83–96% of cases with DID reported coexisting depression, 66–80% reported having attempted suicide, and 92–100% reported having current or past suicidal ideation [2]. Therefore, depression and associated symptoms, such as lability and suicidal ideation, are among the most frequent comorbid psychopathology found in DID [7]. In this chapter, we will explore the relationship between dissociative identity disorder and comorbid depression in greater detail, discuss the disease frequency and risk factors, and explain the neurocircuitry and neuroanatomical changes seen in DID and their links with depression. Furthermore, this chapter outlines the pathogenesis and symptomatology of DID with comorbid depression in comparison to depression without pathological dissociation. We conclude this chapter by discussing diagnostic and therapeutic considerations specific to this population.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_11

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Dissociative Depression Depression is a common, though challenging, highly comorbid disorder associated with dissociative identity disorder. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; [8]), depression in individuals with dissociative identity disorder often has a distinguishing feature: the depressed mood and cognitions fluctuate because they are experienced in some identity states but not others. As a result, the fragmented nature of this disorder may influence the clinical presentation of comorbid depression, perhaps explaining the paucity of scientific literature regarding the clinical correlations of depression in people with DID. Vedat Sar, an internationally renowned psychiatrist specializing in dissociative disorders and trauma-related disorders, introduced the concept of “dissociative depression” to distinguish between comorbid depression in pathological dissociation and primary depressive disorder. Over the past two decades, research focus on dissociative identity disorder has shifted to better understand the polysymptomatic presentation of this psychopathology, including the clinical correlation, frequency, and symptom severity of depressive comorbidity in pathological dissociation. In a clinical study aimed to describe the clinical features of DID in a group of Turkish patients, Sar et al. [9] found that 83% of individuals with dissociative identity disorder received a concurrent diagnosis of major depressive disorder according to the Dissociative Disorders Interview Schedule (DDIS). Moreover, a general population study found that greater levels of pathological dissociation, assessed by the Dissociative Experiences Scale-Taxon (DES-T), were associated with concurrent higher levels of depression, which were assessed using the 21-item Beck Depression Inventory (BID) [10]. As such, this study suggests a significant relationship between DID and depression and, thus, further supports the existing evidence that links depression as a substantial comorbidity in this population. Most recently, a retrospective cohort study in children with dissociative disorders showed that a concurrent diagnosis of anxiety or depression was present in 46% of the sample [11]. The Patient Health Questionnaire-9 (PHQ-9), a nine-item depression scale that can be used to assess the severity of depressive symptoms as well as aid in the provisional diagnosis of depression, is one of the tools frequently used in studies to evaluate the frequency of depression in patients with dissociative disorders. A recent study examined the frequency of depressive symptoms in their sample utilizing the PHQ-9 assessment and determined that 75% of its participants scored within the range of “moderately severe” (PHQ-9 Score = 15–19) and “severe” (PHQ-9 Score = 20–27) depression [12]. These study findings support the hypothesis that

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comorbid depression is highly prevalent in individuals with dissociative identity disorder and arguably suggest that this population may be more depressed than people with primary depression without pathological dissociation [12]. Evidence suggests a strong link between dissociative disorders and psychological trauma, especially early life, usually repeated trauma. As such, we could argue that dissociative identity disorder and depression may represent final common pathways for individuals who have been abused and/or exposed to traumatic events, thus increasing the possibility that DID sufferers also experience comorbid depression at a higher rate. A preliminary study of depression in pathological states, conducted by Fung et  al. [12], supports this hypothesis further as it found severe depression to be associated with both childhood and adulthood betrayal trauma in individuals with dissociative disorders. As a result, adulthood betrayal trauma could also be considered a potential risk factor for the high degree of depression comorbidity in this population [12]. Although dissociative identity disorders have been widely studied, there are limited data available on the clinical correlations and implications of depression in dissociative identity disorder. Increased awareness and research efforts are needed to better understand the presentation of comorbid depression, the frequency, and additional risk factors in this specific population.

Neurophysiology and Neurocircuitry Underlying DID The depression experienced by patients with DID is often linked to past trauma. The most widely supported theory of DID’s etiology posits that the disorder develops in response to past overwhelming, often traumatic, relational experiences. As these individuals take in their dissonant surroundings, they may be unable to integrate numerous conflicting emotions as they cope and develop their sense of self, leading to dissociation [7]. This intrinsic relationship between trauma and dissociation is reflected in their similar neurobiological circuitry. Trauma spectrum disorders (comprising PTSD, BPD, DID, and a subgroup of depression) have repeatedly displayed similar functional neuroanatomy in neuroimaging studies, involving interaction among the amygdala, hippocampus, thalamus, and medial prefrontal cortex [13]. Robust evidence supports the roles of both the individual components of this neuroanatomical circuit and their interactions in trauma spectrum disorders. Numerous studies provide evidence of smaller hippocampal volume in patients with a history of trauma and depression compared to both depressed patients without trauma and to patients without depression or

11  DID and Depression

a significant traumatic experience [14, 15]. Thus, the decreased hippocampal volume appears to be partially attributed to the experience of traumatic events, rather than just to the presence of a psychiatric condition such as MDD. Furthermore, smaller hippocampal and amygdalar volumes have been found in patients with DID compared with healthy control subjects [16]. One potential explanation for hippocampal atrophy in patients who have undergone trauma is the physiological effect of glucocorticoids that act on the hippocampus during stressful experiences. Prolonged exposure to the glucocorticoids released during such experiences could contribute to the hippocampal atrophy seen in both these patients and in those with other psychiatric disorders, such as PTSD, depression, and borderline personality disorder (BPD). Patients with DID and BPD have also been found to have smaller amygdalar volumes compared to healthy controls, although these results have not been seen in PTSD and depressed patients. Smaller hippocampal and amygdalar volumes in patients with DID have also been attributed to genetic factors, suggesting a predisposition toward vulnerability to psychological trauma [17]. Beyond the discrete brain structures showing commonalities across psychiatric diagnoses, there appears to be common neurocircuitry connecting conditions comorbid with dissociative symptoms, such as depression and BPD.  Dissociative symptoms have been associated with hippocampal-pituitary-­ adrenal (HPA) axis functioning, and in depressive patients, cortisol and prolactin were found to be significantly correlated with psychic and somatoform dissociative symptoms [18]. Furthermore, prolactin levels have been shown to correlate with psychological stressors. Stressful experiences associated with passive coping behavior were shown to correlate with higher prolactin levels, while prolactin levels were unchanged or lowered in stressful experiences associated with active coping behavior. Such results support a potential role of the HPA axis in the use of dissociation and avoidance to cope with stressful experiences, which can be exhibited as the hopelessness, social and emotional withdrawal, and disengagement seen in many psychiatric disorders, including depression.

Differences in Symptomatology and Pathogenesis Between Comorbid Depression in DID and MDD Dissociative disorders are heterogeneous conditions that are not viewed as a unitary phenomenon in the mental health community, as opposed to other psychiatric disorders [19]. As a result, the fluctuating course of symptoms and polysymptomatology presents a challenge to both clinicians and researchers alike in the clinical assessment of dissociative identity disorder [19]. This can become particularly difficult when trying to differentiate between a primary mood disorder, such as major depressive disorder (MDD) and comorbid

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depressive symptoms in DID.  Nevertheless, research has shown differences between dissociative depression and primary depression regarding the pathogenesis, the course of illness, and treatment responses. Existing literature suggests that a significant cohort of patients with dissociative identity disorder develops “episodic” or “chronic” depression that is thought to result from ongoing or previous life stressors. Furthermore, many patients with DID experience these “episodic” major depression episodes superimposed on “chronic” dysthymic depression, which fluctuates in severity and throughout the disease course [4, 19]. The term “double depression” has been used to describe this phenomenon. Other findings observed in studies suggest that comorbid depression in DID individuals tends to be resistant to antidepressant pharmacotherapy while resolution of depressive symptomatology has been observed with trauma-focused phase-based psychotherapy [19]. Though it is important to note that treatment-resistant depression (TRD) is not an exclusive phenomenon to DID, as it is also prevalent in primary depressive disorder. However, evidence suggests that when depression co-occurs with another mental disorder, the severity of the two disorders is greater than when one exists alone. The presence of depression comorbidity is also associated with a worse prognosis and higher rates of hospitalizations and suicide attempts [20]. This is a key component when assessing the clinical features of depression in this population, as the high number of psychiatric comorbidities may prevent clinicians from recognizing the dissociative psychopathology that is essential in the overall clinical picture of DID [4]. In other words, dissociative depression is not a primary mood disorder, but rather a depressive facade that masks trauma-related dissociative psychopathology [4]. Another distinguishing feature observed in trauma-related dissociative depression is an earlier age of onset than that of primary depression, with depressed mood and suicidality appearing early in childhood [19]. When compared to women with primary depression, those with dissociative depression reported cognitive symptoms (e.g., worthlessness, guilt, and decreased concentration), suicidal ideation and attempts, and weight and appetite changes more frequently [19]. This further supports the aforementioned statement of depressive comorbidity being associated with a worse clinical presentation and prognosis in patients with DID than those with primary depression alone. Additionally, psychological assessments of individuals with dissociative identity disorder have demonstrated the use of imagination more frequently, greater self-reflective ability, avoidance of emotion, and mixed interpersonal functioning, as well as cognitive complexity and an ideational coping style in this population [21]. These features also differentiate patients with DID from those with depression and other trauma-based disorders. These findings suggest that dissoci-

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ation can serve as a protective mechanism in patients with patients’ depressive symptoms. However, many clinically DID, ensuring that vital emotional and psychological capaci- significant aspects distinguish these states, including earlier ties are preserved and thereby aiding resiliency in the face of onset, higher rates of suicide attempts and hospitalization, trauma. and greater irregularity of depressive mood in trauma-related However, despite the extensive literature that exists on dissociative depression compared to MDD.  Additionally, dissociative identity disorder and its phenomenology, sec- while resistance to treatment-as-usual is seen in both MDD tions for dissociative disorders are lacking in general psychi- and dissociative depression, trauma-focused phase-based atric screening and increased efforts for inclusion in clinical psychotherapy has been shown to resolve depressive symppractice are warranted. Implementing existing self-­ toms in patients with DID.  These results underscore the administered dissociation screening tools, such as the importance of future work delineating MDD from dissociaDissociative Experiences Scale (DES; [22, 23], and diagnos- tive depression at the diagnostic level, as it can lead to earlier tic interview instruments, including the Structured Clinical utilization of therapies that more effectively treat patients’ Interview for DSM-IV Dissociative Disorders, Revised specific underlying issues. Furthermore, early recognition of (SCID-D-R; [24, 25]) and the Dissociative Disorders distinguishing features and adequate targeted therapy could Interview Schedule (DDIS; [26]), in current practice will lead to a reduction in the ostensibly more severe outcomes facilitate better differential diagnosis between dissociative seen in depressive dissociation. identity disorder and other psychiatric disorders. Furthermore, While much progress has been made in understanding it will aid in gathering data about true comorbidities associ- contributors to dissociative and depressive symptoms in ated with DID, including comorbid depression. MDD and DID patients, further work is needed to broadly apply this knowledge to care that best addresses the underlying causes of patients’ symptomatology.

Diagnostic and Therapeutic Considerations

The high rates of comorbid disorders associated with dissociative identity disorder pose an important concern when working with this population. This is because addressing and treating these comorbidities is an essential component in the management and improved outcomes of DID. Studies suggest that patients with high levels of dissociation are at increased risk of treatment failure and higher relapse rates when being treated only for anxiety disorders, depression, or substance abuse without directly addressing the psychopathology responsible for the dissociation [27].

Conclusion Despite the heterogeneity of both DID and MDD, several commonalities between the two conditions explain their comorbidity and can aid in understanding how to best support their mental health. We have commented on some of these common features, including the emotional lability and suicidal ideation that most frequently arise in both conditions. Furthermore, we have discussed similar experiences that may contribute to dissociative episodes within depression and vice versa; most commonly, the experience of trauma and abuse is frequently associated with both dissociation and depression. Finally, we outlined the common neurobiological underpinnings that may contribute to their different clinical features. Differentiation between primary MDD and comorbid depressive symptoms in DID remains an elusive goal for diagnosis, providing a challenge in treating trauma-related psychopathology that may underlie

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Dissociative Identity Disorder and Anxiety

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Kosha Srivastava

Introduction

a “shut-off mechanism” against severe anxiety and severe traumatic events [5]. To protect oneself from emotional Dissociative identity disorder (DID) has been a controversial pain, patients can create different personality states or diagnosis in that it is difficult to recognize because of its ‘alters.’ complex presentation that overlaps with different psychiatric DSM V, the latest edition of the DSMs, extensively states disorders, including anxiety disorder, personality disorders, the diagnostic criteria of dissociative identity disorder in five and post-traumatic stress disorders. The diagnosis of DID points. It clearly states that there are two or more distinct has also been infamously used to get away with crimes in the personality states with disruption of identity [6]. Watkins and court of law through malingering. The Diagnostic and Watkins described the term ‘alters’ in DID as having “their Statistical Manual of Mental Disorders, Third Edition (DSM own identities, involving a center of initiative and experiIII) officially included “dissociative disorders” as psychiatric ence, they have a characteristic self-representation, which disorders in 1980. ‘Multiple Personality Disorder,’ even may be different from how the patient is generally perceived, though its name includes ‘personality disorder,’ was placed have their own autobiographic memory, and distinguish what under the category of dissociative disorders in DSM III.  It they understand to be their own actions and experience from was renamed ‘Dissociative Identity Disorder’ in the DSM IV those done and experienced by other alters, and they have a in 1994 [1]. sense of ownership of their own experiences, actions, and The prevalence of dissociative identity disorder in the thoughts, and may lack a sense of ownership of and a sense general population was found to be 1–3%. Studies in various of responsibility for the action, experiences, and thoughts of countries found 1–5% of DID in inpatient psychiatry units other alters” [7]. [2]. The highest prevalence of DID (6–14%) was seen in In a case report of a 16-year-old female diagnosed with emergency psychiatric departments [3]. DID, it was found that there was the repression of memory to Dissociative identity disorder presents with many symp- protect from the emotional pain resulting from severe anxitoms, anxiety being one of them. In this chapter, we will ety and traumatic events of abuse, which caused DID to focus primarily on anxiety in DID patients. The American occur unconsciously. The researchers conducted a drug-­ Psychological Association defines anxiety as “an emotion assisted interview using lorazepam, and the patient could characterized by feelings of tension, worried thoughts and recall the repressed memories [5]. physical changes like increased blood pressure. People with Anxiety as a symptom of DID is important for discussion anxiety disorders usually have recurring intrusive thoughts separately. Because dissociation often presents with sympor concerns. They may avoid certain situations out of worry” toms of severe anxiety, it is easy for psychiatrists to miss the [4]. This is a very apt definition in the context of DID, as diagnosis of DID as they can focus more on the symptoms of DID patients often undergo dissociation to avoid anxiety-­ anxiety. It is also important to address the associated sympprovoking traumatic experiences. toms in the treatment of DID, both in psychotherapy and More often than not, DID stems from some form of pharmacological therapy [8]. In this chapter, we will cover abuse experienced during childhood or at an early stage of anxiety as a symptom of DID and its management using varilife. Dissociation is a defensive mental process to exigency, ous treatment modalities.

K. Srivastava (*) National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_12

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Discussion Anxiety as a Symptom of DID Anxiety is a normal response to stressful circumstances in life. However, if excessive fear or nervousness is invoked in these situations, anxiety can be considered a symptom of an underlying mental health disorder. Anxiety is often one of the many symptoms seen in DID patients. The third criteria of dissociative identity disorder in DSM V state that “the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” [6]. This makes it imperative for the psychiatrist to pay attention to the symptoms of DID because the ultimate goal is to be able to manage them better, so it is easier to function for these patients under various life circumstances. Research has found that it is significantly more likely for individuals with anxiety, mood, and personality disorders than individuals without these to have dissociative disorders [9]. Since DID is a rare diagnosis, it is seen that DID patients may have been diagnosed with some other psychiatric disorder early on in their lives. A study conducted by Ross et al. found that out of 236 DID cases, 44.3% had received a previous diagnosis of anxiety disorder [9]. The types of anxiety disorders listed in DSM V are separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder [6]. Other previous diagnoses seen in the study done by Ross et al. were affective disorders (63.7%), personality disorders (57.4%), and schizophrenia (40.8%) [10]. It is interesting to note the mixing up and overlap of different diagnoses in patients who were ultimately diagnosed with DID.  One study compared positive and negative symptoms in DID and schizophrenia and found that anxiety (positive symptom) was more severe in DID patients than in patients with schizophrenia [11]. Until DSM-IV, the multiaxial system of diagnosis for mental disorders was used, but it was scrapped in DSM-­ V. The Millon Clinical Multiaxial Inventory (MCMI) scale is a psychological assessment tool intended to provide information on personality traits and psychopathology, including specific mental disorders [12]. In a study published in 1995, 96 DID patients were administered the Millon Clinical Multiaxial Inventory-II (MCMI). Anxiety disorder was seen among elevated Axis I scales in these patients [13]. In literature, specific types of anxiety disorders have been identified in patients with a dissociative identity disorder. A study attempted to determine the prevalence of DID and other dissociative disorders among adolescent psychiatric outpatients. They found that 93.9% of the dissociative adolescents had another psychiatric disorder. Separation anxiety disorder had a higher prevalence than in controls [14]. Another study assessed the possible relationship between social anxiety and dissociation and found that in 94 patients

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with a social anxiety disorder, 31.91% had at least one dissociative disorder [15]. DID has also been associated with phobic anxiety [16]. DID is thought to occur due to exposure to abuse in early childhood to the extent that denial is used as a coping mechanism in which the child believes that the event is happening to someone else [7]. A study explored the patterns of the relation between anxiety, depression, and dissociation for participants who experienced abuse (physical or sexual or both) or no abuse and found that the results differed significantly among individuals who experienced sexual abuse in comparison to other groups. It was concluded that according to the subtype of abuse, dissociative symptomatology might be different in its relation to anxiety and depression [17]. In a study done in Imo state in Nigeria, researchers studied predictive determinants of stress, anxiety, and emotional intelligence on dissociative identity disorder among adolescents in Imo state, Nigeria. They found that anxiety contributes to up to 39.7% of dissociative identity disorder in SS II students in Imo State, Nigeria, public secondary schools. They concluded that anxiety has a significant predictive determinant power on DID among adolescents in Imo state, Nigeria. They recommended that traumatic conditions that make the students anxious should be identified and addressed on time by the teachers for the counselors to help the students overcome such problems [18].

Treatment of Anxiety in DID Patients Since experiencing severe anxiety can disrupt functioning in DID patients, and stressful situations can lead to quicker switching among different alters, it is imperative to treat these patients’ symptoms. It is also worth noting that Axis II disorders and comorbid mental disorders, including anxiety, in DID patients can increase the length of treatment [19]. The goal of treatment in DID patients is to integrate the different personality states so there is a fusion in the range of experiences in all the ‘alters.’ [16] In a study, a total of 135 DID patients were followed up for 2  years to monitor the treatment outcome. The patients showed marked improvement in mood and anxiety disorders. There were significant improvements in patients who were treated up to integration. They showed the most consistent improvement in anxiety, somatic, and psychotic diagnoses [20]. In another study, 35 patients with DID were followed up for 2 years and assessed with the Millon Clinical Multiaxial Inventory-II. During the 2-year follow-up period, eight patients achieved integration. There was significant improvement seen for raw scores on Anxiety scales among other scales in patients who achieved integration and those who did not. In patients who achieved integration, base rate reduction was seen on Anxiety scales that was clinically evident [21].

12  Dissociative Identity Disorder and Anxiety

Different treatment modalities can be used in DID patients, as there is no specific defined treatment for this disorder. DID can also co-occur with other psychiatric disorders, requiring multiple modes of treatment plans to be used in these patients. A female adolescent with DID was treated with individual psychotherapy for a year and was assessed with structured interviews and the Rorschach test [22]. The Rorschach test is a projective psychological test in which the perceptions of inkblots by subjects are recorded and subsequently analyzed with the help of complex algorithms, psychological interpretation, or both [23]. There were improvements seen in the patient in anxiety symptoms along with aggressiveness, impulsivity, and identification with the social environment. Interestingly, with the treatment she received, it was found that upon evaluation after a year that she did not meet the criteria for either DID or Borderline Personality Disorder [22]. A 58-year-old Native American male with DID and major depressive disorder was treated with trauma-informed phase-based psychotherapy and was assessed over a period of 14 months. After treatment, significant improvements were seen in several symptoms, including anxiety. Post-treatment, the patient did not meet the criteria for DID and Major Depressive Disorder [24]. The different types of treatment strategies and interventions that can be used to treat a patient with DID can include psychoeducation, cognitive behavioral therapy, and psychopharmacological methods. Medications for anxiety can be used as an adjunct to the primary treatment plan [25]. Nevertheless, modifications in the standard cognitive therapy protocols for anxiety may be needed. For instance, hypnosis is used by some therapists as it can have a calming and soothing effect, thus alleviating anxiety, and it can also help in the ‘containment’ of dissociative eruptions. Techniques for hypnosis can be used that do not need trance induction using patients’ autohypnotic abilities [25]. Medicines for anxiety such as benzodiazepines or neuroleptics may be used to reduce agitation. In the short term, anxiolytics may be helpful, but it should be kept in mind that the benzodiazepines commonly used can be addictive, and patients with DID might be susceptible to substance abuse [25]. More potent medications for sedation such as trazodone, mirtazapine, and low-dose tricyclic antidepressants (TCAs) have also been used for treating anxiety in DID patients. Neuroleptics or antipsychotic medications have been used to treat chronic anxiety. Some patients have described moderation in anxiety symptoms after being treated with anticonvulsant mood stabilizers. This might be helpful considering DID patients may have mood swings due to PTSD intrusions or upon switching between alternate identities [25]. Patients with DID who are hospitalized and experience acute anxiety and other symptoms such as chaotic switching may be administered oral or intramuscular benzodiazepines or neuroleptics [25].

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A case of a 23-year-old DID patient was reported who responded to hypnosis therapy and also received medications (fluoxetine and diazepam) for anxiety relief and to control aggressive symptoms [26]. This further brings light to the effective combination of treatment strategies, especially one that uses hypnosis. A 46-year-old woman with DID was given psychotherapeutic and pharmacological treatment (haloperidol, lorazepam, and desvenlafaxine). Her anxiety symptoms decreased throughout the sessions [27]. It is observed frequently that among DID patients, medications are prescribed for anxiety as well as mood symptoms. However, it has been seen that no pharmacological treatment reduces dissociation [28]. In one study, researchers used a new treatment approach called Developmental Needs Meeting Strategy, in which they guided the internal resources of a patient with DID to meet developmental needs that were not met in childhood. The patient was treated for 17 months, at the end of which, there was near-total elimination in severity and frequency of symptoms of anxiety, depression, and suicidal thoughts. It was also seen that the patient did not meet the diagnostic criteria for DID anymore and that she functioned well without medication. This is a significant finding as it can help do away with medication and achieve a reduction in anxiety and other symptoms seen in DID patients [29]. Thus, we see that addressing anxiety as a symptom of DID and its treatment is central to the overall management of DID.  Additionally, more research needs to be done in this area as there is dearth of literature that specifically talks about DID and anxiety.

Conclusion Dissociative identity disorder can present with a multitude of symptoms, anxiety being one of them. In this chapter, we have explored anxiety as a symptom of DID and how anxiety disorders can co-exist in patients with DID. DID can, however, be missed or underdiagnosed due to the presence of comorbid disorders, including anxiety. We have also shed light on the fact that dissociation can stem from abuse experienced during childhood to avoid re-experiencing severe anxiety-provoking situations. Furthermore, we have discussed, through literature, the importance of treating anxiety symptoms in DID patients, as it can help in better functioning in their daily lives. We have discussed the various treatment strategies than can be implemented to manage anxiety in these patients and that a combination of such strategies can be most fruitful. These strategies include psychoeducation, cognitive behavioral therapy, and psychopharmacological treatment. Medications such as benzodiazepines or neuroleptics, sedatives, TCAs, and antipsychotics can be used as part of the pharmacological treatment

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plan. Hypnosis as a treatment modality has also been briefly discussed in that it can help produce a calming and soothing effect in the patient. Finally, we have mentioned literature that has explored a new treatment approach that can help get rid of medications and decrease anxiety symptoms in patients with DID.

References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 1994. 2. Chu JA, Dell PF, van der Hart O, et  al. Guidelines for treating dissociative identity disorder in adults, third revision. J Trauma Dissociation. 2011;12:115–87. 3. Dorahy MJ, Brand BL, Sar V, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. 4. American Psychological Association. Anxiety [Internet]. American Psychological Association; 2008. [cited 2022 Jun 2]. https://www. apa.org/topics/anxiety#:~:text=Anxiety%20is%20an%20emotion%20characterized,certain%20situations%20out%20of%20 worry. 5. Mushtaq R, Shoib S, Arif T, Shah T, Mushtaq S. First reported case of lorazepam-assisted interview in a young Indian female presenting with dissociative identity disorder and improvement in symptoms after the interview. Case Rep Psychiatry. 2014;2014:346939, 4 pages. https://doi.org/10.1155/2014/346939. 6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-V. 2013. 7. Watkins JG, Watkins HH. The management of malevolent ego states in multiple personality disorder. Dissociation. 1988;1(1):67–71. 8. Coons PM. The dissociative disorders: rarely considered and underdiagnosed. Pyschiatr Clin North Am. 1998;21(3):637–48. 9. Johnson JG, Cohen P, Kasen S, Brook JS.  Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res. 2006;40(2):131–40. issn:0022­3956. https://doi.org/10.1016/j.jpsychires.2005.03.003. 10. Ross CA, Norton GR, Wozney K. Multiple personality disorder: an analysis of 236 cases. Can J Psychiatry. 1989;34(5):413–8. https:// doi.org/10.1177/070674378903400509. PMID: 2766193. 11. Ellason JW, Ross CA. Positive and negative symptoms in dissociative identity disorder and schizophrenia: a comparative analysis. J Nerv Ment Dis. 1995;183(4):236–41. 12. Millon T, Grossman S, Millon C. MCMI-IV: Millon clinical multiaxial inventory manual. 1st ed. Bloomington: NCS Pearson; 2015. 13. Ellason JW, Ross CA, Fuchs DL.  Assessment of dissociative identity disorder with the Millon clinical multiaxial inventoryII.  Psychol Rep. 1995;76(3):895–905. https://doi.org/10.2466/ ­ pr0.1995.76.3.895. 14. Sar V, Önder C, Kilincaslan A, Zoroglu SS, Alyanak B.  Dissociative identity disorder among adolescents: prevalence in a University Psychiatric Outpatient Unit. J Trauma Dissociation. 2014;15(4):402–19. https://doi.org/10.1080/1529 9732.2013.864748. 15. Belli H, Akbudak M, Ural C, Solmaz M, Dogan Z, Konkan R. Is there a complex relation between social anxiety disorder, child-

K. Srivastava hood traumatic experiences and dissociation? Nord J Psychiatry. 2017;71(1):55–60. https://doi.org/10.1080/08039488.2016.121 8050. 16. Gillig PM.  Dissociative identity disorder: a controversial diagnosis. Psychiatry (Edgmont). 2009;6(3):24–9. PMID: 19724751; PMCID: PMC2719457. 17. Boysan M, Goldsmith RE, Çavuş H, Kayri M, Keskin S. Relations among anxiety, depression, and dissociative symptoms: the influence of abuse subtype. J Trauma Dissociation. 2009;10(1):83–101. https://doi.org/10.1080/15299730802485185. 18. Ekechukwu RO, Isiguzo BC.  Predictive determinants of anxiety, depression and stress on athletics performance of students, University of Port Harcourt, Nigeria: counselling implications. Eur J Educ Stud [S.l.]. 2019. issn:25011111. https://doi.org/10.46827/ ejes.v0i0.2248. https://oapub.org/edu/index.php/ejes/article/ view/2248. Accessed 1 July 2022. 19. Barach PM, International Society for the Study of Dissociation. Guidelines for treating dissociative identity disorder (multiple personality disorder) in adults. J Trauma Dissociation. 2011;12(2):115– 87. http://www.issd.org/isdguide.htm. 20. Ellason JW, Ross CA. Two-year follow-up of inpatients with dissociative identity disorder. Am J Psychiatry. 1997;154(6):832–9. https://doi.org/10.1176/ajp.154.6.832. PMID: 9167512. 21. Ellason JW, Ross CA.  Millon clinical multiaxial inventory— II.  Follow-up of patients with dissociative identity disorder. Psychol Rep. 1996;78(3):707–16. https://doi.org/10.2466/ pr0.1996.78.3.707. 22. Şar V, Erdinc Ozturk MA, Turgut Kundakci MD.  Psychotherapy of an adolescent with dissociative identity disorder. J Trauma Dissociation. 2002;3(2):81–95. https://doi.org/10.1300/ J229v03n02_05. 23. Gacano CB, Meloy JR.  The Rorschach assessment of aggressive and psychopathic personalities. Hillsdale: Lawrence Erlbaum; 1994. isbn:978-0-8058-0980-0. 24. Pollock BE, Macfie J, Christian Elledge L.  Evidence for phase-­ based psychotherapy as a treatment for dissociative identity disorder comorbid with major depressive disorder and alcohol dependence. J Trauma Dissociation. 2017;18(4):595–609. https://doi.org/10.108 0/15299732.2016.1241853. 25. Chu JA, Loewenstein R, Dell PF, Barach PM, Somer E, Kluft RP, Gelinas DJ, Van der Hart O, Dalenberg CJ, Nijenhuis ERS, Bowman ES, Boon S, Goodwin J, Jacobson M, Ross CA, Sar V, Fine CG, Frankel AS, Coons PM, Courtois CA, Gold SN, Howell E. Guidelines for treating dissociative identity disorder in adults. J Trauma Dissociation. 2005;6(4):69–137. 26. Tesfaye E, et  al. Dissociative identity disorder presenting with multiple suicidal attempt: a case report. EC Psychol Psychiatry. 2019;8(6):512–7. 27. Pinilla R, Rodriguez C, Ordoñez B, Hermosillo R. Case report of a dissociative identity disorder. Eur Psychiatry. 2021;64(S1):S496. https://doi.org/10.1192/j.eurpsy.2021.1327. 28. Sadock BJ, Sadock VA.  Kaplan and Sadock’s comprehensive book of psychiatry. 7th ed. Philadelphia: Lippincott, Williams and Wilkins; 2000. 29. Schmidt SJ.  Developmental needs meeting strategy: a new treatment approach applied to dissociative identity disorder. J Trauma Dissociation. 2004;5(4):55–78. https://doi.org/10.1300/ J229v05n04_04.

Dissociative Identity Disorder and Trauma

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Deepak Goyal, Prerana Upadhyaya, Michael Jordan Weaver, and Ian Hunter Rutkofsky

*DSM-IV is the fourth edition, DSM-5 is the fifth edition.

Abbreviations

Introduction

DBSM DD DES DID DSM*

When discussing dissociative identity disorder (DID), it is important to keep in mind there are always going to be discrepancies among clinicians regarding the diagnosis. Some will argue the validity of the disorder itself, and others will claim it to be a constellation of disorders or simply state the patient is having a brief psychotic episode. In earlier works of literature, the disorder was referred to as Multiple Personality Disorder or Split Personality Disorder [1]. The core symptoms of DID are identity confusion, identity alteration, and amnesia [2]. Derealization and depersonalization are not required for the diagnosis, even though these five symptoms are typically present. In an earlier chapter of this book, Dr. Vikram Kumar reviews the diagnostic criteria regarding DID.  This author would suggest briefly reviewing the diagnostic criteria for DID in the DSM-5 and the chapter titled “DSM and Dissociative Identity Disorder.” Trauma is accepted among scholars as the major inciting factor in the development of DID.  More specifically, severe trauma during childhood can include physical, emotional, and sexual abuse.

Discrete Behavioral States Model Dissociative Disorders Dissociative Experience Scale Dissociative Identity Disorder Diagnostic and Statistical Manual of Mental Health Disorders HPA Hypothalamic-Pituitary-Adrenal ICD International Statistical Classification of Diseases and Related Health Problems ISSTD International Society for the Study of Trauma and Dissociation MDD Major Depressive Disorder MID Multidimensional Inventory of Dissociation PTSD Post-Traumatic Stress Disorder SCIDD Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised WHO World Health Organization

D. Goyal (*) College of Biomedical Sciences, Larkin University, Miami, FL, USA UAMS North Central Family Medicine Residency Program, UAMS Regional Programs, Batesville, AR, USA P. Upadhyaya Unity Health Family Medicine Residency Program, Unity Health-White County Medical Center, Searcy, AR, USA M. J. Weaver UAMS North Central Family Medicine Residency Program, UAMS Regional Programs, Batesville, AR, USA I. H. Rutkofsky Amen Clinics, Washington, DC, USA Convenient Psychiatry and Mental Health Services, Maryland, USA

Dissociation Versus Dissociative Disorders In the current fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association, dissociation is defined as “…disruption of the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior…” (DSM-5: 291–298 [3]). In other words, the individual feels disconnected from their thoughts, feelings, behaviors, memories, and themselves. Commonly referred to as “daydreaming” or “zoning out.” Many of us have experienced this while sitting in lecture halls over the years, as an example [4].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_13

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Dissociative Disorders (DD) on the other hand, is a broader category referring to a group of disorders that are broken down further depending on the type. All the symptoms related to each disorder, including DID, can cause an inability to function in the day-to-day acts that are required of us, such as school, work, or home life [3, 4, 5]. Generally illustrated as memory loss of events (different from normal forgetting), and feeling detached from self, which then causes problems with work, increases anxiety, depression, and later self-harm. Specific types of disorders making up the category formally in the DSM-IV are dissociative amnesia, dissociative fugue, depersonalization/derealization, dissociative identity disorder, and dissociative disorder NOS [5, 6, 7]. Per the DSM-5, we now only consider DID, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder. For more information regarding the different types of dissociative disorders, please see the chapter titled “All Kinds of

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Dissociative Disorders Including Dissociative Identity Disorder.”

ICD-10 Criteria The International Statistical Classification of Diseases and Related Health Problems is the full formal name of the more commonly referred to International Classification of Diseases (ICD). It is used around the world as a diagnostic tool, for insurance and billing purposes, and for epidemiology. Numerous revisions since its inception have been created. The system is maintained and published by the World Health Organization (WHO). Table  13.1 will show the diagnostic criteria for dissociative (conversion) disorders along with the associated ICD code. In general, all dissociative disorders fall under a broad “F44.X” category, where “X” is then used to specify the exact diagnosis, e.g., Multiple Personality Disorder F44.81.

Table 13.1  ICD-10 diagnostic criteria for dissociative (conversion) disorders and associated ICD-10 code Dissociative (Conversion) disorders F44 Dissociative amnesia F44.0

(a) There must be no evidence of a physical disorder that can explain the characteristic symptoms of this disorder (although physical disorders may be present that give rise to other symptoms) (b) There are convincing associations in time between the onset of symptoms of the disorder and stressful events, problems, or needs (a)  The general criteria for dissociative disorder (F44) must be met (b) There must be amnesia, either partial or complete, for recent events or problems that were or still are traumatic or stressful (c) The amnesia is too extensive and persistent to be explained by ordinary forgetfulness (although its depth and extent may vary from one assessment to the next) or by intentional simulation Dissociative (a)  The general criteria for dissociative disorder (F44) must be met fugue (b) The individual undertakes an unexpected yet organized journey away from home or from ordinary places of work and F44.1 social activities, during which self-care is largely maintained (c) There is amnesia, either partial or complete, for the journey, which also meets criterion C for dissociative amnesia (F44.0) Dissociative (a)  The general criteria for dissociative disorder (F44) must be met stupor (b) There is a profound diminution or absence of voluntary movements and speech and of normal responsiveness to light, F44.2 noise, and touch (c)  Normal muscle tone, static posture, ad breathing (and often limited coordinated eye movements) are maintained Trance and (a)  The general criteria for dissociative disorder (F44) must be met possession (b)  Either of the following must be present: disorders    1.  Trance. There is a temporary alteration of the state of consciousness, shown by any two of the following: F44.3      •  Loss of usual sense of personal identity      • Narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli      •  Limitation of movements, postures, and speech to the repetition of a small repertoire    2.  Possession disorder. The individual is convinced that he or she has been taken over by a spirit, power, deity, or another person (c) Both (1) and (2) of criterion B must be unwanted and troublesome, occurring outside, or being a prolongation of similar states in religious or other culturally accepted situations (d)  Most commonly used exclusion clause. The disorder does not occur at the same time as schizophrenia or related disorders (F20–F29) or mood [affective] disorders (F30–F39) with hallucinations or delusions Dissociative (a)  The general criteria for dissociative disorder (F44) must be met motor disorders (b)  Either of the following must be present: F44.4    1. Complete or partial loss of the ability to perform movements that are normally under voluntary control (including speech);    2.  Various or variable degrees of incoordination or ataxia, or inability to stand unaided

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Table 13.1 (continued) Dissociative convulsions F44.5 Dissociative anesthesia and sensory loss F44.6 Mixed dissociative (conversion) disorders F44.7 Other dissociate (conversion) disorders F44.8 Ganser’s syndrome F44.80 Multiple personality disorder F44.81 Transient dissociative (conversion) disorders occurring in childhood and adolescence F44.82 Other specified dissociative (conversion) disorders F44.88 Dissociative (conversion) disorder, unspecified F44.9

(a)  The general criteria for dissociative disorder (F44) must be met (b) The individual exhibits sudden and unexpected spasmodic movements, closely resembling any of the varieties of epileptic seizure, but not followed by loss of consciousness (c) The symptoms in criterion B are not accompanied by tongue biting, serious bruising, or laceration due to falling, or urinary incontinence (a)  The general criteria for dissociative disorder (F44) must be met (b) Either of the following must be present:    1. Partial or complete loss of any or all of the normal cutaneous sensations over part of all of the body (specify: touch, pinprick, vibration, heat, cold)    2. Partial or complete loss of vision, hearing, or smell (specify) Mixtures of any of the above disorders (F44.0–F44.6)

Residual code may be used to indicate other dissociative and conversion states that meet criteria G1 and G2 for F44, but do not meet criteria for F44.0–F44.7 listed above

Approximate answers given

(a)  Two or more distinct personalities exist within the individual, only one being evident at a time (b) Each personality has its own memories, preferences, and behavior patterns, and at some time (and recurrently) takes full control of the individual’s behavior (c) The symptoms are not due to organic mental disorders (F00–F09) (e.g., in epileptic disorders) or to psychoactive substance-related disorders (F10–F19) (e.g., intoxication or withdrawal)

Specific research criteria are not given for all disorders mentioned above, since these other dissociative states are rare and not well described. Research workers studying these conditions in detail should specify their own criteria according to the purpose of their studies

Adapted to table format from original work “The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: [6]. License CC BY-NC-SA 3.0 IGO” and from “The ICD-10 classification of mental and behavioral disorders: diagnostic criteria for research. Geneva: [7]. License CC BY-NC-SA 3.0 IGO.” This adaptation was not created by the WHO. WHO is not responsible for the content or accuracy of this adaptation. The original edition shall be the binding and authentic edition

ICD-11 The WHO adopted the ICD-11 in 2019, which went into effect in 2022. The ICD-10 was adopted in 1990 by the WHO and went into effect in 1993, but it was not widely used in the United States of America until October 2015. It is astonishing to think it took over 20 years before formally being used, and as of today, the ICD-10 is over 25 years old. While periodic updates were made to the ICD-10 (the latest version

being 2019), it will be very interesting to see how and when the ICD-11 will be accepted for use in the United States. Mental, behavioral, and neurodevelopmental orders will be in Chap. 6 of the ICD-11 [8]. Within the category of interest, “Dissociative Disorders,” the reader will find the following disorders and their associated codes as outlined in Table  13.2, Coding of Dissociative Disorders. Information contained within the table is directly from WHO-published information and was adapted to tabular form. At first glance, we can see some significant changes from ICD-10 to ICD-

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Table 13.2  ICD-11 coding of dissociative disorders ICD-11 code 6B60 6B61 6B62 6B63 6B64 6B65 6B66 6B6Y

Diagnosis Dissociative neurological symptom disorder Dissociative amnesia Trance disorder Possession trance disorder Dissociative identity disorder Partial dissociative identity disorder Depersonalization-Derealization disorder Other specified dissociative disorders

Adapted to table format from original work “International Classification of Diseases Eleventh Revision (ICD-11). Geneva: [8]. License: CC BY-ND 3.0 IGO.” This adaptation was not created by the WHO. WHO is not responsible for the content or accuracy of this adaptation. The original edition shall be the binding and authentic edition

11. The author would encourage the reader to visit the WHO website for a more detailed look at the ICD-11 (https://icd. who.int/browse11/l-­m/en).

Epidemiology of Dissociative Disorders From around the globe, many scholars have found several dissociative disorders to be common in the general population (apart from those specifically seen in the emergency rooms, inpatient, and outpatient settings). The exact prevalence of the disease is difficult to define. Some reasons are due to the overwhelming discrepancies between mild to moderate dissociation versus severe dissociation and the overt underdiagnosis of the disorders itself. Based on three different studies between 1997 and 2007, the prevalence of DD is said to be between 9 and 18% [5, 9]. The most severe form of DID is thought to be around 1.0–1.5% overall [5, 9]. The prevalence between genders is approximately 1.6% in males and 1.4% in females [3]. While the prevalence of DID may vary in different parts of the world, the generalized figures of 1.0–1.5% still hold.

Neurophysiology Over the years, many scholars have attempted to explain the pathophysiology behind the development of DID. This article will not be going in-depth to explain each component but

rather summarize findings to help create a better understanding. In a review article written by Rutkofsky, they suggested structural changes in the limbic system and cortex are involved in DID [10]. Particularly changes in volumes of the amygdala and hippocampus in the brain. Figure 13.1 gives us a rapid anatomical review of the amygdala and surrounding structures. The amygdala is responsible for our emotions, and the hippocampus is responsible for long-term memory. In the figure, we can see how the hippocampus is longer, which can be further subdivided into anterior and posterior. The anterior portion is more connected with the amygdala and the orbitofrontal cortex, which will be our focus. In contrast, the posterior segment, in conjunction with the parietal lobes, is involved with spatial and cognitive information processing (Fig. 13.1). The scholar Vermetten found patients had a 19.2% reduction in the hippocampus and a 31.6% reduction in the amygdala when compared to the healthy population [11]. One important key fact to this finding is their patient population also had the diagnosis of PTSD according to the DSM-IV at the time. Several other works mentioned by Vermetten also found smaller hippocampal and amygdalar sizes in conditions such as borderline personality disorder, some of which were directly related to early childhood abuse. One issue discussed in the article was their patient population was not adequately matched to the control. In 2015, Chalavi published an article that also looked at the hippocampal volumes [12]. The research showed a negative correlation between the severity of the trauma and hippocampal volume. Furthermore, an additional negative correlation was found between the severity of the dissociative symptoms and hippocampal volume. Chalavi directly commented in the article how their specific findings “support and advance” Vermetten’s findings because their populations were matched. The exact mechanism to explain these neuroanatomical changes remains unclear. Multiple other factors apart from biochemical processes, age, gender, and genetics must be considered as well. Further research of this geographic region of the brain may help us better understand neuroanatomical and neurophysiological changes that are responsible for DID.

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Fig. 13.1  Anatomy of the amygdala and surrounding structures. (Image obtained from Byrne, J. H. and Dafny, N. (eds.), Neuroanatomy Online: An Electronic Laboratory for the Neurosciences, with permission [31])

 tiology of Dissociative Disorders E and Trauma

The “4-D Model” was proposed by Paul Frewen and Ruth A.  Lanius [5, 13]. The Model breaks down the symptoms that occur into a normal awake state and a dissociative state, It is widely accepted that significant trauma is often respon- which is referred to as “trauma-related altered states of consible or is an underlying factor for the development of vari- sciousness” (TRASC) ([5, 13]). The four dimensions of conous psychopathological states. Examples are Major sciousness revolve around emotion, body, time, and thought. Depressive Disorder (MDD), Anxiety Disorder, Post-­ Lanius’ work explains TRASC and the “normal waking state Traumatic Stress Disorder (PTSD), Acute Stress Disorder, of consciousness” (NWC) as quoted directly; “… (1) time and Dissociative Disorders. Multiple models exist to help us (reliving flashbacks [TRASC] versus intrusive memories and understand the complex nature of the role trauma plays. Two reminder distress [NWC]); (2) thought (voice hearing models that will be discussed in detail here are the Discrete [TRASC] versus negative first-person self-­referential thinkBehavioral States Model and the 4-D Model of Trauma-­ ing [NWC]); (3) body (depersonalization [TRASC] versus Related Dissociation. We will also briefly touch on Betrayal hyperarousal [NWC]); and (4) emotion (emotional numbing/ Trauma Theory and the Hypnotic Model. shutdown [TRASC] and compartmentalized emotion versus The Discrete Behavioral States Model (DBSM), proposed general negative affect [NWC])….” It establishes a frameby Frank W. Putnam in 1997, suggests dissociative disorders work to hopefully one day guide a deeper understanding of belong to a group and center around having shifts in con- the disorders. sciousness. Some of the disorders mentioned are bipolar disAdditional models have been theorized to expand on the order, panic disorder, and PTSD. It even suggests that panic understanding of trauma and dissociative symptoms. The attacks or flashbacks of PTSD are an example of the dys- Betrayal Trauma Theory was created by Jennifer Freyd to function of the state [5]. Dissociation, per the DBSM, is the explain childhood amnesia when the trauma experienced natural response to danger, which is meant to be protective. by the child is from a family member or trusted individual Through this response, there is an inherent altered state trig- or someone the child is dependent on versus a stranger [5, gered that causes one to experience pain and time differently, 14]. This amnesia protects the child’s need for attachment along with the “sense of self” [5]. The trauma and memories and preserves emotional and cognitive growth. The theory associated with it are then stored in another portion of the is further supported by the lack of amnesia reported by brain/consciousness, which are not always readily accessible individuals during wartime or natural disasters when speto the individual at baseline hence the dissociative amnesia. cifically compared to “intrafamilial childhood sexual or These memories or events that were experienced in a “state” physical abuse” [5]. The Hypnotic Model suggests that the can later manifest and cause severe distress to the individual, traumatized individual triggers a self-induced autohypnosuch as nightmares or intrusive imagery. In early childhood sis as a defense mechanism. This state then becomes contrauma specifically, because the child has not yet developed tinuous and is later transformed into an independent alter their sense of identity, an aberrant pathway ensues, leading ego. Finally, the Trauma Model and Fantasy Model (also to a discrete state. Lastly, it is very important to note the known as the Sociocognitive Model) are also often found DBSM does not explicitly imply the events in question are in scholarly works. These two models are discussed more forgotten. The “states” that are created can make it difficult in the chapter titled “Causes of Dissociative Identity for the individual to retrieve and verbalize the information. Disorder.”

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As previously mentioned, various models exist to help us better understand the cause of dissociative disorders apart from DID itself. Recently the Fantasy Model and Trauma Model have sparked debates within the community [15–19]. Dell’s subjective/phenomenological Model of DID is yet another to add to the list [19]. No one model can fully explain the exact etiology, but rather it is this author’s opinion we should use them in summation. Physical and sexual abuse are the major forms of trauma experienced in childhood (usually combined) that have been reported in patients with DID. Other forms of trauma exist as well, which need to be considered, such as emotional abuse, witnessing severe family violence, and partner violence, to name a few.

Additional Consideration One form of trauma over the last 10 years or so that has come into the spotlight is cyber trauma, commonly referred to as “cyberbullying” or “trolling.” Individuals are emotionally abused repeatedly and, in some cases, ultimately leads to depression, self-harm, and suicide [20]. When thinking about the various models, is it possible that this specific form of trauma may also induce a state of dissociation? And later, possibly be another potential cause for DID? Not enough literature exists at this time to formally answer the question, but it may be an area for future research.

Evaluating Patients Numerous scales/instruments have been created and evaluated over time to help clinical psychologists, psychiatrists, therapists, or mental health experts screen patients for dissociation. The tools are useful but not always essential in making the diagnosis. It is imperative to understand the differences between screening versus diagnostic tools and what data are ultimately obtained from said instrument. The Dissociative Experience Scale is a 28-item self-report questionnaire that was first published in 1986 by Dr. Eve Bernstein and Dr. Frank W. Putnam [21]. Originally the scale was designed to help screen for patients who have dissociative symptoms and as a research tool. In 1993, Bernstein and Putnam published an update on the scale [22]. They recognized the scale was being used in populations that it was not intended for, such as those between the ages of 12 and 17 and the nonclinical population [22]. An easier version of the DES was created called the DES-II, which made changes to how the items were scored. Regardless of the version, both are reliable and valid. The DES-Taxon model uses eight questions to detect pathological dissociation in patients. The higher score on the DES scale should alert the clinician of possible dissociative pathology that warrants deeper investigation.

D. Goyal et al.

The Multidimensional Inventory of Dissociation is a comprehensive, self-reported questionnaire. However, unlike the DES, the MID is diagnostic [23]. In 2006, Dr. Paul F. Dell published the MID in the Journal of Trauma and Dissociation [24]. When it was first designed, there were 268 items, of which 208 were for dissociation and 60 validity items. The final scale was created after Dell collected 500 data points and conducted an extensive statistical analysis. It is made up of 218 items, of which 168 are specific for dissociation, and contains 50 validity items [23, 24]. The data are then entered into a spreadsheet program, which then provides the score. The interpretive manual, spreadsheet program, and the MID questionnaire itself may be obtained freely from Dr. Dell’s website https://www.mid-­assessment.com/mid/. According to the International Society for the Study of Trauma and Dissociation [23], two other instruments worth mentioning are the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCIDD) and the Dissociative Disorders Interview Schedule (DDIS (freely available at https://www.rossinst.com/ddis) [25]). The SCIDD can diagnose the five disorders based on the DSM-IV criteria and can take 45 min–3 h or more to use. The DDIS does the same and can also assess major depression disorder and substance abuse, among others. It also only takes 30–60 min, which may be time-saving when compared to the SCIDD.  The final difference between the two (which is likely why the two instruments vary in the administration time) is the DDIS does not assess the frequency or severity of the symptoms while the SCIDD does. Both the SCIDD and DDIS have been revised to reflect the DSM-5 changes [26]. For further information on the diagnosis of DID, please see the chapter titled “Dissociative Identity Disorder Diagnosis.” For further information regarding the differential diagnosis, please see the chapter titled “Dissociative Identity Disorder and Differential Diagnosis.”

The Dissociative Subtype of PTSD One change that came about in the latest DSM edition was “PTSD with dissociative symptoms.” To be diagnosed, the individual must first meet the criteria for PTSD and experience recurrent or persistent symptoms of either Depersonalization or Derealization (DSM-5: PTSD section pgs. 271–280 [3]). As per usual, they cannot be explained by another medical condition or due to a physiological response to a substance. It is important to keep in mind that PTSD may be one of the comorbid conditions in patients suffering from DID. In some studies, anywhere from 79 to 100% of the patients identified with DID have comorbid PTSD [27]. The clinician must be able to distinguish the differences between a patient who has PTSD only versus PTSD dissociative subtype ver-

13  Dissociative Identity Disorder and Trauma

sus DID with comorbid PTSD.  Being able to differentiate accurately will prevent the delay in diagnosis and treatment. For further information, please see the chapter titled “PTSD and Dissociative Identity Disorder.”

Impacts of Trauma and Dissociation Trauma and dissociation cause enough distress to an individual to affect their physical health [28]. It can impact how our body responds using the HPA axis, catecholamine release control, and the immune system [28]. Together these may place an individual at risk of developing cardiovascular disease and diabetes and decrease their threshold for pain [28]. Functional impairment may also ensue depending on the severity and comorbidities [28, 29]. The level of trauma experienced in the early stages of life is undoubtedly linked to dissociation later in life. Trauma experienced during childhood and early development causes children to develop attachment issues with their caregivers. Bailey and Brand described disorganized attachment as when a child is seeking attention, but due to fear of their caregiver, they simultaneously try to avoid the caregiver [30]. One study over a 10-year follow-up showed children who had undergone painful medical procedures performed by their parents had an increased likelihood of developing dissociative symptoms. Interestingly, the physical sections of the DSM-5 are organized in a manner to emphasize how trauma-related disorders are related to DD while being different. Under the DD heading of the DSM-5, you will find the following statement, “the dissociative disorders are placed next to, but are not part of the trauma- and stressor-related disorders, reflecting the close relationship between these diagnostic classes.” It is within the sections of the “Trauma- and Stressor-Related Disorders” in the DSM-5 (DSM-5 pgs. 265–290 [3]) where you find the information on disorders such as PTSD, Acute Stress Disorder, and Adjustment Disorder. We know that there is usually a delay in the diagnosis of dissociative identity disorder specifically, and patients are usually treated for other disorders before an accurate diagnosis is made. This delay inherently increases the costs of medical care for these individuals. Additional costs such as those connected to education, welfare, housing, and loss of expected wages (to name several and by no means exhaustive) must also be considered when assessing the overall economic burden [28, 29].

Treatment of Dissociative Disorders The course of treatment for dissociative disorders, in general can be challenging. Treatment of DID, specifically, is more cumbersome and takes a great deal of patience. As outlined

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before, being able to form the correct diagnosis in patients is often the cause for delay. It is prudent that clinicians and physicians be well-versed in the different modalities and how to apply them appropriately. Ultimately being able to help reduce symptoms and increase functioning is the end goal. For further discussion on treatment, please refer to the corresponding chapters as follows, “Pharmacologic Treatment of Dissociative Identity Disorder” and “Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder.”

Permissions The content about ICD-10 and ICD-11 within this chapter is written in accordance with the Creative Commons License(s) provided by the World Health Organization (WHO) (License CC BY-NC-SA 3.0 IGO and/or CC BY-ND 3.0 IGO). These adaptations and even reproductions are based on original works published by the World Health Organization (see [8, 9, 13], and  [6–8]). The adaptations presented within the chapter were not created by WHO. The WHO is not responsible for the content or accuracy of these adaptations. The original editions shall be binding and authentic. Figure 13.1 is from Byrne, J.  H. and Dafny, N. (eds.), Neuroanatomy Online: An Electronic Laboratory for the Neurosciences. http://nba.uth.tmc.edu/neuroanatomy/. Department of Neurobiology and Anatomy, The University of Texas Medical School at Houston (UTHealth)© 2014 to present, all rights reserved. Written permission granted [31].

References 1. Mitra P, Jain A.  Dissociative identity disorder. In: StatPearls. Treasure Island: StatPearls Publishing; 2021. PMID: 33760527. http://europepmc.org/article/NBK/NBK568768. 2. Dorahy MJ, Brand BL, Sar V, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. https://doi.org/10.1177/0004867414527523. https://pubmed.ncbi. nlm.nih.gov/24788904/. 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders DSM-5. 5th ed. Washington: American Psychiatric Press; 2013. 4. Tull M.  Links between trauma, PTSD and dissociative disorders. 2020. https://www.verywellmind.com/how-­trauma-­can-­lead-­to-­ dissociative-­disorders-­2797534. Accessed 28 Aug 2022. 5. Sadock BJ, Sadock VA, Pedro R. Chapter 20. Kaplan and Sadock’s comprehensive textbook of psychiatry, 2 volume set, 10th ed. LWW. 2017. pp. 4777–4992. 6. World Health Organization. The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. https:// www.who.int/publications/i/item/9241544228. 7. World Health Organization. The ICD-10 classification of mental and behavioral disorders: diagnostic criteria for research. Geneva: World Health Organization; 1993. https://apps.who.int/iris/ handle/10665/37108.

84 8. World Health Organization. International classification of diseases eleventh revision (ICD-11). Geneva: World Health Organization; 2022. https://icd.who.int/browse11/l-­m/en. 9. Brand BL, Schielke HJ, Putnam KT, et  al. An online educational program for individuals with dissociative disorders and their clinicians: 1-year and 2-year follow-up. J Trauma Stress. 2019;32(1):156–66. https://doi.org/10.1002/jts.22370. https:// pubmed.ncbi.nlm.nih.gov/30698858/. 10. Rutkofsky IH, Khan AS, Sahito S, Aqeel N, Tohid H. The neuropsychiatry of dissociative identity disorder: why Split personality patients switch personalities intermittently? J Cell Sci Ther. 2017;8:267. https://doi.org/10.4172/2157-­7013.1000267. 11. Vermetten E, Schmahl C, Lindner S, Loewenstein RJ, Bremner JD.  Hippocampal and amygdalar volumes in dissociative identity disorder. Am J Psychiatry. 2006;163(4):630–6. https://doi. org/10.1176/ajp.2006.163.4.630. 12. Chalavi S, Vissia EM, Giesen ME, Nijenhuis ER, Draijer N, Cole JH, Dazzan P, Pariante CM, Madsen SK, Rajagopalan P, Thompson PM, Toga AW, Veltman DJ, Reinders AA. Abnormal hippocampal morphology in dissociative identity disorder and post-traumatic stress disorder correlates with childhood trauma and dissociative symptoms. Hum Brain Mapp. 2015;36(5):1692–704. https://doi. org/10.1002/hbm.22730. 13. Lanius RA. Trauma-related dissociation and altered states of consciousness: a call for clinical, treatment, and neuroscience research. Eur J Psychotraumatol. 2015;6:27905. https://doi.org/10.3402/ejpt. v6.27905. 14. Waters FS. 2016 Healing the fractured child: diagnosis and treatment of youth with dissociation. Springer Publishing Company. https://doi.org/10.1891/9780826199645.0001. https://connect. springerpub.com/content/book/978-­0-­8261-­9964-­5. 15. Dimitrova L, Fernando V, Vissia EM, Nijenhuis ERS, Draijer N, Reinders AATS. Sleep, trauma, fantasy and cognition in dissociative identity disorder, post-traumatic stress disorder and healthy controls: a replication and extension study. Eur J Psychotraumatol. 2020;11(1):1705599. https://doi.org/10.1080/20008198.2019.1705 599. 16. Dalenberg CJ, Brand BL, Gleaves DH, Dorahy MJ, Loewenstein RJ, Cardeña E, Frewen PA, Carlson EB, Spiegel D.  Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull. 2012;138(3):550–88. https://doi.org/10.1037/ a0027447. 17. Dalenberg CJ, Brand BL, Loewenstein RJ, Gleaves DH, Dorahy MJ, Cardeña E, Frewen PA, Carlson EB, Spiegel D. Reality versus fantasy: reply to Lynn et al. (2014). Psychol Bull. 2014;140(3):911– 20. https://doi.org/10.1037/a0036685. 18. Lynn SJ, Lilienfeld SO, Merckelbach H, Giesbrecht T, McNally RJ, Loftus EF, Bruck M, Garry M, Malaktaris A. The trauma model of dissociation: inconvenient truths and stubborn fictions. Comment on Dalenberg et  al. (2012). Psychol Bull. 2014;140(3):896–910. https://doi.org/10.1037/a0035570.

D. Goyal et al. 19. Dell P.  A new model of dissociative identity disorder. Psychiatr Clin North Am. 2006b;29:1–26, vii. https://doi.org/10.1016/j. psc.2005.10.013. 20. Neuman L.  Cyberbullying associated with depression and dissociation in teens. HCPLive. 2017. https://www.hcplive.com/view/ cyberbullying-­associated-­with-­depression-­and-­dissociation-­in-­ teens. Accessed 28 Aug 2022. 21. Bernstein EM, Putnam FW.  Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis. 1986;174(12):727– 35. https://doi.org/10.1097/00005053-­198612000-­00004. https:// pubmed.ncbi.nlm.nih.gov/3783140/. 22. Carlson EB, Putnam FW.  An update on the dissociative experience scale. Dissociation. 1993;6(1):16–27. Note: Dissociative Experiences Scale-II included in Appendix. https://scholarsbank. uoregon.edu/xmlui/handle/1794/1539. 23. International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, Third Revision. J Trauma Dissociation. 2011;12(2):115–87. https:// doi.org/10.1080/15299732.2011.537247. 24. Dell P.  The multidimensional inventory of dissociation (MID): a comprehensive measure of pathological dissociation. J Trauma Dissociation. 2006a;7(2):77–106. https://doi.org/10.1300/ J229v07n02_06. 25. Dissociative Disorders Interview Schedule (DDIS). 2022. Colin A. Ross Institute. https://www.rossinst.com/ddis. Accessed 3 Sept 2002. 26. Mychailyszyn MP, Brand BL, Webermann AR, Sar V, Draijer N.  Differentiating dissociative from non-dissociative disorders: a meta-analysis of the structured clinical interview for DSM dissociative disorders (SCID-D). J Trauma Dissociation. 2020;22:19. https://doi.org/10.1080/15299732.2020.1760169. 27. Loewenstein RJ.  Dissociation debates: everything you know is wrong. Dialogues Clin Neurosci. 2018;20(3):229–42. https://doi. org/10.31887/DCNS.2018.20.3/rloewenstein. 28. Boyer SM, Caplan JE, Edwards LK.  Trauma-related dissociation and the dissociative disorders: neglected symptoms with severe public health consequences. Delaware J Public Health. 2022;8(2):78–84. https://doi.org/10.32481/djph.2022.05.010. 29. Langeland W, Jepsen EKK, Brand BL, Kleven L, Loewenstein RJ, Putnam FW, et al. The economic burden of dissociative disorders: a qualitative systematic review of empirical studies. Psychol Trauma Theory Res Pract Policy. 2020;12(7):730–8. https://doi. org/10.1037/tra0000556. 30. International Society for the Study of Trauma and Dissociation. Guidelines for the evaluation and treatment of dissociative symptoms in children and adolescents. J Trauma Dissociation. 2004;5(3):119–50. https://doi.org/10.1300/J229v05n03_09. 31. Dissociative Identity Disorder. 2022. Traumadissociation.com. http://traumadissociation.com/dissociativeidentitydisorder.html. Accessed 3 Sept 2022.

Dissociative Identity Disorder and Other Specified Dissociative Disorder (OSDD)

14

Christopher Privette, Santroy Samules, and Mohammad Sadik

Introduction The DSM-V dissociative disorders are classified into dissociative identity disorder, depersonalization/derealization disorder, dissociative amnesia, other specified dissociative disorders, and unspecified dissociative disorder [1]. Dissociative identity disorder (DID) is a psychotic disorder that affects 1.5% of the total world population. Individuals suffering from DID present with suicide attempts, substance abuse, and self-injurious behavior. The causes of DID include childhood abuse and trauma. The factors important for the development of DID include overwhelming traumatic experiences that distort reality, the ability to dissociate, lack of external stability, and the creation of altered names and identities. Individuals suffering from DID tend to experience separate identities each of which is autonomous and functions independently of one another. Each identity has separate behaviors, memories, expressions, and language. Changes in posture, trance-like behavior, and eye blinking are the different signs of switching to an altered identity. The characteristic features of DID include disruption of normal behavior, consciousness, identity, and memory. Individuals suffering from DID also experience amnesia, which is referred to as distinct gaps in memory [1]. The diagnosis of other specified dissociative disorders (OSDD) is achieved when the presenting symptoms do not meet the complete criteria of the dissociative disorders. Physicians will write down OSDD to specify the specific reason why the disorder does not meet the criteria for DID. This is done by putting down OSDD followed by one of the examples that C. Privette (*) Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Apollo Beach, FL, USA S. Samules Aventura Hospital and Medical Center, Aventura, FL, USA e-mail: [email protected] M. Sadik California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA

are classified under OSDD [1]. The following sections of the chapter discuss the causes, symptoms, pathogenesis, clinical manifestations, differential diagnosis, and treatment of OSDD.

 ypes of Other Specified Dissociative T Disorder The four clinical presentations of OSDD are described in the subsequent sections [1].

 SDD-I Chronic and Recurrent Syndromes O of Mixed Dissociative Symptoms The first category of OSDD describes disturbance in identity, which is associated with alterations of identity or discontinuities in the sense of oneself. The patients may also present with episodes of possession with an absence of dissociative amnesia.

 SDD-II Identity Disturbance O Due to Prolonged and Intense Coercive Persuasion The second category of OSDD pertains to dissociation in the context of individuals who have been subject to brainwashing, torture, recruitment by terror organizations, and other forms of intense coercive persuasion.

 SDD-III Acute Dissociative Reactions O to Stressful Events The third category of OSDD refers to those conditions that are acute or transient and last for less than a month. This category is marked by perceptual disturbances, depersonali-

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zation, constriction of consciousness, derealization, transient stupor, alterations in the functioning of sensory-motor pathways, and micro-amnesias.

OSDD-IV Dissociative Trance The fourth category of OSDD refers to complete loss or acute narrowing of awareness of the surroundings. This manifests as insensitivity or unresponsiveness to the external stimuli, which is accompanied by stereotypical behaviors such as finger movements that a person is unaware of or cannot control, loss of consciousness, or transient paralysis. Dissociative trance is not a usual constituent of widely acceptable religious and cultural practices.

 hanges to Dissociative Disorder C in the DSM-5 OSDD is a relatively new category under the dissociative disorder that was first established in 2013 with the publication of the DSM-5. Therefore, in order to understand OSDD it is imperative to understand the rationale behind the changes in the DSM-5 as well as its previous categorization of Dissociative Disorders Not Otherwise Specified (DDNOS). Since the publication of the DSM-4, a large number of studies have further developed the body of knowledge surrounding dissociation and associated dissociative disorders. This has led to a restructuring of definitions and diagnostic criteria, which is apparent in the changes seen in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The evolution from the DSM-4, DSM-­ 4-­TR, and DSM-5 reflects changes in our understanding of dissociative phenomenology, course, etiology, and treatment. Therefore, periodic revisions are necessary in order to provide opportunities to reevaluate the assumptions underlying specific diagnoses and the supporting evidence for diagnostic criteria. Further impetus for the changes in the DSM-5 include clarification of language to indicate that different states can be reported or observed as well to reduce the frequency of Dissociative Disorders Not Otherwise Specified (DDNOS) diagnoses [2]. Moreover, changes were made to differentiate normative cultural experiences from psychopathology, increase cross-cultural applicability, and to note that amnesia for everyday events is a common feature [2].

Changes in the Definition of Dissociation The DSM-5 Work Group made moderate revisions to further expand the definition of dissociation. Dissociation can be viewed as both an adaptational process and as a spectrum of

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psychopathologies. The DSM-5 defines dissociation as a disruption or discontinuity of the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior [1]. The DSM-5 further classifies dissociative symptoms as “negative” and “positive”. Positive symptoms can be seen as spontaneous intrusions into awareness and behavior with accompanying discontinuity in the subjective experience of self. Negative symptoms can be conceptualized as an inability to access information or to control mental functions that are normally accessible.

 hanges in Diagnostic Criteria C to the Dissociative Disorders The DSM-5 work group made changes beyond definitions. Perhaps the most notable changes are to the diagnostic criteria and dissociative disorder categories itself. The DSM-4 categorized dissociative disorders into Dissociative Identity Disorder, Dissociative Disorders Not Otherwise Specified (DDNOS), Dissociative amnesia, and Depersonalization disorder. However, the DSM-5 discontinued the DDNOS diagnosis and recategorized dissociative disorders into dissociative identity disorder (DID); dissociative amnesia; depersonalization/derealization disorder; other specified dissociative disorders (OSDD); and unspecified dissociative disorder.

Changes to Dissociative Identity Disorder The criteria for dissociative identity disorder has changed significantly. The DSM-5 concept of dissociative identity disorder moved away from the notion of stable personality states with unsolicited switching [2]. The DSM-5 criteria has moved to a broader more flexible definition that includes the subtle changes that may not be as pronounced and to encompass different presentations in the experience and outward appearance of discontinuity of the subjective sense of self and associated behavior, mood, affect, consciousness, perception, cognitive schema, and memory [2]. In order to make the diagnosis of DID, the DSM-4 required that a physician observe discontinuities in the self-state. Notwithstanding, Dell showed that only 15% of DID cases consistently manifest clear-cut observable alternate identities during diagnostic interviews [3]. Therefore, requiring the presence of a physician to observe a state shift could lead to underdiagnosis. The DSM-5 allows the diagnosis to be made based on reports by the patient and others and, therefore, does not require the physician’s observation of state shifts. Furthermore, the DSM-IV-TR DDNOS example of pathological possession was moved into the diagnostic criteria for

14  Dissociative Identity Disorder and Other Specified Dissociative Disorder (OSDD)

dissociative identity disorder. However, the DDNOS dissociative trance example was moved to OSDD.

 hanges to Dissociative Disorders Not C Otherwise Specified Perhaps, the most notable changes in the DSM-5 was the dissolution of Dissociative Disorder Not Otherwise Specified (DDNOS). DDNOS was very broad and contained several examples that have since became particular areas of attention and since have been further defined, recategorized, and divided up into the DSM-5 Dissociative Identity Disorder (DID), Other Specified Dissociative Disorder (OSDD), and unspecified dissociative disorder. The Dissociative Disorder Not Otherwise Specified category was generally applied to anyone in which the predominant feature is a dissociative symptom that does not meet the criteria for any specific dissociative disorder. This category contained four examples of presentation: 1. Clinical presentation similar to DID in which (a) there are not two or more distinct personality states, or (b) amnesia for important personal information does not occur. 2. Derealization unaccompanied by depersonalization. 3. States of dissociation due to intense coercive persuasion. 4. Dissociative trance disorder and possession trance disorder. DDNOS was the most common dissociative disorder, accounting for an estimated 40% of dissociative disorder diagnosis [2]. The most common presentations of DDNOS involved (a) amnesia with dissociative parts that are not distinct enough to be considered DID and (b) dissociative parts that have distinct “alter” personalities but without the amnesia between them. Derealization has since been moved into its own category termed depersonalization/derealization disorder. Pathological possession trance has since been reclassified as an aspect of DID. Furthermore, Ganser syndrome and DID without the physician observation of switching was classified under DDNOS. Ganser syndrome is characterized by the production of approximate answers (near misses) to very simple questions. An example of this would be when the patient is asked what is two plus two, they respond with “three”. This syndrome was considered controversial and was not included in the DSM-5.

 ther Specified Dissociative Disorders O and Unspecified Dissociative Disorders Both Other Specified Dissociative Disorder (OSDD) and Unspecified Dissociative Disorder were introduced in the

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DSM-5 to replace the diagnosis of Dissociative Disorder Not Otherwise Specified (DDNOS). The equivalent diagnosis in the International Classification of Diseases is partial DID. Clinicians use the Other Specified Dissociative Disorder category to further denote the reason why the presentation does not meet the criteria for a specific dissociative disorder. For example the clinician may record “Other Specified Dissociative Disorder” followed by the specific reason such as “Coercive Persuasion” [1]. The DSM-5 lists four examples under OSDD to assist clinicians in recognizing conditions that can be specified using the “other specified” designation. The examples listed under the other specified dissociative disorder category includes (a) chronic and recurrent syndromes of mixed dissociative symptoms that do not meet the criteria for DID, (b) dissociation due to coercive persuasion, (c) acute dissociative reactions to stressful events, and (d) dissociative trance disorder. It should be noted that these examples currently do not have enough research findings to support them as an individual specified dissociative disorder. However, they are included to assist future research, which may lead to future modification of their criteria and phenomenology. The unspecified dissociative disorder category is used in situations in which the clinician chooses not to indicate the reason why the criteria for a specific dissociative disorder is not met [1]. This includes situations for which there is not enough information to make a more explicit diagnosis such as in the emergency room setting [1].

Epidemiology/Etiology Diagnosing other complex dissociative disorders including dissociative identity disorder and other specified dissociative disorders can be challenging for several reasons. First, patients rarely report dissociative symptoms unless directly asked, standard mental health examination does not routinely ask these questions, and health care professionals do not receive appropriate training to diagnose dissociative disorder [4]. Second, complex dissociative disorder is polysymptomatic, and examiners would rather diagnose with disorders more familiar from clinical practice [4]. As such, dissociative disorders are both underdiagnosed and misdiagnosed [4]. Across community-based studies, dissociative identity disorder had a prevalence of 1–1.5% in the general population, similar to that of schizophrenia [5]. The incidence is found to be even higher amongst patients receiving mental care. Studies of inpatient psychiatric patients in 9 countries have shown that the prevalence of dissociative identity disorder ranges from 0 to 12% with a median of 5% [5]. Studies of patients receiving outpatient psychiatric care in the United States and Turkey have shown prevalence of 0–7% with a median of 2.5% [2].

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There is also a slight female predominance with increasing age. Developmental studies indicate that the ratio of female to male for dissociative identity disorder increases from 1 to 1 in early childhood to 8 to 1 by late adolescence in North America [6]. It is believed that the disproportionate increase in females compared to males is related to the female predominance of those likely to seek care. Also, male cases are more likely to be missed based on how they present clinically and most men cases end up in the criminal justice system and/or the drug treatment system rather than mental health institutions. Several studies have reported a median age of 31 ranging from 22 to 34 years old [6]. Dissociative identity disorder has a high rate of psychiatric comorbidities, which includes PTSD (79–100%), depression (83–96%), substance abuse (83–96%), headaches (79–91%), somatoform disorders (35–60%), neuroleptic seizures, and conversion disorder [2, 5, 6]. Common comorbid personality disorders include avoidant personality disorder 76% of the time and borderline personality disorder 31–83% [2]. Studies have shown that a large proportion of people diagnosed with dissociative identity disorder usually have some history of severe childhood trauma, including physical and/ or sexual abuse beginning before the age of 6 [5]. Data collected in diverse geographic locations, including North America, Puerto Rico, Western Europe, Turkey, and Australia, have documented that dissociative patients report some of the highest frequencies of childhood psychological trauma among all psychiatric disorders. Childhood sexual (57.1–90.2%), emotional (57.1%), and physical (62.9– 82.4%) abuse and neglect (62.9%) [5].

 ther Specified Dissociative Disorder O (OSDD) Type 1: Chronic and Recurrent Syndromes of Mixed Dissociative Symptoms This type of OSDD shares common characteristics with DID. Individuals suffering from OSDD-I present with symptoms that are similar to those of DID; however, the disorder does not meet the complete diagnostic criteria of DID. Subcategories of OSDD-I are OSDD-Ia and OSDD-Ib. OSDD-Ia refers to individuals with dissociative parts that do not sufficiently qualify as alters (the alteration/switching of one’s identity to another identity). On the contrary, OSDD-Ib refers to a condition where the affected individual does not present with amnesia between alters [2]. The individual with highly distinct parts and amnesia is known as the “Part-undivided” or OSDD.  They are rare, though they do exist within this population category. The diagnosis of OSDD-Ia is a difficult process as the association of part with discontinuities in the sense of agency and oneself is not clear. As compared to DID, which comprises two or more parts within their sense of self, OSDD-Ia comprises dissociated parts that do present as different ver-

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sions, and in different modes. However, the affected individual maintains the same identity during these dissociative episodes [2]. Furthermore, each dissociative part has its own emotional reactivity, pattern of interaction, and skills. The dissociative parts lack complete awareness of each other, due to which the presentation of these parts is highly contradictory [2]. For instance, individuals suffering from OSDD-Ia may have a family self, a 5-year-old self, an angry self, and a work self as well as other parts associated with trauma memories. The working self and family self-prioritize work and family, respectively. When other individuals point out behavioral inconsistencies, the parts become agitated or confused. The characteristic features that distinguish OSDD-Ia from other disorders such as complex post-traumatic stress disorder (C-PTSD), borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD) include the presence of a minimum of two parts with attachment needs, emotions, and post-traumatic reactions [7]. However, all individuals affected by OSDD-1 or the abovementioned disorders tend to suffer from dissociative amnesia when stressed or experience the memories of trauma. OSDD-Ib is characterized by the absence of amnesia events between the alters but the affected individuals experience emotional amnesia. Therefore, these individuals may remember the event but not the related emotions. Individuals suffering from OSDD-Ib are unable to subconsciously escape from their trauma. Since these individuals fail to lose their memories, it is difficult for them to control or shift from their system. The following are the types of OSDD-I based on the different symptom clusters. (a) This type comprises general dissociative symptoms, including depersonalization, post-traumatic flashbacks, memory problems, derealization, trance states, or somatoform symptoms. (b) This type comprises partial dissociative intrusions manifesting as self-alteration, passive influence, or hearing alter voices. This type of OSDD-I includes overlapping dissociative self-states or internal interactions. For the diagnosis of DID, the symptoms shall fulfill all the three criteria mentioned above. However, the diagnosis of OSDD-I is confirmed when only two of the abovementioned criteria are fulfilled, with (a) and (b) symptom clusters being the most common [1]. Individuals suffering from OSDD-I experience impairment of daily life memory. On the contrary, these individuals exhibit less spontaneous switching between alters, fewer mental health comorbidities, multiple emotional parts (EP), and only single normal parts (ANP). The absence of multiple ANPs in OSDD-I is linked with the absence of complexity of alters and inter-identity amnesia [2].

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 reatment of Other Specified Dissociative T Disorder Type 1 Management of all dissociative disorders starts with an accurate diagnosis and assessment of comorbidities and the predisposing trauma. When OSDD is suspected the clinician should complete a dissociative screening tool such as the Dissociative Experience Scale  - II (DES-II). If the patient scores above 30 then the clinician should further evaluate the patient using a proven structured diagnostic interview [8]. This is especially important when the presentation is not as clear cut or there exist multiple comorbidities. Treatment principles for OSDD are derived from the treatment approach for Dissociative Identity Disorder, which revolves around improvement of the presenting symptoms and to increase the function and productivity of the affected individuals [7]. Psychotherapy is an effective treatment modality that helps the affected individuals control their dissociative symptoms. Psychotherapy involves memories of previous traumatic experiences and helps the therapy recipients in coping with these experiences. Hypnosis, dialectical behavioral therapy, and cognitive behavioral therapy are effective for alleviating dissociative symptoms [2, 7, 8]. Please refer to the chapters “Pharmacologic Treatment of Dissociative Identity Disorder” and “Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder” for a more comprehensive approach on the management of dissociative disorders.

 ther Specified Dissociative Disorder O (OSDD) Type 2: Coercive Persuasion Definition Coercive Persuasion is an example of OSSD that was recently added with the publication of the DSM-5. The DSM-5 characterizes this category by identity changes due to prolonged and intense coercive persuasion, including brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects/cults or by terror organizations. This may present as prolonged changes in identity or conscious questioning of their identity [1].

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were spies [2]. However, it should be noted that further investigation into these case reports were mixed with some concluding there were no alterations in the individuals basic attitudes. Individuals who have undergone extreme coercion may present similarly to those who were subjected to torture. These individuals may exhibit profound changes in values, attitudes, beliefs, and personality. These changes usually resolve after the coercive persuasion is discontinued. However, it should be noted that these states may be reactivated by circumstances that resemble the traumatic event. The degree of identity alteration is unknown. However, these individuals can exhibit the full spectrum of dissociative symptoms, including depersonalization, trance, emotional numbing, behavioral regression, reduced cognitive flexibility, and or amnesia toward the events [2]. One study that investigated the working memory of special operation forces who were subject to extreme stress during training did show some degrees of dissociation, most notably impaired visuospatial capacity and working memory. However, amnesia of the event was not reported [9].

Treatment There are no empirical studies on the management of individuals who were subject to extreme coercion. However, management principles can be derived from those who have undergone extreme trauma. Therefore, treatment begins with the establishment of a stable safe environment. Once a safe space has been established, further management should include providing the individual with educational information as well as nonsuggestive exploration of the traumatic experience [2]. Further management should be focused on treating comorbidities as well as the integration of the individual back into society with the support of family and friends. Interventions should focus on desensitization as well as increasing the individuals’ sense of self. Please refer to the chapters “Pharmacologic Treatment of Dissociative Identity Disorder” and “Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder” for a more comprehensive approach on the management of dissociative disorders.

 ther Specified Dissociative Disorder O (OSDD) Type 3: Acute Dissociative Reactions The concept of thought reform or brainwashing is a contro- to Stressful Events Diagnosis and Clinical Features

versial concept that has emerged in the last century. Dissociation due to coercive persuasion occurs in the context of extreme physical, psychological, and social coercion such as with prisoners of war, extreme interrogation, and religious cults. For example, reports of some individuals who were prisoners of war during the Korean War falsely insisted they

Definition Acute Dissociative Reactions to Stressful Events is an example of OSDD that was recently added with the publication of the DSM-5. This category describes an acute, transient con-

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dition with mixed dissociative symptoms that last less than 1  month. The DSM-5 characterizes this condition by constriction of consciousness, depersonalization, derealization, perceptual disturbances, micro-amnesias, transient stupor, and/or alterations in sensory-motor functioning [1].

C. Privette et al.

an animal or catatonic-­like symptoms [2, 7, 10]. Delusional phenomena may be reported and speech can appear disjointed and intermittent and can be confused with a psychotic thought disorder. However, during these episodes the apparent delusions are related to the traumatic experiences and once the patient stabilizes there is no evidence of disorganized thoughts or fixed false beliefs. Dissociation can be seen in almost every Diagnosis and Clinical Features psychiatric disorder and the distinction between the two different psychopathologies are often not clear cut. Therefore, Example 3 (Acute Dissociative Reactions to Stressful recent literature has made a point to identify symptoms that Events) of OSDD encompasses brief episodes of mixed dis- can be used to differentiate psychotic disorders from complex sociative symptoms that usually occur in the context of dissociative disorders. One study found that patients with a trauma or extreme stress and may persist for up to a few complex dissociative disorder were more likely to hear multiweeks after the stressor dissipates [1]. ple voices and hear child voices when compared to patients It is worth bearing in mind that all the dissociative disor- with a psychotic disorder [10]. Furthermore, patients with a ders are frequently found in the context of trauma or extreme dissociative disorder often experience hallucinations that stress. The DSM-5, both places and makes notes that the dis- involve multiple sensory modalities such as tactile, auditory, sociative disorders are placed next to the trauma and stressor-­ gustatory, or olfactory [10]. Evaluation after remission of the related disorders to demonstrate the close relationship acute episode can help confirm the diagnosis. between these diagnostic categories as well as highlight their separateness. For example, acute stress disorder can contain dissociative symptoms such as amnesia and intrusions of Nonpsychotic Cases unwanted thoughts and, therefore, it is imperative to distinguish between the different disorders to better understand The generally more mild and uncomplicated cases of them and to better assist clinicians when making a diagnosis. Example 3 are nonpsychotic and typically characterized as Although patients may not report a stressor, a stressful event acute onset with predominantly dissociative symptoms. They is often later revealed to be the initial catalyst once more usually present with disturbances in interpersonal relationinformation is obtained from others more familiar with the ships and work-related functioning. Although cases typically individual [2]. The stressor can range from mild events such last only a few days; crisis intervention is still required. as a breaking off a relationship to more extreme stressors Similar to the psychotic cases, the nonpsychotic presentation such as the death of a loved one. However, it should be noted may closely resemble other psychopathologies. The acute that exposure to trauma or extreme stress is not required to nature and association with stressors mirrors acute stress dismake the diagnosis of Example 3 of OSDD. order. Moreover, acute stress disorder often exhibits dissoAcute dissociative reactions cover a spectrum of severity ciative symptoms such as amnesia, flashbacks, numbing, and and, therefore, the DSM-5 makes the distinction of two acute depersonalization/derealization. Additionally, peritraumatic presentations. Example 3 of OSDD can be categorized into dissociation is often seen in ASD and its presence increases acute dissociative reactions with or without psychotic symp- the likelihood for progression into PTSD [7]. The predomitoms. Cases of Example 3 with psychosis are sometimes nance of dissociative symptoms and absence of other sympreferred to as hysterical psychosis or reactive dissociative psy- toms such as hyperarousal and avoidance can aid in chosis [7, 10]. These patients often exhibit extreme ambiva- differentiating nonpsychotic cases of Example 3 from acute lence with a labile affect due to rapidly shifting emotional and stress disorder. Furthermore, Example 3 does not require the mental states [7]. Case reports describe acute dissociative psy- presence of traumatic exposure, which distinguishes this chosis as a mix of dissociative, somatic, and psychotic symp- condition from ASD. toms. Patients often experience dissociative symptoms such as flashbacks to the traumatic event as well as dissociative amnesia [2]. In some cases, neurological somatic (conversion) Treatment symptoms are described as the most prominent presenting symptom and can even include palpitations, fainting, shaking, There are no systematic studies on the treatment of Example and seizures [2]. Other presentations of acute dissociative 3 of Other Specified Dissociative Disorders. Therefore, treatreaction with psychotic features can resemble a delirium, ment principles are derived from the treatment approach for mania, or schizophrenic disorder. Psychotic cases of Example Dissociative Identity Disorder and from the management of 3 often describe patients as experiencing multimodal halluci- certain “folk illnesses” such as Ataques de nervios [8]. nosis, age regression, and bizarre behavior such as behaving as Management of all dissociative disorders starts with an accu-

14  Dissociative Identity Disorder and Other Specified Dissociative Disorder (OSDD)

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rate diagnosis and assessing for comorbidities and the predisposing trauma. During acute dissociative reactions the primary goal should be to make the patient feel safe enough that they can “let go” of the symptoms. There is no high-­ quality, unequivocal evidence to support one treatment intervention over the other. However, after stabilization the cornerstone of treatment for all dissociative disorders is psychotherapy, which includes interventions such as cognitive behavioral therapy, hypnosis, psychodynamic therapy, specialized physiotherapy, paradoxical intervention and psychoeducation. [8] In general, most treatment models work through the integration of dissociated parts and by the transformation of maladaptive thoughts toward more adaptive and appropriate thoughts. Please refer to the chapters “Pharmacologic Treatment of Dissociative Identity Disorder” and “Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder” for a more comprehensive approach on the management of dissociative disorders.

Dissociative Trance can be viewed as the splitting of consciousness as well as loss of somatic control. While DID and Possession trance can be conceptualized as the splitting of identity. Both dissociative and possession trance states occur involuntarily and result in significant distress or impairment. Dissociative Trance is a transient altered state of consciousness that is widely reported across the world. It can present as loss of the customary sense of personal identity, however, without a change in identity [11]. This could manifest as the individual referring to false autobiographical details while still maintaining their actual identity [11]. Furthermore, dissociative trance experiences can present with feelings of being disconnected from oneself and surroundings. During a trance episode the person often exhibits a repeated set of limited movements, postures, sounds, or words [7, 11]. Moreover, they can be accompanied by both visual and auditory hallucinations [11].

 ther Specified Dissociative Disorder (OSSD) O Type 4: Trance Disorder

Cultural Syndromes

Definition Dissociative Trance is an example of OSDD that the DSM-5 defines as an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice [1].

Clinical Presentation When discussing dissociative trance disorder, it is important to understand pathological possession, which was initially grouped with dissociative trance in the DSM-IV-TR but later recategorized as an element of dissociative identity disorder in the DSM-5. The DSM-5 states that possession-form identities typically manifest as behaviors that appear as if a “spirit,” supernatural being, or outside person has taken control, such that the individual begins speaking or acting in a distinctly different manner. The identities that arise during possession-form dissociative identity disorder present recurrently, are unwanted and involuntary, cause clinically significant distress or impairment (Criterion C), and are not a normal part of a broadly accepted cultural or religious practice (Criterion D).

In some cultures, both visual and auditory hallucinations may be considered a normal part of an accepted religious or cultural practice. Both Mediumship and Channeling are spiritual phenomena that have been found across cultures and throughout time. They can be characterized as a state where a person communicates with a deceased person and is considered a nonpathological form of dissociation. It should be noted that most people who undergo a channeling experience are well-adjusted, high functioning individuals with better social adjustment scores and fewer psychiatric symptoms than the general population [12]. Therefore, it is important to maintain this consideration to avoid cultural bias. This is especially important when it comes to culture-bound syndromes such as amok and bebainan, Latah, pibloktoq, and ataque de nervios [8, 11].

Treatment There are no systematic studies on the treatment of Example 4 of Other Specified Dissociative Disorders. However, patients with this condition may require a neurological evaluation including EEG and brain imaging to rule out seizure disorders and other neuropathologies [11]. Furthermore, depending on the presentation a cardiac workup may be performed to rule out hypotension and or arrhythmias. Similar to all psychiatric disorders, the gold standard approach for diagnosing dissociative trance disorder is with the clinical interview. The Dissociative Trance Disorder Interview Schedule (DTDIS) is a structured interview that was developed to inquire about dissociative symptoms from a cross-­

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cultural perspective as well as related symptoms and diagnoses [11]. The DTDIS has been shown to consistently differentiate Dissociative Trance Disorder from other disorders when the diagnosis is not so clear cut [11]. In general, treatment should focus on the patient understanding the nature of their trance states. Patients with dissociative trance often demonstrate high hypnotizability. Assessment of hypnotizability has been shown to be effective in both diagnosis and treatment because it may lead to an increased sense of control as well as help the patient recognize autohypnotic states [11]. Similar to all dissociative disorders, the cornerstone of treatment is psychotherapy. Please refer to the chapters “Pharmacologic Treatment of Dissociative Identity Disorder” and “Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder” for a more comprehensive approach on the management of dissociative disorders.

References 1. Dissociative disorders. In: Diagnostic and statistical manual of mental disorders: DSM-5. New Delhi: CBS Publishers & Distributors; 2017. 2. Sadock BJ, et  al. Dissociative disorders. In: Kaplan & Sadock’s comprehensive textbook of psychiatry, Wolters Kluwer, Philadelphia, 2017. 3. Dell P. The long struggle to diagnose multiple personality disorder (MPD) II. Partial MPD. 2009. 4. Pietkiewicz IJ, Bańbura-Nowak A, Tomalski R, Boon S.  Revisiting false-positive and imitated dissociative identity dis-

C. Privette et al. order. Front Psychol. 2021;12:637929. https://doi.org/10.3389/ fpsyg.2021.637929. PMID: 34025510; PMCID: PMC8134744. 5. Bryant RA, Panasetis P. The role of panic in acute dissociative reactions following trauma. Br J Clin Psychol. 2005;44(Pt 4):489–94. https://doi.org/10.1348/014466505X28766. PMID: 16368028. 6. Brand BL, Lanius RA.  Chronic complex dissociative disorders and borderline personality disorder: disorders of emotion dysregulation? Borderline Personal Disord Emot Dysregul. 2014;1:13. https://doi.org/10.1186/2051-­6673-­1-­13. 7. The many faces of dissociation: opportunities for innovative research in psychiatry. Clin Psychopharmacol Neurosci. 2014;12:171–179. https://doi.org/10.9758/cpn.2014.12.3.171. 8. Subramanyam AA, Somaiya M, Shankar S, Nasirabadi M, Shah HR, Paul I, Ghildiyal R.  Psychological interventions for dissociative disorders. Indian J Psychiatry. 2020;62(Suppl 2):S280–9. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_777_19. 9. Morgan CA 3rd, Doran A, Steffian G, Hazlett G, Southwick SM.  Stress-induced deficits in working memory and visuo-­ constructive abilities in special operations soldiers. Biol Psychiatry. 2006;60(7):722–9. https://doi.org/10.1016/j.biopsych.2006.04.021. Epub 2006 Aug 24. PMID: 16934776. 10. Schiavone FL, McKinnon MC, Lanius RA.  Psychotic-like symptoms and the temporal lobe in trauma-related disorders: diagnosis, treatment, and assessment of potential malingering. Chronic Stress (Thousand Oaks). 2018;2:2470547018797046. https://doi. org/10.1177/2470547018797046. PMID: 32440584; PMCID: PMC7219949. 11. During EH, Elahi FM, Taieb O, Moro MR, Baubet T.  A critical review of dissociative trance and possession disorders: etiological, diagnostic, therapeutic, and nosological issues. Can J Psychiatry. 2011;56(4):235–42. https://doi. org/10.1177/070674371105600407. PMID: 21507280. 12. Pederzoli L, Tressoldi P, Wahbeh H. Channeling: a non-­pathological possession and dissociative identity experience or something else? Cult Med Psychiatry. 2022;46:161–9. https://doi.org/10.1007/ s11013-­021-­09730-­9.

Dissociative Identity Disorder and Schizophrenia

15

Sindhura Kompella and Shivani Kaushal

Introduction DID and schizophrenia are psychiatric disorders that share some common symptomatology; however, research directly comparing patients with these disorders is sparse. The roles of comorbidity, common physiological pathways, genetics, and environment must be explored to disentangle the common and distinguishing aspects of these conditions.

DID Vs Schizophrenia Dissociative identity disorder and schizophrenia are generally considered to be unrelated syndromes; however, it is important to be aware of the similarities and differences in order to help clinicians distinguish both illnesses. This is especially relevant due to similar clinical presentations in both illnesses, such as dissociative symptoms and or auditory hallucinations. Studies show similarities in clinical scales, wherein DID shows higher dissociation scores, dissociative symptoms, and voices that may be persecutory or child-like in nature. Similarly, patients with schizophrenia can present with persecutory, negative, or command auditory or visual hallucinations in addition to dissociation-like phenomena with false reality testing. Some differences in clinical presentation are significant to note between the conditions; for example, dissociative symptoms in DID can present with multiple personalities, while reality testing can be unaltered or disorganized behaviors are less likely. Schizophrenic patients also tend to have higher delusion scores compared to DID patients.

S. Kompella (*) Department of Psychiatry, University of Miami, Miller School of Medicine, Aventura, FL, USA S. Kaushal Nova Southeastern University, Medical School, Davie, FL, USA

Thus, careful consideration of these symptoms is important to distinguish clinical presentations of conditions with complex symptoms and etiologies, such as DID and schizophrenia [1]. Moreover, patients with DID or other dissociative disorders have better insight into their reality testing compared to patients with schizophrenia and have equivalent insight compared to other disorders such as obsessive compulsive disorder (OCD) or depression [2]. Per literature review, dissociative patients tend to have cognitive insight into their illness and are able to have self-reflective capacity in comparison to schizophrenia patients, wherein cognitive insight is usually lacking and in the psychotic range, sometimes including the perception of bizarre delusions. Moreover, comprehensive consideration of various contributors such as risk factors, etiology, and age can play an important role in distinguishing schizophrenia from DID.  Regarding etiology, DID is thought to have environmental factors such as psychosocial stressors, and trauma plays a pivotal role in initiation of symptoms for different personalities. Schizophrenia’s etiologic causes are epigenetic in origin wherein genetics seems to play an important role in addition to environmental factors; therefore, there seems to be child onset, early onset, and adult onset schizophrenia [3]. Hence, it is important to keep these factors in mind in complex-presenting cases. Recent research has also shown that DID can have similar etiologic factors as schizophrenia. For example, trauma can play a role in both conditions, thus sometimes obscuring diagnosis. In these scenarios it is important to rely on other factors such as age of onset, genetic family history, and presentation per DSM-5 diagnostic criteria. Hence it is important to be wary of the differences and similarities of both clinical presentations, including consideration of factors such as developmental history. Moreover, data show that there is an elevated occurrence of psychosis in DID patients, making it important to be vigilant that sometimes these disorders can co-occur [3, 4].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_15

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DSM-5 Criteria Vs Schizophrenia Vs DID DID diagnostic criteria per the DSM-5 describe that there is a disruption of identity by two or more different personalities that have discontinuity from one’s sense of self and is accompanied by changes in affect, cognition, and memory, with symptoms perceived by oneself or others. There can be recurrent gaps in recall of everyday events, traumatic events, or everyday activities, which are more severe than everyday forgetfulness. Moreover, these changes cause emotional distress and significant changes in social functioning. The DSM-5 added the modifier that these changes are not better explained by cultural beliefs. The symptoms are also not to be confused with fantasy play in children, and they cannot be an effect of substance use or other medical illness. In comparison, per DSM-5, diagnosis of schizophrenia is defined as two (or more) of symptoms such as delusions, hallucinations, disorganized speech, or grossly disorganized behaviors/catatonia, wherein each is present for at least 6 months and active symptoms should present for at least a 1 month period in these 6  months. Additionally, they should have negative symptoms such as apathy, avolition, or alogia. Similar to DID and other psychiatric conditions, significant social malfunctioning and emotional distress are also part of the diagnostic criteria for schizophrenia. The diagnostic criteria of these conditions show some areas of potential overlap in how patients may present. For example, gaps in recall supposedly signifying dissociation may be related to episodes of negative symptoms of psychosis, while hallucinations and delusions can be experienced in both DID and schizophrenia spectrum disorders. Hallucinations, in particular, have been compared across these and other conditions.

Auditory Hallucinations Distinguishing between dissociative and psychotic hallucinations is especially important at the outset of symptom presentation, as the treatments for each differ significantly (psychotherapy versus antipsychotics, respectively).

Epidemiology DID and Schizophrenia DID affects approximately 1–1.5% of the population and schizophrenia also affects about 1% of the general population [2, 5]. Despite these similar incidences in the population, schizophrenia has been studied much more comprehensively. The prevalence of dissociation in patients with schizophrenia as measured by Dissociation Experience scale was studied in one of the studies and found that schizophrenia spectrum patients scored higher on dissociation than healthy controls. However, further analysis due to large effect size

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shows that healthy adolescents also report dissociative symptoms similar to schizophrenia spectrum patients. More importantly, it also shows that schizophrenia spectrum patients actually scored significantly lower in comparison to healthy controls on dissociative-like symptoms once they were stabilized suggesting that dissociative-like symptoms can be high during the acute phase of psychosis but resolve as the patient is more stabilized. Another important factor to keep in mind is etiologic factors such as trauma, studies show that patients who have traumatic experiences are more likely to report dissociative symptoms in the schizophrenia spectrum group compared to those without traumatic experiences [6]. On the contrary, the same study shows that patients with DID are found to have first rank auditory hallucinations in at least 50–90% of the patients. Moreover, about 55% of patients experience delusions; however, bizarre delusions are less likely. Importantly, delusions of thought insertion or delusions of control are more common in patients with DID in comparison to schizophrenia patients wherein delusions can be persecutory or bizarre. In comparison to the general population, patients with DID report 0.5% first rank symptoms and patients with schizophrenia report 0.9% of first rank symptoms. Some similarities in DID patients is the presence of positive symptoms that are similar to schizophrenia. About 16–20% of patients with DID report visual hallucinations and about 70% have auditory hallucinations. Patients with DID have also shown negative symptoms even though it may not be as commonly seen as with patients with schizophrenia. For instance, patients with DID scored higher than schizophrenia on the general psychopathology scale on the PANSS questionnaire. Moreover, patients with DID and trauma also display catatonic symptoms in 68% of the patients and approximately half of these patients also had alexithymic symptoms. However, there are some differences, patients with DID have a much younger age of onset and often are child-like voices in comparison to patients with schizophrenia. More importantly the reality testing is intact many times as they alter through two or more personality types. Patients also display varied affect and cognition unlike schizophrenia patients wherein reality testing is limited [6].

 tiology/Risk Factors in DID Vs E Schizophrenia The widely accepted etiologies of schizophrenia (highly affected by genetic factors) and DID (largely rooted in trauma) contribute to these disorders’ characterizations as unconnected independent syndromes. However, there may be some common contributing factors to these seemingly disparate conditions, particularly because psychotic symp-

15  Dissociative Identity Disorder and Schizophrenia

toms and traumatic experiences can be present in both [3]. Some studies have even explored a potential causal link between traumatic events such as sexual abuse and the development of positive psychotic symptoms. Additionally, childhood experiences of maltreatment have been reported more frequently in psychotic patients compared to controls [7]. However, these preceding traumatic events have shown distinct relationships with dissociative and psychotic symptoms and disorders. Specifically, scores rating childhood trauma were associated with dissociative symptoms and dissociation scale scores, but not associated with core symptoms of schizophrenia. Investigation into these scales revealed a trauma-related dissociative subtype of schizophrenia [8]. It has been hypothesized that the presence of fixed false beliefs in both DID and schizophrenia may suggest common etiologic factors (i.e., a potential connection between childhood trauma and the development of delusional beliefs). However, the content of these delusions differs significantly between these conditions, detracting from the likelihood that similar delusions are held in both conditions [9].

Pathophysiology for DID Vs Schizophrenia

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 nvironmental Factors, Nutrition Status, E and Maternal Infections Familial societal and cultural factors play a role in the rise for traumatic experiences that are most commonly seen as an etiology for DID. Patients may have disrupted sense of self due to disruption of cognitive processes after enduring decoupling of psychological modes. However, these factors are sometimes similar for the rise of schizophrenia as well [11]. However, there is increased risk for schizophrenia in patients with prenatal infections since this increases proinflammatory cytokines in pregnancy. Urban areas are also more prone to schizophrenia in comparison to rural areas. Per literature review, none of these factors are etiologic in nature for DID even though symptoms may be similar and this is better explained by dimensional model and network structure model [12].

 etwork Structure Theory Vs Dimensional N Model

Network structure theory states that one symptom which is psychopathological in nature can cause other symptoms as well. There is high co-occurrence of schizophrenia and DID etiology is multifactorial, whereas psychosocial etiolo- DID due to this theory since there is a network of interactgies such as developmental traumatization and biological ing symptoms. Similarly other factors such as personality factors such as trauma generated responses are likely playing traits and environmental factors can influence these differa role in epigenetic mechanisms. There is no clear genetic ent networks and cause similar symptoms in different indilink that has been observed in patients with DID; however, viduals. The dimensional model states that problems in childhood adversity in particular has been seen as an impor- one domain can cause problems in another domain. For tant etiologic factor. instance, patients with DID present with dissociation, Schizophrenia, on the other hand, is more heritable in which can lead to impaired testing due to epigenetic faccomparison to DID and about 70% twin studies show herita- tors or network theory and cause psychotic symptoms bility. Moreover, genetic factors such as rare chromosomal eventually. Combining the effects of network and dimendeletions and duplications can increase risk for this disorder. sional models can explain why some symptoms can coSome genes that have an impact include disrupted-in-­ occur in both of these illnesses [6]. schizophrenia-­1 (DISC1), neuregulin-1 (NRG1) [10]. Refer to Fig. 15.1 wherein various stages of schizophreOther etiologic factors such as gender are also variable in nia exist as a syndrome rather than one illness as explained schizophrenia and DID. Schizophrenia is more often present by Ross et  al. (https://connect.springerpub.com/content/ in male and DID is more prevalent in females [11]. book/978-­0-­8261-­2318-­3/chapter/ch01).

Biological Factors

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Fig. 15.1  Varying stages of schizophrenia and the spectrum of positive vs. negative symptoms

Trauma History DID is generally thought to be caused by trauma and schizophrenia is thought to be caused by genetic factors; however, the biopsychosocial model shows both environmental and biological factors tend to have an impact on the etiology of both the illnesses. Moreover, trauma can result in similar symptoms in both DID and schizophrenia. More severe and early onset of abuse in childhood helps to differentiate DID with other illnesses. In most cases, childhood abuse and neglect were reported in more than 90–100% of the DID patients. Milder presentations of DID have covert trauma history and further analysis shows that there are dysfunctional communication or relationship issues within family members such as emotional neglect in these cases as well. More importantly, disorganized attachment style may increase the likelihood for DID. Pathophysiology for this explained by Bowlby wherein there are changes in the internal working models when a child is frightened by the caregiver there is an impending connection, which results in disorganized attachment. This initiates a belief within the child that they are different from the others and experience depersonalization or derealization. This alienation later gives rise to DID from the experiences of PTSD.  If relational support is absent then the child is unable to comprehend the traumatic experiences in a con-

structive manner. This is when affective states may become activated and inhibit the patient from integrating the trauma with other autobiographical experiences. Further traumatic experiences can make the child feel more isolated, the child’s ability to develop an ordinary sense of self in relation to the others is impaired giving rise to dissociative identities (Şar et al. [11].

Prognosis for DID Rather than SCZ The clinical prognosis for schizophrenia and DID, both more heavily stigmatized compared to many other mental health conditions, has improved in recent years with the development of greater insight into their etiologies. However, DID remains much less studied and represented by the literature. With the significant resources committed to the treatment of schizophrenia, therapeutic goals have developed from reducing symptoms to larger goals of reaching functional recovery and attaining better quality of life. Although outcomes for patients with schizophrenia are quite heterogeneous due to the multifactorial nature of the disease, recent literature supports a positive long-term prognosis in a moderate proportion of these patients. Upon review of multiple long-term studies, Vita et al. report that approximately half of schizophrenic patients experience significant improvement or

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recovery long term, though they note that such outcomes are obfuscated by the lack of a consistent, comprehensive definition for schizophrenia recovery. Specifically, outcome measures for successful treatment in schizophrenia should include improvement in psychosocial functioning, as interventions solely addressing schizophrenia symptoms fail to address the significant lifestyle contributions of psychosocial functioning and interpersonal relationships. Thus, it has been proven that a multifaceted approach to schizophrenia treatment, incorporating maintenance antipsychotic therapy and psychosocial interventions, is most effective for contributing to recovery and improving functional outcomes in patients. The prognosis of DID is less understood, though some efforts have been made to follow its trajectory in patients. In a study examining treatment progress of patients with dissociative disorders (DD), clinically significant general psychiatric and post-traumatic symptoms persisted after 30 months of treatment (though they did improve). When compared to older patients in this sample, younger patients were able to develop a more rapid response to treatment. Despite this increased rate of improved functioning, however, younger patients had higher levels of dissociation than older patients both before and after the 30-month treatment period [13]. Generally, the sparse data that have been collected have concluded that consideration of typical adolescent development, including the role of normative identity formation, is imperative in the treatment of young patients with DD in order to best understand their treatment trajectories. Further analysis has been conducted on clusters of DID symptoms as potential prognostic indicators. While some of this analysis is mainly guided by clinical experience, an arguably subjective basis, it provides important background when assessing patients’ potential responses to treatment. An example of classification of DID treatment responses is a system of three DID subgroups proposed by Loewenstein and Kluft [14, 15]. Prognoses were correlated with various characteristics of DID patients. For example, ability to judge and handle situations and minimal self-destructive behavior were correlated with positive response to treatment, whereas dysregulation of affect and impulsive behavior characterized patients with longer treatment regimens and more clinical admissions. The group with the worst prognosis tended to have distinctive patterns of attachment to their therapists (either excessive dependence on or detachment from the clinician) and features of psychotic, affective, and personality disorders. In one study, therapists specializing in DID and PTSD were surveyed for prognostic factors in stabilization-­ oriented treatment of these disorders, followed by prioritization of different factors and subsequent weighting of group judgments for clusters of factors [14]. This process resulted in eight clusters of prognostic factors, which were labeled as the following: lack of motivation, serious Axis I comorbidity, serious Axis II comorbidity, lack of healthy relationships, lack of healthy therapeutic relationships, poor attachment,

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self-destruction, and lack of other internal and external resources. The authors conclude that the factors within these clusters can be used as a checklist to categorize patients and tailor treatment toward specific goals within each cluster of symptoms. Again, the methodology of such a prognostic model is prone to bias, particularly due to the subjective nature of delineating features within categories, and has not been tested empirically as of yet. However, within the current ambiguous landscape of DID prognosis, these patterns observed through clinician experience are valuable information to consider in the context of a DID patient’s entire clinical picture. Thus, noticing patterns of patients’ treatment trajectories, and patterns observed to correlate with them, can inform clinicians’ focus on certain symptoms and the therapeutic approaches they take.

 linical Case Presentation for DID or C Schizophrenia Our case report shows a 50-year-old African American female with a history of comorbid anxiety disorder. She transitions from multiple personalities such as a 10-year-old child, a personality, which is a teenager and a male person. She reported that she became aware of her personalities after someone she knew told her about them. She reported that stressful situations could aggravate the changes in her personality. While changing from one personality to another she also had different affect, voice change, and cognition according to her age group. She was hospitalized after isolating herself and being suicidal after realizing she was different personalities. Her speech would be more pressured or changed to a male voice when she changed into another personality while on the inpatient unit, she would also dress accordingly. She also reported hearing voices when she altered from one personality to another and paranoid schizophrenia was considered as a differential; however, she did not endorse delusions or negative symptoms for a period of 6  months or more. She also had intact reality testing with good insight into her hallucinations, and denied any delusions. The treatment included psychotherapy, which was at least for 6 months. She was also treated with drugs to help with anxiety and depression. The patient was prescribed escitalopram 15 mg PO daily for mood. After 6 months, the patient continued to have alternate personalities; however, her anxiety has improved overtime.

Diagnosis Clinical Interview Thorough history and physical exam and use of clinical interview including DSM 5 criteria is the main way to diag-

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98 Table 15.1  Interview questions to consider for dissociative identity disorder vs. schizophrenia Open-ended Forgetful events Objects missing/present Different handwriting Voices “The other person” Collateral history

Memory problems? You behave differently in different circumstances You either miss certain events or places or they are present at odd times You find you write differently at different times and can’t recall the handwriting at times You may hear auditory hallucinations You may feel like another person altogether or “not you” Family or friends may tell you about various events that you may be forgetful about or didn’t know has occurred

nose DID (refer to Table 15.1). Additional collateral information from family/friends if possible, history of trauma, developmental stressors, and other substance use and medical comorbidities need to be considered to rule out differential diagnoses. Additionally, the following tools can be used to assess for DID in patients with other comorbidities: the Dissociative Experiences Scale, a 28-item self-report tool; the Dissociation Questionnaire, a self-report tool with 63 questions; and the Difficulties in Emotion Regulation Scale (DERS), a 36-­question self-report tool. Questions to consider during clinical interview (https:// connect.springerpub.com/content/sgremdr/9/2/114).

Differential Diagnosis The reported case of above 50-year-old woman with a history covert child abuse as later determined through history taking demonstrates a case for dissociative personality disorder. Some differential diagnosis as discussed included but not limited to schizophrenia, schizoaffective disorder, possible borderline or histrionic personality disorder due to changes in affect and personality, Bipolar disorder (especially Bipolar II disorder), Asperger syndrome, or even Munchausen syndrome in some cases. Important to consider any substance abuse LSD, mescaline, or peyote. Additionally, other differentials include medical conditions that can present similarly such as epilepsy and traumatic brain injuries. [16, 17].

Treatment Options Pharmacological and Psychotherapy Psychopharmacological treatments are not first line for DID and they have not shown to improve prognosis for DID per literature review. However, psychotropic medications such as antipsychotics, stimulants, or antidepressants may be used

for symptom improvement. Antipsychotics such as atypical antipsychotics may be used in co-occurring schizophrenia and DID. Three types of therapy that can be used for DID are psychodynamic psychotherapy that focuses on reducing self-­ injurious behaviors, work on traumatic memories by processing them via trauma-based approaches. Final step can include understanding self as a whole and in line with the world. PTSD is usually comorbid and results in DID as discussed above and trauma-focused cognitive behavioral therapy and dialectical behavioral therapy (DBT) can be helpful in overlapping personality disorders. Other therapeutic options include hypnosis and Eye Movement Desensitization and Reprocessing (EMDR).[18].

Conclusion DID and schizophrenia, despite their apparent differences (as a dissociative and psychotic disorder, respectively), have several similarities warranting consideration in the treatment of both conditions.

References 1. Laddis A, Dell PF.  Dissociation and psychosis in dissociative identity disorder and schizophrenia. J Trauma Dissociation. 2012;13(4):397–413. 2. Dorahy MJ, Brand BL, Sar V, Krüger C, Stavropoulos P, Martínez-­ Taboas A, Lewis-Fernández R, Middleton W.  Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. 3. Foote B, Park J. Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues. Curr Psychiatry Rep. 2008;10(3):217–22. 4. Tschöke S, Steinert T.  Dissoziative Identitätsstörung oder Schizophrenie? Fortschr Neurol Psychiatr. 2010;78(1): 33–7. 5. Mitra P, Jain A.  Dissociative identity disorder. In: StatPearls. StatPearls Publishing; 2021. 6. Renard SB, Huntjens RJ, Lysaker PH, Moskowitz A, Aleman A, Pijnenborg GH.  Unique and overlapping symptoms in schizophrenia spectrum and dissociative disorders in relation to models of psychopathology: a systematic review. Schizophr Bull. 2017;43(1):108–21. https://doi.org/10.1093/schbul/sbw063. 7. Khosravi M, Bakhshani N-M, Kamangar N. Dissociation as a causal pathway from sexual abuse to positive symptoms in the spectrum of psychotic disorders. BMC Psychiatry. 2021;21(1):1–12. 8. Sar V, Taycan O, Bolat N, Ozmen M, Duran A, Oztürk E, Ertem-­ Vehid H.  Childhood trauma and dissociation in schizophrenia. Psychopathology. 2010;43(1):33–40. 9. Martinez AP, Dorahy MJ, Nesbit A, Palmer R, Middleton W. Delusional beliefs and their characteristics: a comparative study between dissociative identity disorder and schizophrenia spectrum disorders. J Psychiatr Res. 2020;131:263–8. 10. Moran P, Stokes J, Marr J, Bock G, Desbonnet L, Waddington J, O’Tuathaigh C.  Gene × environment interactions in schizophrenia: evidence from genetic mouse models. Neural Plast. 2016;2016:2173748. https://doi.org/10.1155/2016/2173748.

15  Dissociative Identity Disorder and Schizophrenia 11. Şar V, Dorahy MJ, Krüger C.  Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychol Res Behav Manag. 2017;10:137–46. https://doi. org/10.2147/PRBM.S113743. PMID: 28496375; PMCID: PMC5422461. 12. Khandaker GM, Zimbron J, Lewis G, Jones PB. Prenatal maternal infection, neurodevelopment and adult schizophrenia: a systematic review of population-based studies. Psychol Med. 2013;43(2):239– 57. https://doi.org/10.1017/S0033291712000736. 13. Myrick AC, Brand BL, McNary SW, Classen CC, Lanius R, Loewenstein RJ, Pain C, Putnam FW.  An exploration of young adults’ progress in treatment for dissociative disorder. J Trauma Dissociation. 2012;13(5):582–95.

99 14. Baars EW, van der Hart O, Nijenhuis ERS, Chu JA, Glas G, Draijer N. Predicting stabilizing treatment outcomes for complex posttraumatic stress disorder and dissociative identity disorder: an expertise-­ based prognostic model. J Trauma Dissociation. 2011;12(1):67–87. 15. Kluft RP.  Dissociative identity disorder. In: Michelson LK, Ray WJ, editors. Handbook of dissociation: theoretical, empirical, and clinical perspectives. Springer US. 1996. pp. 337–366. 16. Shibayama M. [Differential diagnosis between dissociative disorders and schizophrenia]. Seishin Shinkeigaku Zasshi. 2011;113(9):906–911. Japanese. PMID: 22117396. 17. Rathbun JM, Rustagi PK. Differential diagnosis of schizophrenia and multiple personality disorder. Am J Psychiatry. 1990;147(3):375. https://doi.org/10.1176/ajp.147.3.375a. PMID: 2309967.

Child and Adolescent DID

16

Young Jo, Neena E. Thomas, and Sara Khan

Introduction The effects of trauma on children and adolescents have recently become a subject of interest in the field of neuroscience. Scientific developments have noted brain abnormalities in children as a result of physical abuse, sexual abuse, verbal abuse, and neglect [1]. Events such as natural disasters, terrorism, displacement, and war have increased awareness among mental health professionals [2]. A further developed interest in dissociative disorders found in children and adolescents with a significant history of trauma has been recently noted. Dissociative identity disorder (DID) was initially documented in the 1980s by Fagan and McMahon in four children and was called “incipient multiple personality disorder” [3]. In 1992, Hornstein and Putnam completed a study on 64 children from 2 sites and determined that many of the patients exhibited symptoms of dissociation, including “divided identities.” [4]. DID is a rare condition in children and adolescents. The prevalence of DID can be estimated at 3.3% based on a study assessing fantasy in subjects aged 8–1 [5].

Theory of Dissociated Identity Disorder There are various theories on the development of dissociative disorders in children and adolescents. One prominent theory developed by Van Der Hart, Nijenhuis and Steele is the structural dissociation model [6]. The theory proposes that during trauma, the brain’s adaptive system and defensive system become disconnected. With more trauma, the personY. Jo (*) Department of Child and Adolescent Psychiatry, University of Florida, Gainesville, FL, USA e-mail: [email protected] N. E. Thomas Pontiac General Hospital, Pontiac, MI, USA S. Khan University of South Florida, Tampa, FL, USA e-mail: [email protected]

ality is split into further fragments called secondary and tertiary dissociation. Other clinicians believe this theory follows a lack of “developmental integration” rather than “splitting” [7]. A second theory is that shame underlies severe dissociative pathology. A child who has experienced sexual abuse may avoid the pain of shame by adopting a different self-­ conception [8]. Without support, children and adolescents may incorporate shame-based concepts of self leading to a different self-concept [9]. A third theory proposes that a constant traumatic environment causes a child to remain in rigid and impermeable states [10]. Children and adolescents who grow up with attentive and loving parents allow a child to independently self-regulate. Lastly, there is research that suggests a childhood history of neglect contributes to dissociation symptoms. Longitudinal research has found that disorganized attachment styles between children and parents can predict dissociation in teenagers [11].

Clinical Presentation of DID Five classes of symptoms related to dissociation have been identified; these include perplexing shifts in consciousness, vivid hallucinatory experiences, marked fluctuations in knowledge, moods, or patterns of behavior and relating, perplexing memory lapses for one’s own behavior or recently experienced events, and abnormal somatic experiences [12]. Perplexing shifts in consciousness refers to lapses in attention and focus. The child may appear to be in a trancelike state and unarousable. While this behavior may appear similar to absence seizures or attention-deficit disorders, the child may report being in an imaginary world during the lapse. Children may be diagnosed with psychogenic nonepileptic seizures (PNES) due to the lack of findings associated with epilepsy such as abnormal EEG findings and postictal state [13]. Some children may report changes in their sense of identity, such as an angry or upset state. A case series of DID in Korean adolescents reported the emergence of vio-

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lent identity states in both patients during recollection of past traumatic events [14]. Hallucinations may also be reported among patients with dissociative disorders. When assessing the presence of auditory hallucinations in children, it is important to minimize the risk of misinterpretation. Children may describe the voices of imaginary friends in their mind, which is a part of normal development up to age 8 and not the same as auditory hallucinations [15]. Marked fluctuations in knowledge may be triggered by an internal or external stimulus associated with a past traumatic experience [16]. However, these changes may also be unpredictable and seemingly come about without warning. Cognitive skill may also undergo fluctuations, resulting in inconsistencies in academic performance. Memory lapses may include not recognizing caregivers, difficulty remembering events during an angry state, or forgetting that they completed a school assignment. Somatic symptoms are common in children with dissociative disorders. These symptoms may include pain at a previous site of injury inflicted by an abusive caregiver or nighttime enuresis or encopresis due to conditioned avoidance responses in the anogenital areas due to past sexual abuse [12].

Diagnosis Various assessment tools have been developed to aid in the diagnosis of dissociative disorders in children and adolescents. The assessment tools vary in design, some utilize the ratings of observers while others are based on self-report data from the patient. The Child Dissociative Checklist (CDC) is a 20-question screening tool designed that employs the responses of parents or other observers. The checklist asks parents or observers to rate from 0 to 2 how often a child exhibits specific behaviors, including vivid imaginary friends, sleep disruptions, and sexual precocity [17]. Another screening instrument is the Children’s Dissociative Experience Scale and Traumatic Stress Inventory, which directly asks latency age children to rate how alike or different they are to described children with dissociative traits [12]. A similar tool was developed for adolescents, the Adolescent Dissociative Experiences Scale (A-DES), which asks adolescents to rate how often they experience dissociative symptoms such as amnesia, depersonalization, and fantasy involvement in various contexts such as family and school [18]. An adolescent version of the Multidimensional Inventory of Dissociation (MID), originally designed for adult patients, has also been developed. The MID for adolescent patients includes items that are more age-congruent to facilitate self-report by adolescent patients [19].

Y. Jo et al.

These screening measures serve as useful tools for the initial assessment of children or adolescents who may have DID, but the definitive diagnosis of DID requires a comprehensive clinical interview that evaluates children and adolescents for characteristic symptoms [7]. A complete diagnostic workup for DID includes an evaluation from psychiatrist as well as psychologists. It is not unreasonable to require longitudinal assessments to confirm diagnosis of DID.  There must also be neurological examinations and a drug screen to rule out other medical conditions, which explain the dissociative symptoms.

Differential Diagnoses Post-traumatic stress disorder (PTSD) may occur after indirectly or directly experienced traumatic events, which can include threatened or actual experience of any form of assault. As described earlier, exposure to trauma is understood to be a major etiology behind DID.  Several symptoms of PTSD including negative alterations in cognition and dissociative reactions such as flashbacks are also similar to clinical presentations of DID. The dissociative subtype of PTSD specifically involves persistent and recurrent symptoms of personalization and derealization. Thus, it is important to evaluate any patient presenting with dissociative symptoms for PTSD. Moreover, the preschool subtype of PTSD, designed for diagnosing children under the age of 6, includes extreme temper tantrums as a possible symptom. Extreme temper tantrums may resemble dissociative states in which the individual assumes an irritable and aggressive personality. Dissociation symptoms may also be secondary to psychosis as part of a psychotic illness or a severe mood disorder with psychotic features. Those diagnoses must be ruled out prior to confirming diagnosis of DID. Borderline personality disorder (BPD), which involves a pattern of unstable interpersonal relationships alternating between idealization and devaluation, identity disturbances including unstable self-image, recurrent suicidal behavior, and marked impulsivity, is another differential diagnosis. Similar to DID, BPD has an association with childhood abuse. While BPD and other personality disorders are generally diagnosed in adults, several studies have assessed children and adolescents who met the full criteria for BPD. Due to the limited literature, specific symptomatology of BPD in children and adolescents cannot be deduced. However, the history of unstable interpersonal relationships and affect lability associated with BPD may be similar in presentation to patients with DID.  Stress-related dissociative symptoms such as depersonalization have also been associated with BPD, and individuals may self-mutilate during these periods to bring relief [20].

16  Child and Adolescent DID

Management Current approaches for treatment of DID in children and adolescents involve establishing safety and psychotherapy. It is paramount to confirm safety for children and adolescents with DID as they often present with suicidal ideation and self-injurious behaviors. After stabilization, the goal of therapy is to create a strong therapeutic alliance and work on traumatic memories in an attempt to tolerate and process past trauma. Trauma-based cognitive behavioral therapy, psychodynamic psychotherapy, and dialectical behavioral ­ therapy are all good modalities of therapy to consider. Another evidence-­validated form of treatment is child–parent psychotherapy. As we understand trauma to be a key component in development of DID, it is possible that early clinical interventions via CBT may be helpful to prevent not only PTSD but also DID. However, this area requires further research [21]. There are no medications indicated for treatment of DID at this time. Current research shows no efficacy in several medication classes, including antipsychotics and mood stabilizers [22]. Another treatment modality is eye movement desensitization and reprocessing (EMDR), which has some evidence in treatment of PTSD.  However, patients must be stable and competent with using coping skills or grounding techniques [23].

Commentary Dissociative identity disorder, commonly known to patients as multiple personality disorder, has been depicted and sensationalized in popular media. With the advent of social media, self-diagnosis of psychiatric conditions have become common, especially in the more impressionable child and adolescent population. One of the more popular self-­diagnosed conditions in this group is DID. While it is important to validate a patient’s lived-in experience, presence of dissociative symptoms we have detailed earlier does not mean the patient automatically meets criteria for diagnosis. It is important to assess for and rule out more common psychiatric comorbidities prior to diagnosing children with DID.

References 1. Teicher M, Samson JA, Polcari A, McGreenery CE.  Sticks and stones and hurtful words. Relative effects of various form of childhood maltreatment. Am J Psychiatry. 2006;163:993–1000. 2. Brom D, Pat-Horenczyk R, Ford JD, editors. Treating traumatized children: risk, resilience and recovery. London: Routledge; 2008. p. 225–39. 3. Fagan J, McMahon PP. Incipient multiple personality in children. J Nerv Ment Dis. 1984;172:26–36.

103 4. Hornstein NL, Putnam FW.  Clinical phenomenology of child and adolescent dissociative disorders. J Am Acad Child Adolesc Psychiatry. 1992;31:1077–85. 5. Donfrancesco R, Vezzani C, Pinto G, Bigozzi L, Dibenedetto A, Melegari MG, Gregori P, Andriola E, Di Roma F, Renzi A, Tambelli R, Di Trani M.  The validation of the free fantasy questionnaire for children and adolescents: from imaginary playmate to “Dreamtime”. Front Psychol. 2019;10:1343. 6. Van Der Hart O, Nijenhuis ERS, Steele K. The haunted self: structural dissociation and the treatment of chronic traumatization. New York: W. W. Norton; 2006. 7. Lewis M.  Handbook of developmental psychopathology, 3rd ed. Springer; 2014. 8. Lewis M.  Shame: the exposed self. New  York: The Free Press; 1992. 9. Feiring C, Taska L, Lewis M. A process model for understanding adaptation to sexual abuse: the role of shame in defining stigmatization. Child Abuse Negl. 1996;20(8):767–92. 10. Putnam FW. Dissociation in children and adolescents: a developmental approach. New York: Guilford Press; 1997. 11. Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egeland B.  Development and the fragmented self: longitudinal study of dissociative symptomatology in a non-clinical sample. Dev Psychopathol. 1997;9:855–979. 12. Silberg JL. The child survivor: healing developmental trauma and dissociation. New York: Routledge; 2013. 13. Perez DL, LaFrance WC Jr. Nonepileptic seizures: an updated review. CNS Spectr. 2016;21(3):239–46. https://doi.org/10.1017/ S109285291600002X. 14. Kim I, Kim D, Jung HJ. Dissociative identity disorders in Korea: two recent cases. Psychiatry Investig. 2016;13(2):250–2. https:// doi.org/10.4306/pi.2016.13.2.250. 15. Taylor M.  Imaginary companions and the children who create them. New York: Oxford University; 1999. 16. Grimminck E. Emma (6 to 9 years old)–from kid actress to healthy child: treatment of the early sexual abuse led to integration. In: Wieland S, editor. Dissociation in traumatized children and adolescents: theory and clinical interventions. New York: Routledge; 2011. p. 75–96. 17. Putnam FW, Helmers K, Trickett PK.  Development, reliability, and validity of a child dissociation scale. Child Abuse Negl. 1993;17(6):731–41. https://doi.org/10.1016/ s0145-­2134(08)80004-­x. 18. Armstrong J, Putnam FW, Carlson E, Libero D, Smith S.  Development and validation of a measure of adolescent dissociation: the adolescent dissociative experience scale. J Nerv Ment Dis. 1997;185(8):491–7. https://doi. org/10.1097/00005053-­199708000-­00003. 19. Dell PF.  The multidimensional inventory of dissociation (MID): a comprehensive measure of pathological dissociation. J Trauma Dissociation. 2006;7(2):77–106. https://doi.org/10.1300/ J229v07n02_06. 20. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. 2013. https://doi.org/10.1176/appi. books.9780890425596. 21. Qi W, Gevonden M, Shalev A. Prevention of post-traumatic stress disorder after trauma: current evidence and future directions. Curr Psychiatry Rep. 2016;18(2):20. https://doi.org/10.1007/ s11920-­015-­0655-­0. 22. Dorahy MJ, Brand BL, Sar V, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. https://doi.org/10.1177/0004867414527523. 23. Fine CG, Berkowitz AS. The wreathing protocol: the imbrication of hypnosis and EMDR in the treatment of dissociative identity disorder and other dissociative responses. Eye movement desensitization reprocessing. Am J Clin Hypn. 2001;43(3–4):275–90. https://doi. org/10.1080/00029157.2001.10404282.

DID in Male Patients

17

Sindhura Kompella, Felicia Gallucci, Sara Jones, Joseph Ikekwere, and George Ling

Introduction Dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD), has long been considered a disease that prototypically affects females. In media representation and case reports of DID, the phenotypic DID patient is white, North American, 30 years old, and female [1]. While exact figures vary, male patients have been reported to account for just 5–30% of the DID patient population, with most studies reporting that approximately 10% of DID patients are male [2–10]. As a result, males are largely neglected in the DID literature. This chapter will focus on differences in presentation of DID between males and females, as well as risk factors for the development of DID in male patients. Additionally, this chapter will offer guidance on screening and treating male patients for DID.

Epidemiology Community-based studies on DID present varying estimates of DID prevalence, with some research suggesting that the prevalence of DID in patients in outpatient psychiatric care is as high as 6% [11]. The prevalence of DID in the general population, when accounting for methodological differences in study designs, is believed to be approximately 1% [12]. However, prior studies have consistently found DID to be significantly more common in female patients, with the reported ratio of females to males ranging from 4:1 to 9:1

[13]. Accordingly, the prevalence of DID in the general male population is believed to be significantly less than the previously cited 1% population prevalence. Of note, research indicates that male and female DID patients do not differ significantly on other demographic factors, including age at presentation and socioeconomic status [14]. While there is a clear difference in DID prevalence between genders, the reason for this difference is not particularly well understood. As we will explore in this chapter, there are several different explanations that may account for the lower prevalence of DID in men. In particular, the gender discrepancy may be explained by clinician and societal perceptions of DID as a female disease. Alternatively, it is also possible that the prevalence of DID is truly lower in male patients due to differing rates of childhood victimization and differential exposure to risk factors.

Risk Factors for DID in Men The prevalence of childhood abuse does not vary between male and female DID patients [14]. About 45–50% heritability was found to be the case with the patients. However, there is no reported association of DID and family history. DID is highly comorbid with other psychiatric conditions, including depression, PTSD, anxiety disorders, somatoform disorders, and functional neurological disorder [12]. For male patients, the average time from presentation to diagnosis of DID is 4.2 years [13].

Locations of Presentation S. Kompella (*) · F. Gallucci · S. Jones Department of Psychiatry, University of Miami, Miller School of Medicine, Miami, FL, USA J. Ikekwere Department of Psychiatry, University of Illinois, Chicago, IL, USA G. Ling Southwest Psychiatric Services, Orland Park, IL, USA e-mail: [email protected]

Male DID patients are often encountered in criminal justice and substance use treatment environments [15]. One study found that 47% of male DID patients reported prior incarceration for criminal activity [14]. Another study reported that male DID patients were incarcerated at a rate of 29%, compared to 10% in female DID patients [13]. One explana-

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tion for these presentations found in male DID patients compared to females is related to the symptomatology that predominantly characterizes their past trauma. Men often present with rage, fear, and dissociation possibly precipitating substance use and/or incarceration in comparison to female DID patients who present with higher rates of self-­ injurious behavior [13, 16]. Female DID patients, therefore, are often encountered in inpatient psychiatric settings, particularly those of high acuity [17].

Symptomatology at Presentation Males with DID are less likely to exhibit somatic symptoms, phobias, obsessive-compulsive symptoms, self-mutilation, and disordered eating [14]. Males are more likely to exhibit alcohol use disorder and criminal behavior. Moreover, patients with DID regardless of male or female has same etiology such as childhood trauma or emotional neglect due to either physical/sexual abuse or dysfunctional family [11, 14]. Males are less likely to be diagnosed with an affective disorder and prescribed medication, but actual depressive symptoms do not vary significantly between genders. Females with DID are also more likely to have more personalities when compared to males with DID [14, 18]. Males may have a less “florid” presentation of DID, as they typically experience fewer personalities and are less likely to display notable differences between personalities, such as accent and posture [14]. According to one case study, androgens had an impact on mood and it has been shown that increases in testosterone levels are linked to an increase in energy, irritability, violence, and impulsivity. Especially, since testosterone acts on the subcortical regions of the amygdala and hippocampus, which is an emotion regulation center for aggression. High levels of testosterone have also shown to downregulate functions of the prefrontal cortex wherein regulation of aggression occurs thus leaving patients uninhibited and more aggressive. More research needs to be done to evaluate the relationship of testosterone on dissociative symptoms and trauma. It is also relevant to explore such changes in transgender population and LGBTQ population since discrimination and traumatization are already high in this group and there is chance for emotion dysregulation and emergence of more severe dissociative phenomenon as a result of severe trauma [19].

Diagnosis of DID in Men Because the presentation of DID in males may be less striking than its presentation in females, it is believed that DID in males is underdiagnosed. Even in patients in whom DID is not initially suspected, it has been recommended to screen all male substance use patients for dissociative symptoms and

histories of child abuse [14]. Clinicians should also have a low-threshold for screening males who are incarcerated [13]. Screening may be accomplished using the Dissociative Experiences Scale (DES) [20]. Clinicians may also screen patients for dissociation with simple questions such as, “Do you have any periods of time that you cannot account for?” and “Do you ever feel as if your body is not yours?” The Structured Interview of Reported Symptoms (SIRS), along with its trauma index, can be reliably used to distinguish DID from patients who may be feigning DID [12, 21].

Treatment of DID in Men The standard of care for DID patients of any gender is phasic trauma therapy, focused on establishing safety and stability, maintaining safety and stability while resolving trauma-­ related emotions and behaviors, and integration of identities in order to live without relying on dissociation as a coping mechanism [12]. There is no specific role for pharmacotherapy in the treatment of DID, except for treating comorbid conditions. Men with DID report significant burdens from stigma and shame related to their diagnosis, in addition to feeling gender-­ related pressures that prevent them from seeking treatment [22]. Clinicians should be aware of these concerns and appropriately validate the lived experiences of male DID patients. Overall, literature lacks randomized controlled studies in assessing treatment efficacies in DID patients, let alone gender-specific treatment recommendations. These gaps in research highlight the importance of first identifying DID patients by screening and assessing for DID in all patient populations, which in turn can assist in expanding treatment-based research.

Men in the Sociocognitive Model According to the sociocognitive model, patients with DID are enacting a socially constructed role. This model also includes the belief that DID can be created iatrogenically by suggestive therapies. Under this model, the low reported prevalence of men with DID would be a direct result of the portrayal of the typical DID patient as female. The expectation that primarily females experience DID would thus lead fewer male patients to fulfill that “role.”

Men in the Trauma Model According to the trauma model of DID, DID is a direct result of experiencing severe childhood trauma. In this model, dissociation and amnesia arise as coping mechanisms that persist into adulthood.

17  DID in Male Patients

Studies have reported that child abuse, particularly sexual abuse, is more frequently perpetrated against female children [23]. This discrepancy may somewhat account for the lower prevalence of DID in males. Alternatively, it is also possible that men are less willing to both disclose trauma and disclose DID symptoms, thus resulting in a lower rate of diagnosis.

Conclusion Male patients account for approximately 10% of DID cases, but they are believed to be underdiagnosed. Childhood sexual abuse is correlated with higher levels of dissociation. Male patients with DID may present more subtlety than female patients and, in some settings, screening for dissociative symptoms is warranted. Recommended ­treatment for male patients with DID does not differ significantly from recommended treatment for female patients.

References 1. Acocella JR.  Creating hysteria: women and multiple personality disorder. 1st ed. San Francisco: Jossey-Bass Publishers; 1999. 2. Boon S, Draijer N.  Multiple personality disorder in the Netherlands: a clinical investigation of 71 patients. Am J Psychiatry. 1993;150(3):489–94. https://doi.org/10.1176/ ajp.150.3.489. 3. Ellason JW, Ross CA, Fuchs DL. Lifetime axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry. 1996;59(3):255–66. https://doi.org/10.1521/00332747. 1996.11024766. 4. Modestin J, Ebner G, Junghan M, Erni T.  Dissociative experiences and dissociative disorders in acute psychiatric inpatients. Compr Psychiatry. 1996;37(5):355–61. https://doi.org/10.1016/ S0010-­440X(96)90017-­6. 5. Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM.  The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry. 1986;47(6):285–93. 6. Ross CA, Miller SD, Reagor P, Bjornson L, Fraser GA, Andersen G. Structured interview data on 102 cases of multiple personality disorder from four centers. Am J Psychiatry. 1990;147(5):596–601. https://doi.org/10.1176/ajp.147.5.596. 7. Şar V, Tutkun H, Alyanak B, Bakim B, Baral I.  Frequency of dissociative disorders among psychiatric outpatients in Turkey. Compr Psychiatry. 2000;41(3):216–22. https://doi.org/10.1016/ S0010-­440X(00)90050-­6.

107 8. Şar V, Yargiç LI, Tutkun H. Structured interview data on 35 cases of dissociative identity disorder in Turkey. Am J Psychiatry. 1996;153(10):1329–33. https://doi.org/10.1176/ajp.153.10.1329. 9. Saxe GN, Van Der Kolk BA, Berkowitz R, Chinman G, Hall K, Lieberg G, Schwartz J.  Dissociative disorders in psychiatric inpatients. Am J Psychiatry. 1993;150(7):1037–42. https://doi. org/10.1176/ajp.150.7.1037. 10. Tutkun H, Sar V, Yargiç LI, Özpulat T, Yanik M, Kiziltan E. Frequency of dissociative disorders among psychiatric inpatients in a Turkish University Clinic. Am J Psychiatry. 1998;155(6):800– 5. https://doi.org/10.1176/ajp.155.6.800. 11. Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D. Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry. 2006;163(4):623–9. https://doi.org/10.1176/ajp.2006.163.4.623. 12. Dorahy MJ, Brand BL, Şar V, Krüger C, Stavropoulos P, Martínez-­ Taboas A, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. https://doi. org/10.1177/0004867414527523. 13. Ross CA, Norton GR.  Differences between men and women with multiple personality disorder. Hosp Community Psychiatry. 1989;40(2):186–8. https://doi.org/10.1176/ps.40.2.186. 14. Loewenstein RJ, Putnam FW. The clinical phenomenology of males with MPD: a report of 21 cases. Dissociation. 1990;3(3):135–43. 15. Lewis DO, Yeager CA, Swica Y, Pincus JH, Lewis M.  Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. Am J Psychiatry. 1997;154(12):1703– 10. https://doi.org/10.1176/ajp.154.12.1703. 16. Sigurdardottir S, Halldorsdottir S, Bender SS.  Deep and almost unbearable suffering: consequences of childhood sexual abuse for men’s health and well-being. Scand J Caring Sci. 2012;26(4):688–97. 17. Sar V, Akyüz G, Dogan O.  Prevalence of dissociative disorders among women in the general population. Psychiatry Res. 2006;149(1):169–76. https://doi.org/10.1016/j. psychres.2006.01.005. 18. Bliss EL. A symptom profile of patients with multiple personalities, including MMPI results. J Nerv Ment Dis. 1984;172(4):197–202. https://doi.org/10.1097/00005053-­198404000-­00002. 19. Mun M, Gautam M, Maan R, Krayem B.  An increased presence of male personalities in dissociative identity disorder after initiating testosterone therapy. Case Rep Psychiatry. 2020;2020:8839984. https://doi.org/10.1155/2020/8839984. 20. Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis. 1986;174(12):727–35. https://doi.org/10.1097/00005053-­198612000-­00004. 21. Brand BL, Tursich M, Tzall D, Loewenstein RJ.  Utility of the SIRS-2  in distinguishing genuine from simulated dissociative identity disorder. Psychol Trauma. 2014;6(4):308–17. https://doi. org/10.1037/a0036064. 22. Zeligman M, Greene JH, Hundley G, Graham JM, Spann S, Bickley E, Bloom Z.  Lived experiences of men with dissociative identity disorder. Adultspan J. 2017;16(2):65–79. https://doi.org/10.1002/ adsp.12036. 23. Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-­ Kranenburg MJ.  A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011;16(2):79–101. https://doi.org/10.1177/1077559511403920.

DID in Borderline Personality Disorder

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Sindhura Kompella and George Ling

Introduction Dissociative identity disorder and borderline personality disorder have been documented to have similar psychopathology and share many core features such as emotional dysregulation and dissociation, hence, it is important to be able to distinguish both illnesses so misdiagnosis is limited [1]. This is specifically difficult in the adult inpatient population where more than 55% of patients diagnosed with borderline personality disorder also meet criteria for dissociative identity disorder on the Dissociative Disorders Interview scale, whereas only 22% of non-BPD patients meet the criteria [2]. Moreover, trauma, as seen in many etiology factors for DID, plays a significant role in disease initiation. Similarly in patients with borderline personality disorder, trauma also plays a key role in emotion regulation and splitting traits. According to literature review, about 79% of borderline personality disorder had traumatic experiences and about 55% of the same subset in this population group have complex PTSD. Similarly, 41% of patients with BPD also experience DID [3]. The pathology appears to be related to the dysregulation of negative emotions and dissociation, which occur as protective instincts in response to trauma. Consequently, we observe a high comorbidity of BPD in the patient population with DID.  Importantly, resilience and being less skilled at management of trauma-related emotions appears to be one of the mechanisms by which dissociative symptoms ensue according to Brand et al. [4, 5]. Therefore, it is important to keep in mind that these illnesses can co-occur and for clinicians to be vigilant about impulsive behaviors and self-­ injurious behaviors in the DID population group. This can S. Kompella (*) Department of Psychiatry, University of Miami, Miller School of Medicine, Miami, FL, USA Aventura, FL, USA G. Ling Department of Psychiatry, University of Miami, Miller School of Medicine, Miami, FL, USA e-mail: [email protected]

play a significant role in reducing hospitalizations and readmission rates, although studies need to be done to investigate this further.

Epidemiology The largest adult survey in the United States considered to capture criterion for borderline personality disorder is the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), with its latest wave (NESARC-III) surveyed between 2012 and 2013, during the era of DSM-IV.  Grilo and colleagues [6] estimated that out of 36,309 interviewed respondents, 2171 (6%) met at least 5 out of 9 DSM-IV criteria for borderline personality disorder. This largely matches estimates in NESARC Wave II conducted between 2004 and 2005, which estimated a lifetime prevalence of 5.9% in 34,653 interviewed respondents, although a more stringent criteria applied by Trull and colleagues estimated that the prevalence was closer to 2.7% [7, 8]. Previous estimates in the DSM-IV era have suggested that community lifetime prevalence of borderline personality disorder ranges from 0.5 to 1.8%, although the most cited range in the literature appears to be 1–3% ([9–13]; Samuels et al.). Lifetime prevalence of dissociative symptoms has been estimated to reach 20% in the general population. The lifetime prevalence for DID is estimated at 1% [2]. A New York City general population study showed 9.1% prevalence of any dissociative disorder (DSM-IV), evenly distributed between male and female, and a 1.5% prevalence of DID in the general population, evenly distributed between males and females [10, 11]. In clinical practice, borderline personality disorder has historically been accepted as the most common personality disorder, with significantly increased prevalence in the clinical vs general population, and recorded as significantly more in women vs men [14]. A 2009 outpatient review estimates that about 59–77% of diagnosed borderline personality dis-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_18

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order patients have a diagnosed dissociative disorder, with 10–24% having a diagnosis of DID [15]. In inpatient practice, a 2000 McLean inpatient study reported 68% prevalence of severe dissociative symptoms in diagnosed borderline personality disorder patients [16, 17]. Prevalence of dissociative disorders in international psychiatric populations is 10% with a range of 4.3–35.7%, 5% prevalence of DID [18]. Foote and colleagues [19] noted the prevalence of DID to be 6% in a study of inner city, ­psychiatric outpatients. Among adult psychiatric inpatients, estimates of prevalence have varied from 0.9 to 5% [20–22].

Etiology/Risk Factors As described earlier, trauma and attachment difficulties in early childhood play a significant role in initiating dissociative personality disorder since they contribute to difficulties with effectively managing emotion regulation. Individuals with DID have reported that childhood physical abuse is about 95–97% according to one article in comparison to about 80–96% in borderline personality disorder patients. A significant difference between the trauma in DID vs borderline personality disorder is that it may occur at an earlier age and can be more severe traumatic experiences have been reported. Similarly, emotion dysregulation is a core feature in both illnesses and impairment in identity with poor self-image is noted in both illnesses according to the study by Brand et al. [4, 5]. Hence, patients with BPD are diagnosed with DID in about 30–70% of the times and likewise DID is seen in patients with BPD in about 40–70% of the times [23, 24]. Patients with BPD are more aware of the dissociative amnesia symptoms than patients with DID; however, patients with both illnesses had the highest level of amnesia. Dissociation is one of the key hallmarks of borderline personality disorder, although DSM-IV criterion 9 bundles it together with paranoid ideation. NESARC-III estimates that 69.7% of respondents who meet the criteria for borderline personality disorder have severe dissociative symptoms or paranoid ideation.

Prognosis The long-term prognosis of untreated DID in BPD is difficult to extract due to the above many shared etiologies and symptoms, and the high prevalence of suicide attempts and nonsuicidal self-injury (NSSI) in both conditions. Studies have shown that the dissociative symptoms are an independent risk factor for increased rates of suicide attempts and NSSI, leading to sixfold increase in lifetime suicide attempts and sevenfold increase in lifetime NSSI events. The presence of

DID with other comorbid psychiatric conditions such as BPD leads to independent increases in suicide attempts and NSSI [25, 26]. Comorbidity with alcohol and drug use is expectedly high, due to the confounding independent risk factor of intoxication for suicide attempts and the confounding dissociative effect of substance abuse. [25] report that comorbid substance use led to prevalence of suicide attempts and NSSI of 50–60%. Data from multiple treatment institutions for the treatment of DID in BPD are promising in both inpatient and outpatient settings [27]. In the community, a naturalistic study found that the average treatment duration of dissociative disorders was 8.4 years with a 100% reduction in suicide attempts and 95% reduction in hospitalizations. A 30-month prospective study showed odds of suicide attempts to decrease by 6% per month and odds of hospitalizations to decrease by 31% per month of treatment [4, 5]. A 10-year naturalistic follow-up in hospitalized BPD patients with severe dissociative symptoms led to an astounding 92% remission of severe symptoms, although over the course of the study 38% had a recurrence of severe symptoms [16, 17]. Therapy in the community also appears to be well-­ tolerated. A 6-year follow-up study on 102 patients led to 9% of patients ending therapy due to dissatisfaction, 5% of patients ending therapy with incomplete resolution of symptoms, and 3% adverse outcomes [28, 29]. Global assessment of function scores, rates of attending school, and volunteering improve with treatment [30]. In studies of patients with adverse outcomes, revictimization, trauma, and stressors have been cited as exacerbating factors. Despite treatment, many patients (48%) still have absent or poor romantic relationships. Patients with remission of severe adverse outcomes such as suicide attempts and severe dissociation symptoms, still had symptoms above the threshold for dissociation, PTSD, and general stress, indicating that treatment does not lead to a “cure” [4, 5, 28, 29].

Clinical Presentations Clinicians can be clued into borderline personality disorder from a pervasive pattern of instability in several areas (interpersonal relationships, self-image, and affects) associated with marked impulsivity. Persistent paranoia, gaps in memory, expressions of derealization, and unexplained behavior should be indicators for evaluation of comorbid dissociative disorders. Below is commentary for common presentations of dissociative symptoms and dissociative disorders in comorbid borderline personality disorder from clinical reports and literature [20, 31–35]. Dissociation in borderline personality disorder is commonly a component of an unstable self-image. Patients will

18  DID in Borderline Personality Disorder

frequently dissociate during times of stress, with the majority complicated by a history of traumatic stress, acute stress disorder, and post-traumatic stress disorder. Commonly there is a history of overwhelming childhood stressors, including physical, sexual, and/or emotional abuse. This makes the presentation of dissociative identity disorder more difficult to differentiate from other dissociative disorders, which can impact the approach taken by therapists who specialize in dissociative disorders. Care must be taken not to confuse ­dissociation with cultural, religious, or otherwise personal beliefs. Substance use and other comorbid medical conditions must be ruled out. At lower scores on the Dissociative Experiences Scale, DID is not ruled out; however, differentials of PTSD and other dissociative disorders must be considered. DID in isolation does not appear to differentiate from DID in borderline personality disorder, and the clinical considerations do not differ significantly. Undiagnosed DID can be presented via collateral information, or initially by the patient as awareness of anterograde amnesia, depersonalization, derealization, dissociative fugue, impulsivity, and otherwise unexplained behaviors. The most common presentation is anterograde amnesia, or a description of “deja vu.” Psychosomatic symptoms commonly include headache. Psychosis, delusion, paranoid ideation, and other personality disorders are common psychiatric features independent of comorbid psychiatric diagnoses. DID is commonly associated with the delineation of “alters,” which frequently have independent names, genders, ages, intelligence, and defining characteristics, some of which include apparent physical changes such as facial expressions, voice, and psychosomatic complaints. There may be one or more “principle” alter. Commonly, these alters can also be defined by the presence of psychogenic amnesia, which can also be retrograde in nature, with important life memories stratified among alters. Gaps in memories and psychological understanding of time and history of each alter may be confabulated, confused, or ignored. Alters may have some combination of awareness of other alters. Alters will commonly incorporate personalized interpretation of significant life events, with historical, fantasy, and even evolving current or iatrogenic information. Presentation of alters can be associated with clearly transparent and identifiable emotions and objectives separated from the other alters. Examples include an alter that is overwhelmingly expressive of a singular emotion, such as anger or sadness, or has a singular objective such as expression of sexuality, suicidality, or otherwise social, psychological, or cultural taboo. Although “switching” between alters is commonly associated with a triggering event, this is not a necessary condition, and switching can occur without an apparent trigger.

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Diagnosis Clinical Interview The DSM-V provides a basic presentation of DID in the diagnosing criterion:  1. Two or more distinct personalities 2. Amnesia of everyday events 3. Distress or trouble functioning 4. Not part of normal cultural or religious practice 5. Not due to direct physiological substance or medical condition Complete history and physical exam during interview are the main ways to diagnose DID or borderline personality disorders. DSM V criteria is used to identify these illnesses DID or borderline personality disorder should be used (refer to Table 18.1). Collateral information should be obtained from family/ friends, if possible, thorough evaluation of trauma, developmental stressors, and other substance use and medical comorbidities need to be considered to rule out differential diagnoses.

Table 18.1  DSM V criteria for borderline personality disorder and DID [33] A pervasive pattern of instability in several areas (interpersonal relationships, self-image and affects) associated with marked impulsivity, which arises in adolescence or early adulthood and can be recognized in a variety of contexts, as indicated by five (or more) of the following criteria: 1. Intense fear of abandonment, which subjects frantically try to avoid, be it real or imagined 2. A tendency to have unstable and intense interpersonal relationships, which alternate between extremes of idealization and devaluation 3. Identity disturbance, characterized by markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two potentially self-damaging contexts (e.g., spending, sex, substance use, reckless driving, binge eating) 5. Recurrent suicidal (gestures or threats) or self-mutilating behavior 6. Marked reactivity of mood leading to affective instability (e.g., intense episodic dysphoria, irritability or anxiety, usually lasting a few hours and only rarely more than a few days) 7.  Chronic feelings of emptiness 8. Difficulty controlling anger, which is often inappropriate or excessive (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient and stress-related paranoid ideation or severe dissociative symptoms Modified from DSM-5, APA, 2013

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Differentials Some differential diagnosis as discussed in Chap. 17 include, but are not limited to, schizophrenia, schizoaffective disorder, bipolar disorder (especially Bipolar II disorder), Asperger syndrome, or even Munchausen syndrome in some cases. Borderline or histrionic personality disorder are also possible due to changes in affect and personality. Consideration of any substance abuse, such as LSD, mescaline, or peyote, is important. Additionally other differentials include medical conditions, which can present similarly such as epilepsy and traumatic brain injuries [36, 37].

Treatment Options Some treatment options for borderline personality disorder include dialectical behavioral therapy, cognitive behavioral therapy, and schema therapy. Similarly, patients with DID and borderline personality disorder can be treated with counseling; however, treatment can have a long course due to the nature of the illness as discussed above. Some patients may also be treatment resistant due to the severity of illness and distorted symptomatology. However, it is important for clinicians to be aware of the symptom presentation, so appropriate diagnosis and treatment options do not delay the recovery process for these patients [38].

Conclusion The majority of patients with borderline personality disorder experience severe dissociative symptoms, with 10–20% meeting criteria for dissociative identity disorder (DID), colloquially known as “multiple” or “split identity” personality disorder. Hence it is important for physicians to be vigilant, so misdiagnosis is limited and treatment options and plan of care are appropriately rendered in this population group.

References 1. Brand BL, Lanius RA.  Chronic complex dissociative disorders and borderline personality disorder: disorders of emotion dysregulation? Borderline Personal Disord Emot Dysregul. 2014;1:13. https://doi.org/10.1186/2051-­6673-­1-­13. 2. Ross CA, et al. Dissociative experiences in the general population. Am J Psychiatry. 1990;147(11):1547–52. https://doi.org/10.1176/ ajp.147.11.1547. 3. Sack M, et  al. [Trauma-related disorders in patients with borderline personality disorders. Results of a multicenter study]. Nervenarzt. 2013;84(5):608–614. https://doi.org/10.1007/ s00115-­012-­3489-­6. 4. Brand B, et al. A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by

S. Kompella and G. Ling community clinicians. Psychol Trauma Theory Res Pract Policy. 2009;1(2):153–71. https://doi.org/10.1037/a0016210. 5. Brand BL, et al. A longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. Psychol Trauma Theory Res Pract Policy. 2013;5(4):301–8. https://doi. org/10.1037/a0027654. 6. Grilo CM, Udo T.  Association of borderline personality disorder criteria with suicide attempts among US adults. JAMA Netw Open. 2021;4(5):e219389. https://doi.org/10.1001/ jamanetworkopen.2021.9389. 7. Grant BF, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2008;69(4):533–45. https://doi.org/10.4088/jcp. v69n0404. 8. Trull TJ, et al. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. J Personal Disord. 2010;24(4):412–26. https://doi. org/10.1521/pedi.2010.24.4.412. 9. Lenzenweger MF, et  al. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;62(6):553–64. https://doi.org/10.1016/j. biopsych.2006.09.019. 10. Johnson JG, et  al. Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res. 2006;40(2):131–40. https://doi.org/10.1016/j. jpsychires.2005.03.003. 11. Johnson JG, et  al. Personality disorders evident by early adulthood and risk for anxiety disorders during middle adulthood. J Anxiety Disord. 2006;20(4):408–26. https://doi.org/10.1016/j. janxdis.2005.06.001. 12. Swartz M, et al. Estimating the prevalence of borderline personality disorder in the community. J Personal Disord. 1990;4(3):257–72. https://doi.org/10.1521/pedi.1990.4.3.257. 13. Torgersen S, et al. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry. 2001;58(6):590–6. https:// doi.org/10.1001/archpsyc.58.6.590. 14. Widiger TA, Weissman MM. Epidemiology of borderline personality disorder. Hosp Community Psychiatry. 1991;42(10):1015–21. https://doi.org/10.1176/ps.42.10.1015. 15. Korzekwa MI, et al. Dissociation and borderline personality disorder: an update for clinicians. Curr Psychiatry Rep. 2009;11(1):82– 8. https://doi.org/10.1007/s11920-­009-­0013-­1. 16. Zanarini MC, et  al. Risk factors associated with the dissociative experiences of borderline patients. J Nerv Ment Dis. 2000. https:// journals.lww.com/jonmd/Abstract/2000/01000/Risk_Factors_ Associated_with_the_Dissociative.5.aspx. Accessed 12 July 2023. 17. Zanarini MC, et  al. The course of dissociation for patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study. Acta Psychiatr Scand. 2008;118(4):291– 6. https://doi.org/10.1111/j.1600-­0447.2008.01247.x. 18. Sar V.  Epidemiology of dissociative disorders: an overview. Epidemiol Res Int. 2011;2011:1–8. https://doi. org/10.1155/2011/404538. 19. Foote B, et  al. Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry. 2006;163(4):623–9. https://doi. org/10.1176/ajp.2006.163.4.623. 20. Ross CA.  Borderline personality disorder and dissociation. J Trauma Dissociation. 2007;8(1):71–80. https://doi.org/10.1300/ J229v08n01_05. 21. Gast U, Rodewald F, Nickel V, Emrich HM. Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic. J Nerv Mental Dis. 2001;189(4):249–57. https://doi. org/10.1097/00005053-­200104000-­00007. 22. Rifkin A, Ghisalbert D, Dimatou S, Jin C, Sethi M.  Dissociative identity disorder in psychiatric inpatients. Am J Psychiatry. 1998;155(6):844–5. https://doi.org/10.1176/ajp.155.6.844.

18  DID in Borderline Personality Disorder 23. Putnam FW, et  al. The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry. 1986;47(6):285–93. 24. Zalewski C, Archer RP.  Assessment of borderline personality disorder. A review of MMPI and Rorschach findings. J Nerv Ment Dis. 1991;179(6):338–45. https://doi. org/10.1097/00005053-­199106000-­00006. 25. Calati R, et  al. The link between dissociation and both suicide attempts and non-suicidal self-injury: meta-analyses. Psychiatry Res. 2017;251:103–14. https://doi.org/10.1016/j. psychres.2017.01.035. 26. Ford JD, Gómez JM.  The relationship of psychological trauma and dissociative and posttraumatic stress disorders to nonsuicidal self-injury and suicidality: a review. J Trauma Dissociation. 2015;16(3):232–71. https://doi.org/10.1080/15299732.2015.98956 3. 27. Choe BM, Kluft RP. The use of the DES in studying treatment outcome with dissociative identity disorder: a pilot study. 1995. https:// psycnet.apa.org/record/1996-­03674-­004. Accessed 12 July 2023. 28. Myrick AC, Brand BL, et al. For better or worse: the role of revictimization and stress in the course of treatment for dissociative disorders. J Trauma Dissociation. 2013;14(4):375–89. https://doi.org/ 10.1080/15299732.2012.736931. 29. Myrick AC, Webermann AR, et  al. Six-year follow-up of the treatment of patients with dissociative disorders study. Eur J Psychotraumatol. 2017;8(1):1344080. https://doi.org/10.1080/200 08198.2017.1344080. 30. Lampe A, et al. Long-term course in female survivors of childhood abuse after psychodynamically oriented, trauma-specific inpa-

113 tient treatment: a naturalistic two-year follow-up. Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie. 2014;60(3):267– 82. https://doi.org/10.13109/zptm.2014.60.3.267. 31. Andorfer JC.  Multiple personality in the human information-­ processor: a case history and theoretical formulation. J Clin Psychol. 1985;41:309. 32. Bliss EL. Multiple personalities: a report of 14 cases with implications for schizophrenia and hysteria. Arch Gen Psychiatry. 1980;37:1388. 33. Bozzatello P, et al. Borderline personality disorder: risk factors and early detection. Diagnostics (Basel). 2021;11(11):2142. https://doi. org/10.3390/diagnostics11112142. 34. Kluft RP. Dissociative identity disorder. In: Michelson LK, Ray WJ, editors. Handbook of dissociation. Springer US; 1996. pp.  337– 366. https://doi.org/10.1007/978-­1-­4899-­0310-­5_16. 35. Sar V, et al. Structured interview data on 35 cases of dissociative identity disorder in Turkey. Am J Psychiatry. 1996;153(10):1329– 33. https://doi.org/10.1176/ajp.153.10.1329. 36. Rathbun JM, Rustagi PK.  Differential diagnosis of schizophrenia and multiple personality disorder. Am J Psychiatry. 1990;147(3):375. https://doi.org/10.1176/ajp.147.3.375a. 37. Shibayama M. [Differential diagnosis between dissociative disorders and schizophrenia]. Seishin Shinkeigaku Zasshi. 2011;113(9):906–11. 38. Turkus JA, Kahler JA. Therapeutic interventions in the treatment of dissociative disorders. Psychiatr Clin North Am. 2006;29(1):245– 62, xi. https://doi.org/10.1016/j.psc.2005.10.015.

Dissociative Identity Disorder and Bipolar Disorder

19

Sindhura Kompella, Felicia Gallucci, Sara Jones, and George Ling

Introduction DID and bipolar disorder are both complex psychiatric conditions that may present with perceptual disturbances and fluctuating mood. The relationship between the two disorders is complex, as they can co-occur but may also be mistaken for each other.

DID Vs Bipolar DID is characterized by disruption of identity with two or more distinct personality states and recurrent gaps in recall inconsistent with ordinary forgetting. The symptoms must cause clinically significant distress or impairment and must not be a normal part of a broadly accepted cultural or religious practice. The symptoms can also not be attributed to substance use or another medical condition [1]. The diagnosis of bipolar I disorder is defined by meeting criteria for at least one manic episode. The occurrence of the manic episode cannot be better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum or psychotic disorder. Bipolar II disorder requires at least one lifetime major depressive episode and at least one episode of hypomania [1]. A study in Turkey that investigated DID patients with bipolar history and childhood trauma questionnaire was used to assess traumatic experiences. The study showed that dissociative S. Kompella (*) Department of Psychiatry, University of Miami, Miller School of Medicine, Miami, FL, USA

symptoms were present in about 20% of the patients with bipolar disorder especially when trauma such as emotional neglect/ physical abuse in childhood were evident. [2]. Therefore, it is important for clinicians to be aware of this illness presentation in the DID patient population since treatment options can be complex in underlying illnesses that can sometimes co-occur with personality disorders as well. It is also very important to treat the underlying comorbidities in DID rather than DID alone since this can have more symptom relief and less burden on the patients to make them more insightful and manage their illness with coping strategies that can help with DID [3].

Epidemiology For bipolar I, the 12-month prevalence estimate in the United States is 0.6% [4]. The 12-month prevalence estimate of bipolar II in the United States is 0.8% [5]. Accordingly, the combined prevalence of bipolar disorders in the United States is approximately 1.4%. The reported prevalence of DID in the United States varies considerably with differential study methodologies and patient populations; however, a small community study reported the 12-month prevalence to be 1.5% [6]. This means that, according to some estimates, bipolar disorders and DID are approximately equally prevalent; however, they may also co-occur. Bipolar disorders are more frequently diagnosed in high-­ income countries [7], where patients have increased access to psychiatric care. Further research is needed on the diagnosis of DID in a global context.

Etiology/Risk Factors

Aventura, FL, USA F. Gallucci · S. Jones Department of Psychiatry, University of Miami, Miller School of Medicine, Miami, FL, USA G. Ling Aventura, FL, USA e-mail: [email protected]

The male-to-female prevalence ratio of bipolar I disorder is 1.1:1 [4]. A 2012 study reported that 61% of individuals with bipolar I have a first-degree relative with an affective illness or substance use disorder [8]. The concordance rate for identical twins is 57% [9].

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DID is strongly associated with childhood trauma [10]. Approximately 90% of those with DID were victims of childhood abuse and/or neglect [11]. The reported male-to-­ female prevalence ratio of DID varies from 1:4 to 1:9 [12]. There is no known association between family history and DID risk.

Prognosis The prognosis of DID varies widely and can be improved with the proper therapies, with most patients showing drastic improvements. Prognosis is negatively impacted by retraumatization, delays in treatment, and mental and medical comorbidities. As many patients with DID experience comorbid mental health conditions, the comorbid conditions are more often indicative of prognosis than DID itself. Additionally, studies on the prognosis of patients with DID are generally limited by the presence of comorbid conditions. Contrastingly, significant data exist on the prognosis of patients with bipolar disorders. Approximately 30% of bipolar disorder patients display severe impairments in vocational function [13]. Additionally, individuals with bipolar disorder have a lifetime risk of suicide that is at least 15 times that of the general population [14]. Accordingly, prognosis in bipolar disorders can be most positively impacted by treating the bipolar disorder itself, while positive prognostication for DID patients typically relies on successful treatment and management of comorbid conditions.

Clinical Presentations DID patients are unlikely to present with overt indications of multiple identities [11, 15]. Instead patients are typically misdiagnosed with mood disorders, obsessive-compulsive disorder, paranoia, psychotic mood disorders, or cognitive disorders due to memory lapses [15]. On average, at the time of diagnosis, DID patients have been receiving mental healthcare for 6.8 years and has received more than 3 diagnoses [16]. Patients with bipolar disorder typically present either in acute mania, which has resulted in an inability to function, or with severe depression. In the case of depression, the patient must be screened for a history of mania. In either state, delusions and other perceptual disturbances may be present [17]. An example of a clinical presentation as summarized in Lakshmanan et al. shows a 45-year-old woman who had several blackouts, which would last for about a day with no recall for patient of the events occurring during the day.

During these episodes it is noted per family that patient would spend money uncontrollably, meet strangers at public places, engage in sexual activity, and these were not characteristic of the patient. She was also noted to have voice change during blackouts compared to her usual tone and her affect was also “more malicious.” There was no substance abuse history or medical history for seizures. There is evidence for sexual abuse history in her childhood, other psychiatric illnesses were ruled out using scales such as Mood disorder questionnaire. She was treated for her bipolar symptoms with ability 10 mg po daily, which improved her insight and through therapy she worked on her trauma history that caused her alternate personalities/DID. It shows the importance of treating the underlying comorbidities and how this is successful in a case wherein bipolar disorder is comorbid with dissociative identity disorder [3].

Diagnosis Patients suspected of having a bipolar disorder should be asked about duration and frequency of mood episodes, substance use, family history, previous diagnoses, history of psychiatric treatments, age of onset, and symptoms of psychosis [17]. No specific labs are indicated, but toxicology studies may be of use. DID should be suspected in patients with 3 or more psychiatric diagnoses without successful treatment. Presentation is also characterized by somatic symptoms, history of amnesia, and hearing voices within one’s own head. Patients should be asked about a history of trauma. Diagnosis may be aided by asking patients to keep journals, which may reveal alternative identities. The Dissociative Experiences Scale (DES) is the most widely used tool for screening for dissociation. In the case of DID, if partial complex seizures are suspected, an EEG should be performed [18].

Differentials Differentials for DID include mood disorders, PTSD, psychotic disorders, personality disorders, conversion disorder, partial complex seizures, and factitious disorder/malingering. Differentials for bipolar disorder include other mood disorders, anxiety disorders, PTSD, ADHD, and personality disorders. While patients with DID may experience drastic fluctuations in mood, these are usually reported to occur numerous times within the day or week, which is a key difference from bipolar disorders, where mood disturbances last for a minimum of several days.

19  Dissociative Identity Disorder and Bipolar Disorder

Treatment Options The standard of care for DID patients is to use therapeutic modalities such as psychodynamic therapy, which may focus on first and foremost identifying if there are any safety ­concerns. Further CBT or DBT may be used to focus on traumatic experiences and stabilize these experiences for the patient and resolve emotion dysregulation or identifying self in comparison to others instead of relying on dissociation as a coping mechanism to their traumatic experiences [19]. There is no specific role for pharmacotherapy in the treatment of DID, except for treating comorbid conditions as is the case above in the clinical presentation. However, treating the underlying conditions has been found to be more beneficial and hence it is important for clinicians to be vigilant in identifying the complex nature of the presentation. This has been shown to have a major impact on symptom relief and reduction in disease burden in this population group, further research specific to hospitalizations, financial burden is limited but should be studied in the future. Bipolar disorders are generally treated pharmacologically, with lithium, antipsychotics, and anticonvulsants as indicated [17].

Conclusion Bipolar disorders and DID may be mistaken for each other; however, they are distinguishable with thorough history taking. It is also possible for the disorders to co-occur, but this can only be established if the mood disruptions present in bipolar disorder persist in every altered identity in DID.

References 1. American Psychiatric Association, D.  S. M.  T. F.  Diagnostic and statistical manual of mental disorders: DSM-5 5th ed. Arlington: American Psychiatric Association; 2013. 2. Hariri AG, Gulec MY, Orengul FF, Sumbul EA, Elbay RY, Gulec H. Dissociation in bipolar disorder: relationships between clinical variables and childhood trauma. J Affect Disord. 2015;184:104–10. https://doi.org/10.1016/j.jad.2015.05.023. Epub 2015 May 21. PMID: 26074019. 3. Lakshmanan MN, Meier SL, Meier RS, Lakshmanan R. An archetype of the collaborative efforts of psychotherapy and psychopharmacology in successfully treating dissociative identity disorder with comorbid bipolar disorder. Psychiatry (Edgmont). 2010;7(7):33–7. 4. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, Kessler RC. Lifetime and 12-month prevalence

117 of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64(5):543–52. https://doi. org/10.1001/archpsyc.64.5.543. 5. Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, et  al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241–51. https://doi.org/10.1001/ archgenpsychiatry.2011.12. 6. Johnson JG, Cohen P, Kasen S, Brook JS.  Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res. 2006;40(2):131–40. https://doi. org/10.1016/j.jpsychires.2005.03.003. 7. Ormel J, Petukhova M, Chatterji S, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, et  al. Disability and treatment of specific mental and physical disorders across the world. Br J Psychiatry. 2008;192(5):368–75. https://doi.org/10.1192/bjp.bp.107.039107. 8. Baldessarini RJ, Tondo L, Vázquez GH, Undurraga J, Bolzani L, Yildiz A, et  al. Age at onset versus family history and clinical outcomes in 1,665 international bipolar-I disorder patients. World Psychiatry. 2012;11(1):40–6. https://doi.org/10.1016/j. wpsyc.2012.01.006. 9. Alda M.  Bipolar disorder: from families to genes. Can J Psychiatry. 1997;42(4):378–87. https://doi. org/10.1177/070674379704200404. 10. Kluft RP.  Childhood antecedents of multiple personality. Washington: American Psychiatric Press; 1985. 11. Spiegel D, Lewis-Fernández R, Lanius R, Vermetten E, Simeon D, Friedman M.  Dissociative disorders in DSM-5. Annu Rev Clin Psychol. 2013;9(1):299–326. https://doi.org/10.1146/ annurev-­clinpsy-­050212-­185531. 12. Ross CA, Norton GR. Differences between men and women with multiple personality disorder. Psychiatr Serv. 1989;40(2):186–8. https://doi.org/10.1176/ps.40.2.186. 13. Judd LL, Schettler PJ, Solomon DA, Maser JD, Coryell W, Endicott J, Akiskal HS. Psychosocial disability and work role function compared across the long-term course of bipolar I, bipolar II and unipolar major depressive disorders. J Affect Disord. 2007;108(1):49–58. https://doi.org/10.1016/j.jad.2007.06.014. 14. Marangell LB, Bauer MS, Dennehy EB, Wisniewski SR, Allen MH, Miklowitz DJ, et al. Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorders followed for up to 2 years. Bipolar Disord. 2006;8(5 Pt 2):566–75. https://doi. org/10.1111/j.1399-­5618.2006.00369.x. 15. Kluft RP.  Clinical presentations of multiple personality disorder. Psychiatr Clin North Am. 1991;14(3):605–29. 16. Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM.  The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry. 1986;47(6):285–93. 17. Cerimele JM, Chwastiak LA, Chan Y-F, Harrison DA, Unützer J. The presentation, recognition and management of bipolar depression in primary care. J Gen Intern Med. 2013;28(12):1648–56. https://doi.org/10.1007/s11606-­013-­2545-­7. 18. Kluft RP. Diagnosing dissociative identity disorder. Psychiatr Ann. 2005;35(8):633–43. 19. Dorahy MJ, Brand BL, Şar V, Krüger C, Stavropoulos P, Martínez-­ Taboas A, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17. https://doi. org/10.1177/0004867414527523.

Understanding Dissociative Identity Disorder

20

Rasha Almousa

Introduction According to the DSM-5, DID is described as a disruption of identity characterized by two or more distinct personality states or an experience of possession [1]. Each of these personality states or identities functions independently of the other; as it displays its unique behavioral patterns, stored memories, languages, and even forms of expression. The disintegration of identity usually results in what is referred to as asymmetric amnesia. In this type of amnesia, what is recognized by one identity may or may not be recognized by another. Different identities interact with one another using an elaborate inner world [2]. Apparent signs to notice when a switch occurs from one identity to another are a change in affect, eye blinking or rolling, and a change in posture. Moreover, DID patients experience amnesia—an “inability to recall important autobiographic information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting” according to the DSM 5. To diagnose amnesia in DID, substance use should be ruled out as a cause of memory loss. Finally, it should be severe enough to interfere with the daily function of the patient [3].

Criteria The DSM-5 provides the following criteria to diagnose DID [1].

R. Almousa (*) Faculty of Medicine, University of Jordan, Amman, Jordan Weiss Memorial Hospital, Chicago, IL, USA e-mail: [email protected]

1. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-­ motor functioning. These signs and symptoms may be observed by others or reported by the individual 2. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting 3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 4. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play 5. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or other medical condition (e.g., complex partial seizures) (American Psychiatric Association 2022)

Predisposing Factors and Causes Severe childhood or early life trauma and abuse are thought to be the strongest predisposing factors for DID. Aside from the trauma itself, the resulting stress overbearing the patient might distort their perception of the incident(s). Consequently, they may falsely believe that the event did not happen or eliminate details of it that, in fact, did happen. In addition, they might also experience dissociation or a feeling of “leaving one’s body” [4]. The most commonly accepted theory explaining the etiology of DID is the Theory of Structural Dissociation. In short, a “unified sense of self” fails to form due to early trauma, resulting in alternate identities as an attempt to self-soothe the traumatized individual [2, 3]. This will be explained in further detail after multiple key terminologies needed to understand the theory are described below.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_20

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In psychology today, it is postulated that an individual’s behavior is operated by what is referred to as “action systems.” Action Systems are what that determine an individual’s response to external events and experiences. This function comes with an end goal of contributing to the survival of species, caretaking of offspring, energy management, and defense against threat [end goal of contributing to our perception and response to external experiences as well as keeping us alive] [5]. There are two types of Action Systems that determine human behavior. One is referred to as the “Apparently Normal Part” or ANP, which is the part of the personality that works to carry out the functions of daily life. It is the rational part of the individual that takes the responsibility to be present when carrying out tasks in daily life, thus making the individual “apparently normal”—as the name implies. The other one is the “Emotional Part” or the “EP”, which is the part that handles responses to threat or emotionally traumatic events. The EP stores memories of trauma and its related parts that have not been processed by the individual [5]. Each action system is characterized by its own sensory, cognitive, somatic, and perceptual experiences. The ANP’s functions include exploration (work/study), play, energy management (sleep, eating), social interaction, reproduction, and caretaking. The EP’s functions include fight, flight, freeze, total submission or collapse, social submission, attachment cry, and recuperation. As one can tell, the EP’s functions are defense mechanisms against a perceived threat to the individual’s psyche, while ANP’s functions are concerned with an individual managing their day to day living. With that being said it is safe to give an alternative

name to the ANP as the Daily Living Action System and the EP as the Defensive System. In the person with intact mental health, the ANP and EP work together to consolidate the individual’s experiences and store this information. They are viewed as two systems with different functions that are open and accessible to each other. This also means that they each regulate and coordinate the other to work as a whole functioning system. Whenever an experience occurs, a memory is synthesized and stored by the work of both systems to make sense of it for the individual. It is imperative for the purpose of understanding this theory to acknowledge that in a healthy individual, two action systems work together to perform as a whole. This is portrayed in Fig. 20.1 below [6].

Daily System and Defensive System

Whole Individual

Daily Living System

Defensive System

Fig. 20.1 Daily Living System openly communicating with the Defensive System in a healthy individual

20  Understanding Dissociative Identity Disorder

 rauma and the Interruption of Open T Communication Between the Two Action Systems When trauma occurs, the open communication between the two action systems is interrupted. The two action systems become incapable of operating as a whole. Trauma and its impactful somatosensory input disrupt the action systems’ ability to work harmoniously (i.e. process the unhealed emotional event in the Defensive action system but also continue their daily life with Daily Living system functioning normally.) To understand why this occurs, one needs to understand how the Defensive system deals with emotional threat. As mentioned previously, the Defensive system’s functions include fight, flight, freeze, total submission, social submission, attachment cry, and recuperation. It is easy to see that the major pattern seen in the Defensive system’s responses includes “freezing in time” when a traumatic event occurs. To manage unhealed hurt, the Defensive system needs to pause in time to relive the emotional trauma and process it whether recent or far in the past. As a result of this, the defensive system that deals with emotional hurt does not acknowledge the present. The clash occurs when the daily living action system tries to operate and carry out day-to-day tasks in the present moment while the defensive system is frozen and busy reliving the unhealed traumatic event in the past. In order to maintain its “apparently normal” look to carry out daily tasks in life, the daily living system omits or shuts out the defensive system. This is what we call the daily living system’s avoidance response. The defensive system undergoes a fixation response on the traumatic event (Fig. 20.2) [7].

Traumazed Individual Open access disrupted

Daily Living System

Defensive System

Fig. 20.2  A visual demonstration of disrupted open access between the Daily Living System and the Defensive System

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 he Relationship of Daily System T and the Defensive System The Daily Living System’s Avoidance Response The avoidance response that is adopted by the Daily Living System in order to retain normality in daily life is carried out through several ways: 1. Avoidance of the trauma and its related triggers, cues, and details stored by the Defensive Action System 2. Numbing techniques (amnesia, shut down, and anesthesia) and as a result appearing undisturbed, living a normal life 3. While trying to carry out avoidance techniques, it does not participate in integrating the painful traumatic event It is important to note that the ANP is still interrupted by intrusions of the EP’s traumatic memories. As time passes by, the intrusions become too overwhelming for the ANP to function normally; however, this is with advanced stages of DID. For the purposes of describing this initial stage of the traumatized individual’s psyche, the ANP develops an avoidance response and the EP intrudes it occasionally [7–9].

The Defensive System’s Fixation Response The EP remains stuck in reliving the traumatic event and is incorrectly time oriented. It views the present with the self-­ imposed beliefs of the past traumatic event. These self-­ imposed beliefs could include but are not limited to: “It is all my fault” “I am not safe” “I am a bad person” Thus, the traumatized individual’s EP carries negative self-beliefs and relives the traumatic event, which severely impacts their view on the present and future. Without the harmonious relationship between the daily living and defensive action system, the memory will never be properly integrated and is maladaptively stored [7–9].

Structural Dissociation When the action systems were first introduced in this chapter, it was said that there are two definitive action systems that communicate together as a whole to govern a person’s behavior and character.

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Primary, Secondary, and Terary Structural Dissociaon

Fig. 20.3  Demonstration of the effect of trauma timing on the level of dissociation that occurs in an individual. The earlier the trauma, the more severe the dissociation

Terary Structural Dissociaon ex. Dissociave Identy Disorder Secondary Structural Dissociaon Ex. C-PTSD,

Severity of dissociaon during adulthood

Primary Structural Dissociaon Ex. Simple PTSD

Timing of trauma relave to individual’s birth

After an overwhelming traumatic event, the action systems stop operating as whole and a Structural Dissociation is said to have occurred between the previously harmonious communicating systems [7–9]. In order to understand the structural dissociation theory further, it is important to keep in mind that there are levels of dissociation between the ANP and EP in correlation to the trauma that happened in an individual’s life. Each of these levels underlies a proposed pathophysiology for a disorder in the dissociative spectrum of disorders that we know today. The level of dissociation depends on the timing and chronicity of the trauma, as well as the individual’s predisposition to dissociation. The earlier the trauma, the higher the level of dissociation of an individual [8–10]. With trauma that happens later in one’s life, the action systems mentioned previously can separate from each other to form two distinct systems. If trauma goes unintegrated early in an individual’s life and lasts chronically, each action system will itself divide into different parts (Fig. 20.3).

 rimary, Secondary, and Tertiary Structural P Dissociation To sum up, the healthy personality has two main systems that should communicate openly but separate from each other and into further subsystems to cope with intense and early trauma. This will be explained further below [1, 6, 7, 11, 12].

Primary Structural Dissociation Primary Structural Dissociation is the initial and most basic form of dissociation that was discussed above that occurs when the two action systems become separate and no longer

function as a whole. The EP is fixated on the trauma and ANP is avoiding it. The EP is kept from integrating with the ANP or in other words, is dissociated from the part of the personality that handles day to day life. It is all a defense against the traumatic event held in the EP that could overwhelm the ANP and annihilate its effort to maintain day-to-­day functions. Post-Traumatic Stress Disorder or PTSD is an example of Primary Structural Dissociation. The ANP is avoidant of the EP’s traumatic triggers. Its avoidant techniques work until there is an overwhelming trigger and the EP intrudes the ANP’s consciousness. It can be in the form of flashbacks, panic, irritability, emotional outbursts, and somatic symptoms. This causes the individual to live and experience the unhealed traumatic event fully as if it is happening in the present. Keeping in mind that the EP is not time aware, once it is activated it will relive the experience regardless of its timing as if it is happening right now. The goal of treatment for individuals with primary structural dissociation is to prompt the ANP to reconnect with the EP, acknowledge it, and process the events in it [6, 7].

Secondary Structural Dissociation Secondary Structural Dissociation occurs when primary structural dissociation is not enough for the individual to handle early and chronic trauma. In addition to the ANP and EP separating, the EP develops parts within itself. This happens when trauma occurs early in a person’s life, lasts longer, and is usually imposed by a family member during childhood [12]. Individuals with disorganized attachment to their caregivers during early childhood have been associated with the development Secondary Structural Dissociation during adulthood.

20  Understanding Dissociative Identity Disorder

In this type of dissociation, the EP divides itself into separate parts. Different groups of memories, feelings, trapped emotions, and internalized self-beliefs are associated with different EPs. Each EP is fixated around a particular response related to a memory it stores. Each of these responses are included within the defense functions mentioned previously for the EP.  For example, one EP

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could hold a sad abandoned child (attachment cry) while another EP could hold a rage-­full teenage memory (fight). Examples of Secondary Structural Dissociation include Complex Post Traumatic Stress Disorder and Borderline Personality Disorder (Fig. 20.4) [1, 6, 7, 11, 12].

The Process of Secondary Structural Dissociation

Fig. 20.4  A visal demonstration of the transformation of Primary Structural Dissociation to Secondary Structural Dissociation

PRIMARY STRUCTRUALLY DISSOCIATED INDIVIDUAL

Apparently Normal Part

Emoonal Part

Chronic, earlier life trauma SECONDARY STRUCTURALLY DISSOCIATED INDIVIDUAL Emoonal Part 1 (Fight) Apparently Normal Part

Emoonal Part 2 (Cry) Emoonal Part 2 (Flight)

Emoonal Part 3 (Freeze)

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 ertiary Structural Dissociation T and Dissociative Identity Disorder Tertiary Structural Dissociation occurs when the ANP forms into separate parts in addition to the ENP separating into different parts as well. As established previously, the ANP is the apparently normal part of the personality. Unlike other forms of dissociation, multiple parts of the ANP are developed in this one; consequently, the individual transitions from one apparent personality to the other during their day-to-day life. The subsystems of the ANP may include “mother”, “student”, “wife”, “doctor”, and “therapist”. These are all roles that the day-to-day self recognizes and tries to maintain despite being separated or unaware of each other. There are also multiple EPs, similar to Secondary Structural Differentiation. However, the EPs in Tertiary Structural Dissociation are more complex and deeply evolved. Each has its own characteristics, attachment patterns, and internalized messages. Since they are more developed, they do not “freeze in time” but rather carry out the EP’s tasks such as exploration, play, and socialization, and view themselves to be connected to a range of ages. This type of dissociation lays out the proposed pathophysiology for Dissociative Identity Disorder. The multiple ANPs and EPs formulate what was explained at the beginning of this chapter to be “identities” or “personas” [6, 10, 12]. Patients diagnosed with DID are likely to form new ANPs and EPs in response to their day-to-day needs and experiences. New ANPs may result when giving birth to children to assume the role of the “mother”, or when there is a need to handle new work responsibilities. New EPs are likely to occur with new trauma [7]. An example is demonstrated by a DID patient who suffered from sexual abuse as a child. She presented as a pregnant lady who needed a prenatal examination. Stimulus generalization due to past trauma triggered her sexually abused “child” stored in the EP. As a result, she needed to develop a new ANP to keep up with the physical examination without intrusion of the triggered EP (Fig. 20.5) [5].

Psychobiology of DID There are several studies that were carried out to identify any changes in the neuroanatomy of patients with DID. One study’s results suggested markedly reduced cortical thickness in the insula, anterior cingulate, and parietal regions of the brain of DID patients. There was also reduced surface area in the temporal and orbitofrontal cortices. These findings were correlated in patients exposed to early childhood traumatization (0–3 years of age) [13].

R. Almousa

The excessive release of stress hormones at a young age due to abuse could explain the reduced cortical thickness and thus the reduced ability to carry out integrative mental functions in DID individuals. It was found that in response to stress, these neurochemicals mostly concentrate in the hippocampus and the prefrontal cortex. These are the regions mostly responsible for integrating experiences and solidifying them into memories [14]. Some studies found that the artificial stimulation of the hippocampus can trigger dissociative symptoms [15]. Finally, in a study conducted to identify abnormalities in cerebral blood flow in patients with DID, the regional cerebral blood flow was reduced in the orbitofrontal regions bilaterally. Additionally, it was increased in the median and superior frontal regions bilaterally [16].

History of DID Throughout history and across a variety of cultures, DID has been thought to be a form of possession. When this concept was beginning to be questioned, DID was classified as a type of hysteria. In the Statistical Manual for the Use of Institutions for the Insane in 1918, DID was first enlisted as a subclassification of Psychoneurosis and Neuroses that was characterized by multiple states of consciousness that stem from unclear impulses, amnesia, and sensory as well as motor problems [17]. Despite this acknowledgment, DID was still referred to under the category of hysteric illnesses. Even when doctors were attempting to diagnose it, they grouped it under the umbrella of other common psychiatric illnesses of that era. For example, in 1927, the reported number of schizophrenia cases increased tremendously, while the number of reported DID cases decreased. It could be plausible to theorize that it was due to the fact that one of the main characteristics of schizophrenia described at that time was multiple personalities. However, as records of several patients over time were studied, the characteristics of DID began to mold into a unique disorder of its own [18]. The first case in history that describes a typical DID profile was recorded in 1584. Of course, it was not acknowledged back then as a medical illness; but her exorcist records outline a typical match for the DID criteria that exist today. Jeanne Fery displayed an array of different personas, now referred to as “alters”. Each had its own name and characterizing features. The actions carried out by these different alters ranged from self-harm to self-healing. Each had an audible voice inside her head and took control over her physical body. She suffered from disrupted eating habits and conversion symptoms. These different identities were a consequence of childhood physical and probably sexual abuse.

20  Understanding Dissociative Identity Disorder Fig. 20.5  A visual demonstration of the transformation of Secondary Structural Dissociation to Tertiary Structural Dissociation

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SECONDARY STRUCTRUALLY DISSOCIATED INDIVIDUAL

Emoonal Part 1 Apparently Normal Part

Emoonal Part 2 (Cry)

Emoona l Part 3 (Freeze)

Emoonal Part 2 (Flight) Chronic, earlier life trauma

TERTIARY STRUCTRUALLY DISSOCIATED INDIVIDUAL Apparently Normal Part 1

Apparently Normal Part 2

Emoonal Part 1 (Fight) Apparently Normal Part 4 Apparently Normal Part 3

In 1623, documents about Sister Benedetta reported she was thought to be possessed by three angelic boys who would inflict physical pain upon her to cause long-lasting pain. Each time one of the “angels” took over, they had a different mode of verbal and facial expression, as well as tone of voice. It seemed that one of these angels was frozen at the age of nine, the age Sister Benedetta was when her father had passed away [19]. In 1882, Louis Auguste Vivette was the first patient to be officially diagnosed with DID.  Following a childhood of

Emoonal Part 2 (Cry)

Emoona l Part 3 (Freeze)

Emoonal Part 2 (Flight)

extreme neglect and abuse, Louis began having “attacks of hysteria”. At the age of 17 he was bitten by a snake, which triggered an attack of hysteria that prompted him to lose the ability to use his lower limbs. A year later, he suffered a 50-h hysteria attack, in which he regained the ability to control his legs. However, he developed different demeanors and core values. Louis was treating everyone differently, and seemed to have forgotten his treating physicians and patients he knew for a while back. With attacks following that, he would alternate between an aggressive and impulsive person to a

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kind and gentle one. By 1884, some attacks would prompt him to steal, which is the habit he resorted to in his childhood to survive. Other attacks would trigger the loss of control over his legs again. In 1888, he was reported to have ten different personalities [20].

References 1. Ciccarelli SK, Noland J.  Psychology: DSM 5. 5th ed. Boston: Pearson; 2013. 2. Dissociative identity disorder—Psychiatric disorders [Internet]. MSD Manual Professional Edition. [cited 2023 Mar 31]. https:// www.msdmanuals.com/professional/psychiatric-­d isorders/ dissociative-­disorders/dissociative-­identity-­disorder. 3. Mitra P, Jain A. Dissociative identity disorder [internet]. PubMed. Treasure Island: StatPearls Publishing; 2021. https://www.ncbi. nlm.nih.gov/books/NBK568768/. 4. Anthony JL, Lonigan CJ, Hecht SA.  Dimensionality of posttraumatic stress disorder symptoms in children exposed to disaster: results from confirmatory factor analyses. J Abnorm Psychol. 1999;108(2):326–36. 5. Nijenhuis E, van der Hart O, Steele K.  Trauma-related structural dissociation of the personality. Act Nerv Super. 2010;52(1):1–23. 6. van Ellert SK.  The haunted self: structural dissociation and the treatment of chronic traumatization. New  York: W.  W. Norton & Company; 2006. 7. Nijenhuis E, et  al. Trauma information [Internet]. 2004. www. trauma-­pages.com. http://www.trauma-­pages.com/a/nijenhuis­2004.php. 8. Frewen P, Lanius RA. Healing the traumatized self: consciousness, neuroscience, treatment. New  York: W.W Norton & Company; 2015. 9. Lanius UF, Paulsen SL, Corrigan FM. Neurobiology and treatment of traumatic dissociation: toward an embodied self. New  York: Springer Publishing Company; 2014. 10. Van Der Hart O. Structural dissociation of the personality: the key to understanding personality: the key to understanding chronic

R. Almousa traumatization and its chronic traumatization and its treatment [Internet]. 2008 [cited 2023 Mar 31]. http://www.estd.org/conferences/presentations/Onno%20van%20der%20Hart.pdf. 11. Cloitre M, Garvert DW, Weiss B, Carlson EB, Bryant RA.  Distinguishing PTSD, complex PTSD, and borderline personality disorder: a latent class analysis. Eur J Psychotraumatol. 2014;5(1):25097. 12. Mosquera D, Gonzalez A, Leeds AM. Early experience, structural dissociation, and emotional dysregulation in borderline personality disorder: the role of insecure and disorganized attachment. Borderline Personal Disord Emot Dysregul. 2014;1(1):15. 13. Reinders AATS, Chalavi S, Schlumpf YR, Vissia EM, Nijenhuis ERS, Jäncke L, et al. Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder. Acta Psychiatr Scand [Internet]. 2018 [cited 2019 Nov 13];137(2):157–170. https://www.ncbi.nlm.nih.gov/pubmed/29282709. 14. McGaugh JL.  Significance and remembrance: the role of neuromodulatory systems. Psychol Sci. 1990;1(1):15–25. 15. Halgren E, Walter RD, Cherlow DG, Crandall PH. Mental phenomena evoked by electrical stimulation of the human hippocampal formation and amygdala. Brain. 1978;101(1):83–115. 16. Sar V, Unal SN, Ozturk E. Frontal and occipital perfusion changes in dissociative identity disorder. Psychiatry Res Neuroimaging. 2007;156(3):217–23. 17. American Psychiatric Association. Statistical manual for the use of Institutions for the Insane. 1918. 18. Rosenbaum M. The role of the term schizophrenia in the decline of diagnoses of multiple personality. Arch Gen Psychiatry. 1980;37(12):1383. 19. Fery J.  A sixteenth-century case of dissociative identity disorder [Internet]. (PDF). ResearchGate. https://www.researchgate.net/ publication/11735549_Jeanne_Fery_A_sixteenth-­century_case_ of_dissociative_identity_disorder. 20. Faure H, Kersten M, Koopman D, Onno Van Der Hart M. Henri. /95; Camuset, 1882; Mabille & Ramadier, 1886; Voisin, 1885, 1887), and many secondary sources have subsequently cited this case. Azam [Internet]. 1885;104. https://scholarsbank.uoregon. edu/xmlui/bitstream/handle/1794/1825/Diss_10_2_5_OCR_rev. pdf?sequence=4.

Dissociation in Animals

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Hasan Belli

Introduction The title of “dissociation in animals” has to contain an evolutionary perspective. The evolutionary perspective ties all humans with animal species that had come before and relates us also to other animals that evolved in parallel with us. In the pathological dissociation approach, we work with a deficiency of the human mind and brain, such as deterioration of identity, memory, attention, and consciousness. But, experts in the field are often interested in evolutionary views about psychopathology, most of them do not consider understanding evolutionary aspects of the normal or adaptive process as a basis for pathology. Discussions in this concept may choose to focus on an animal-human continuity model of dissociation, evaluating whether certain stressors or other states lead to specific changes in the animal’s brain, which leads to a dissociative process. Some authors have suggested that the behavior and physiology of the freeze response are routinely seen in the wild. Yet, as data provided evidence that freezing has a state of alert immobility, as in the mammalians that assume an immobile state in the presence of a predator. To understand dissociation in the animal model, as some authors pointed out, one must also acknowledge the many similarities to behavior in animals in whom freezing has been elicited in a state of helplessness with later prevention of spontaneous recovery from immobility. Some animals manifest alert immobility has been considered to be primarily defense mechanism as “animal hypnosis”. Similarly, dissociation also may be associated with a mainly parasympathetic tone, deformed cognition, and learning behavior, and a propensity for conditioned perpetuation [1, 2]. An accepted conception of the evolutionary view of dissociation is to assume that understanding freezing mechanisms in mammalians may provide a basic approach to the human dissociative process. H. Belli (*) Department of Psychiatry, Bagcılar Education and Research Hospital, Health Sciences University, Istanbul, Turkey

Evolution has been the driving power that has shaped humans, apes, and other animals’ brains in the same way as it has developed body characteristics. Many adaptations about human identity, emotions, memory, consciousness, attention, and behavior emerged in habitual environments of evolutionary adaptedness, from which social living conditions deviate in one way or another. Such social living conditions and current environmental traits such as childhood traumatic experiences may cause the pathological process of the operation of these capacities. Yet, this is not to declare that any psychopathological symptoms of dissociation define an adaptation. Contrarily, signs and symptoms are really maladaptive in both the standard understanding of the term and its evolutionary meaning. Psychopathological symptoms may reflect the extremes of variation that may become dysfunctional due to their abnormal frequency, intensity, or inappropriateness in the current context. Authors attempt to classification the dissociative symptoms with many and varied forms and expressions. These symptoms are characterized by large variety, particularity, and complexity such as emotional, perceptual, cognitive, or functional forms. Dissociative process-related phenomenon is signs of impaired mind functions that alter the perception of time, space, sense of self, and reality. Altered sensory perceptions may produce variable anesthesia, analgesia, and intolerable pain perception. Motor expressions consist of weakness, paralysis, and ataxia but may also present as tremors, dysarthria, shaking, and convulsions. Cognitive fluctuation handles confusion, dysphasia, dyscalculia, and severe deficits in attention. Memory alteration may include hypermnesia in the form of flashbacks, amnesia in fatigue states, or more selective traumatic amnesia [1]. Some interesting findings have emerged from the results of animals used in scientific experimentation. Ferdowsian et al. have reviewed the relationship between human and animal physiological and behavioral similarities. This literature on defining the various terms used in trauma, pain, and stress research exists; there is a parallelism between human experiences of pain and psychological distress and those of animals

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founded on shared brain structures and physiological mechanisms [3]. Some findings have also emerged from the field of experimental mammalian brain studies, indicating that the dissociative process, neurophysiological outcomes, some receptors, and neurotransmitters are intertwined. Stress or some neurochemical stimuli-related alterations in the mammalian brain become important in that they may serve as salient factors in the natural development or pathogenesis of dissociation. Besides the recent debates focusing on identifying pathological manifestations of dissociation, some studies have examined neural mechanisms underlying dissociation. A study has demonstrated how some of the consequences of N-methyl-d-aspartate (NMDA) antagonists in animals are blocked by drugs that attenuate glutamate release. Clinical investigations state that NMDA antagonists may transiently provoke glutamate release and create symptoms resembling dissociative states in humans [4]. Advanced imaging studies have been used extensively to examine cell-type-specific neural activity across the mammalian brain, potentially enabling the exploration of how brain-wide dynamical patterns give rise to complex behavioral states. In terms of the dissociation-like states, researchers have detected some important data from animal studies. A dissociation-like state has been precipitated by precisely-dosed administration of ketamine or phencyclidine in mice. From these results, it may be clear that molecular, cellular, and physiological properties of a conserved deep posteromedial cortical rhythm may underlie states of dissociation [5]. Since this area of the investigation remains in a relatively immature stage of inquiry, the chapter concludes with a discussion of limited data such as freezing mechanisms in mammalians and some experimental mammalian brain studies.

Freeze Response in Animals Many findings of behavior and physiology of the freeze response have emerged from the field of animal studies and observations in the wild. Yet, as data provided evidence freezing has a state of alert immobility, as in the mammalians that assume an immobile state in the presence of a predator. If an animal is attacked by a predator, this state may proceed to sudden flight or, to a deeper state of freeze, which is associated with apparent unresponsiveness and with marked changes in basal autonomic state [1]. The answer to such situations may provide a conceptual framework that will clarify the common evolutionary mechanisms. This situation can be considered animal hypnosis and may point to the biological origins of the dissociation mechanism. Ultimately, this mechanism serves the survival of mammals. Debates in this area may choose to focus on an evolutionary model,

H. Belli

evaluating whether certain stressors or psychiatric states lead to specific changes in the mind and body. Hofer has attempted to correlate freezing reactions and parasympathetic systems in laboratory animals. The limited literature on defining the terms in stress research exists a stressor is a stimulus situation that the animals perceive as a threat to their ability to cope. In the occurrence of an attack, when the animal is provoked helplessly, a different state of freezing is stimulated, as cited. A study evaluated the rodents that were exposed to stress at a variety of predator-related stimuli in an open space with no means of flight. All rodents joined a deep phase of freeze, continuing for up to 30 min. The freezing response was likely to be a manifestations of large bradycardia associated with cardiac arrhythmias, presenting a prominent state of vagal or parasympathetic tone [6]. Richter has demonstrated an association between freezing response and helplessness, or lack of control. In suffocation investigations, feral rats will swim for up to 60  h before dying from fatigue. If these rats experience inactivity in the researcher’s hand and are then released into the water, they will drown within minutes. Some rats experience sudden death during induced immobility [7]. From these approaches, some important points emerge. While the freezing response is a survival strategy, it causes death in environmental changes. So, it turns into an inappropriate reaction. Furthermore, as in this experiment, the intensity of a stressor should be a life-threatening feature. The stress response is the normal reaction to a stressor, and in the typical situation, once homeostasis is achieved, the stress terminates. A few studies have examined the relationship between intensive stress and inescapable shock. Some literature reviewed the representation the animals revealed to effective shock triggers in an escape-proof environment predictably freeze with the next shock exposure. The following introduction of ways of escape in these animals does not evoke escape behavior—the animals stay frozen and resume to show helplessness. They seem unable to learn from new experiences, even those that encourage escape or survival. But, animals exposed to escape route shock soon learn to use the escape route and do not freeze [1]. Furthermore, to discuss the critical factor in trauma, It is necessary to emphasize the relationship of controllability of the development of the threat versus a condition of helplessness. The author has emphasized the great similarities between the human reaction to trauma and the animal response to inescapable shock, the author has also indicated that inescapable shock may be a biological prototype for posttraumatic stress disorder [8]. As stated in an article, the authors presented the new dissociation model in humans as an analogy to the change in defense and recovery behavior in animals exposed to inescapable shock [2]. Threat-related conditioned stimuli in this model will automatically elicit a thaw or freeze response rather than a more specific conditioned response to the stimulus. Thus, persis-

21  Dissociation in Animals

tent dissociation will make the animal or human susceptible to a wide variety of stimuli that can be associated with the threat of continued freezing or dissociation [1]. This trend is an intermediate stage and is based on post-­ encounter defensive behavior: flight, freeze, and fight. In general, the freezing response noted has been in the direction of a defense mechanism in the survival chance. When a predator has been spotted, as mentioned earlier, the freezing response is the basic post-encounter mechanism in some species. Thus, the freezing response is not likely to be merely manifestations of physical escape from threat and may have some aspects on the face of a potential escape route [2]. The effort to survive and reproduce is a fundamental evolutionary trend in living things. In this context, the freeze response serves this purpose. This title has presented a brief review of the relevant areas of investigation and inferences that state that the freezing response and the dissociative mechanism are interconnected. Yet, it is an important shortcoming that the animals studies and literature are limited and old. New research and discussions are needed.

 iological Aspects of Dissociation B in the Mammalian Brain NMDA-type glutamate receptor antagonists provide the resemble effects of dissociation in healthy individuals. Glutamatergic systems are general biological entities of all brain structures, but the cortex, hippocampus, thalamus, amygdala, and forebrain areas are especially sensitive. Under normal conditions, individuals who have received ketamine have reported some dissociative symptoms and alterations in the sense of self. The identity changes may occur like depersonalization and derealization [4]. Ketamine has been introduced as an “anesthetic, hallucinogen, and dissociative agent”. But, some researchers tend to suggest that ketamine is a new type of antidepressant and anti-posttraumatic stress disorder (PTSD) drug [9, 10]. Not only is the NMDA receptor’s activity, but their neurometabolic activity, when the effects on animals are studied, offers the possibility of improving knowledge of the neurobiology of dissociative disorders, an essential step towards the elucidation of their etiology. As a result of these scientific investigations of animals’ brains, we can now better define the dissociative process. Therefore, many judgments in this section are derived from animal studies. NMDA receptor is also localized in high concentrations throughout the cortex, hippocampus, and amygdala; the activity of NMDA receptors affects neuronal action. NMDA activity plays a role in both neural plasticity and excitotoxicity. These two opposite activities are quite interesting. There is great interest in the development of clinically relevant NMDA receptor antagonists that block excitotoxic NMDA receptor activation with-

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out interfering with NMDA receptor function required for normal synaptic transmission and plasticity [4, 11]. Several studies have shown that a single dose of subanesthetic ketamine is associated with transitory psychotic-like symptoms in healthy individuals and aggravates psychotic symptoms in patients with schizophrenia [12, 13]. Although not surprising to researchers in human and animal studies, who have recognized the connections between the dose of subanesthetic ketamine and dissociative, psychotic-like symptoms, some findings have shown that the long-term frequent use of ketamine is associated with persistent neuropsychiatric symptoms, this situation is generally characterized as cognitive dysfunction and working memory deficits [12, 14]. Researchers have also evaluated the effect of chronic use of ketamine on brain structures by neuroimaging techniques. Researchers have found that chronic ketamine use is associated with atrophy in the frontal, parietal, and occipital cortices [10, 11], the disruption of white matter integrity [15], and reduced connectivity between thalamic nuclear groups and cortical regions [1]. Authors have emphasized that glutamatergic and dopaminergic dysfunction has been an important factor in the neurotoxic effects of ketamine [12]. The specific metabolic changes of repeated ketamine exposure that may be associated with some metabolites in the brain have not been adequately evaluated in animals and humans. For example, A study has shown that the many changed metabolites such as purine metabolism and glycerophospholipid metabolism have been identified in the prefrontal cortex, hippocampus, and striatum after repeated ketamine exposure in the rats. After 1 week of withdrawal intervention, most of the changed metabolites in the hippocampus and striatum were restored to control levels, while the metabolite changes in the prefrontal cortex were persistent. These results revealed that repeated ketamine exposure significantly altered purine metabolism and glycerophospholipid metabolism in the prefrontal cortex, hippocampus, and striatum, which may be involved in ketamine’s neurotoxic effects [12]. The most consistent presence of mental abnormality found in extreme stress may have great value in neurobiological aspects. It may be that the reflection is seen in the induction of long-lasting forms of neural plasticity and neurotoxicity in some regions of the brain. Furthermore, several studies have emphasized the relation between neurophysiological response to environmental stress and increased glutamatergic activity in particular brain regions. As modeled with NMDA antagonists, the glutamatergic transmission may be related to dissociative symptoms, as shown in animal and human studies [4, 16, 17]. Recently, several studies have suggested that high-speed recording and neuronal activity are associated with enabled biological and causal neural-circuit dynamics spanning the animal brain. Not surprising to researchers in this area, who have considered the connection between neural-circuit dynamics and dissociation, these findings have been gener-

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ated from technological advancements as the cellular application of altered behavioral conditions. The normal integration of cognitive processing is disrupted in dissociation, which can occur for a variety of reasons, such as stress, epilepsy, dissociative drugs, or certain neuropsychiatric disorders. A selective detachment can be observed, where emotional or emotional responses are separated from sensory perceptions and the sense of self is separated from body position or action [5]. Vesuna et al. have evaluated the dissociative-like behavioral condition utilizing high-speed, brain-wide processes in both mice and humans, and recognized underlying deep posteromedial-­cortex rhythmic dynamics along with molecular, cellular, and physiological agents. They have used ketamine or phencyclidine in mice for a dissociation-like state. They have found that these dissociative agents elicited a 1–3 Hz rhythm in layer 5 neurons of the retrosplenial cortex. They have also observed that electrophysiological recording with four simultaneously inserted high-density probes revealed rhythmic fusion of the retrosplenial cortex with anatomically connected components of the thalamus circuit but separation from other brain regions—including a notable inverse correlation with anteriorly protruding thalamic nuclei. While testing for causal significance, they found that rhythmic optogenetic activation of retrosplenial cortex layer 5 neurons recapitulated dissociation-like behavioral effects. Cyclic-nucleotide-gated potassium channel 1 pacemaker activated by local retrosplenial hyperpolarization have been required for systemic ketamine to induce this rhythm and elicit dissociation-like behavioral effects. From these results, it may be clear that molecular, cellular, and physiological properties of a conserved deep posteromedial cortical rhythm may underlie states of dissociation. Moreover, the authors have emphasized that in animals with these changes compared to human focal epilepsy, simultaneous intracranial stereo encephalography recordings from all over the brain have revealed a similarly localized rhythm in the homologous deep posteromedial cortex, which temporally correlated with preseizure self-reported dissociation, and local brief electrical stimulation of this region has elicited dissociative experiences [5]. This section has briefly reviewed the salient studies and debates regarding possible dissociative mechanisms in the mammalian and human brain. The study of the biological mechanism of dissociation in animals may provide an additional perspective.

 he Phenomena of Trauma and Distress T in Animals Existing evidence shows the presence of various phenomenological dimensions of PTSD in chimpanzees and other animals [18, 19]. Further evidence comes from studies focusing on the fear and stress elicited in mice experiments. Mice

H. Belli

show increases in hyperarousal, emotional blunting, persistent fear, and sensitive fear of social withdrawal, as seen in PTSD [20]. A study, on juvenile rats which have been designed for childhood trauma, has shown that exposing the rats to garbage washed in cat urine raised the likelihood that they would create long-term behavioral disturbances thought to describe PTSD symptom equals. Responses continued when rats were exposed a second time in adulthood [21]. Mice with juvenile trauma were also more likely to have been re-traumatized later in life. They may have more current PTSD-like symptoms. Automatic regrettable memories, distressing dreams, dissociative effect, intensive psychological distress, and physiological stress replies at exposure to internal or external cues that symbolize aspects of the traumatic event may occur, whereby affected individuals undertake efforts to avoid thoughts, memories, and feelings associated with the traumatic event. Distorted cognitions regarding the causality or results are frequently associated with acute stress disorder and PTSD, usually concerning self-blame and negative anticipations about oneself or others [22]. A single or repeated experience of severe traumatic, life-­ threatening events causes acute stress disorder and PTSD. Concerning the character of the trauma, events that threaten the purpose of important biosocial plans are more likely to produce acute stress disorder and PTSD than events that do not interfere with biosocial goals. Behaviorally, PTSD can be viewed as a defensive strategy [23]. PTSD contains several defenses that seem to be arranged hierarchically. These include avoidance, mindful immobility, withdrawal, aggressive defense, appeasement, tonic immobility, vigilance, and risk check. All of these can be conceptualized as ancient survival instruments, some of which evolved millions of years ago in our vertebrate ancestors. Others more closely reflect our primate lineage and human aspects of memory formation [24]. Several reports suggest that PTSD may occur in captive non-human primates following traumatization through the early detachment of infants from their mothers, solitary accommodation in small cages, and repetitive anesthesia for biomedical research [18, 22]. High attention levels help notice potential risks; thus, attention can serve, above all, the goal of preparing the organism for imminent danger [23]. From an ethological point of view, detailed observation of the environment may have evolved to avoid the predator threat. In species that live under stable predator threats, such vigilance is adaptive and chronic predator threats do not disrupt the stress response system [25]. It seems that species with a long life history are more likely to have chronic stress responses, while species with a short lifespan do not generate signs of chronic stress [22]. Animals of many species need early parental support for their development. This situation is a basic process that can directly be observed. Animals also commonly bond with their

21  Dissociation in Animals

species for adequate social support and development. This view drives attachment as the primary biological development during early life. Interaction between the parent and offspring, especially the mother, becomes a very important biological factor. While noting the developmental effects of this interaction, if the mother is absent early in life, some authors claim that the offspring are likely to develop stereotypic behaviors. Mother-deprived animals develop several changes in neurotransmitter activity and anxiety and stress responses, including increases in stereotypical behavior [3, 26]. Researchers have reported that early separation from mothers also results in a range of negative behavioral and social effects in primate infants [3]. Early separation from mother can be considered as a serious traumatic experience for animals as well. Evolution is an approach that cannot directly be observed. It has to be inferred from observation; nonetheless, there is no suspicion that evolutionary approaches have shaped humans and animals cognition, emotion, behavior, and traumatic experiences in the same way as neurobiology. Biological defense mechanisms developed against traumatic and stressful experiences may have a common origin in this context.

Conclusion This chapter has presented a brief review of the relevant areas of investigation and debates that some neurobiological reactions in animals and the dissociation-like process are prominently interconnected. As for freeze response on possible neurobiological mechanisms of the brain, the trigger influence of stress on the brain has been described as well as the dissociation-like appearance of animals and the effects of neural reaction on the hypnotic phenomenon. The similarity between hypnotic phenomena and dissociative processes is obvious. The role of the freeze response-related hypnotic phenomenon and its neurobiological mechanisms in mediating this neural interaction should be investigated further. Common evolutionary influences on this activity included evidence that certain neural system products may have profound effects on the function of survival as a dissociative defense mechanism. The apparent interdigitations between the dissociation and evolutionary survival mechanisms may provide the basis for investigations into the relationship between specific stressful, traumatic experiences and neurobiological mechanisms such as complex dissociative disorders in human beings. It is suggested that mechanisms in the occurrence of PTSD and pathological dissociation similarity be evaluated in animal studies. Phenomena occurring in PTSD tend to have a high level of dissociative symptoms and similar formation mechanisms and thus may be more likely to have stress responses originating from basic evolutionary defense

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mechanisms. However, the studies evaluating dissociation and PTSD-like symptoms have not adequately addressed common evolutionary mechanisms in animals. Whether the basic evolutionary defense mechanisms associated with the dissociative process may be specific in animals and humans awaits clarification. Of equal importance is a better understanding of the biological mechanisms underlying PTSD-­ related alterations. Thus, by studying dissociation and PTSD in animal models, more about brain functioning in both processes (pathological or natural) may be learned. This chapter has also reviewed the salient studies and debates regarding the consequences of NMDA antagonists in animals that are blocked by drugs that attenuate glutamate release. It is suggested that NMDA antagonists may transiently provoke glutamate release and create symptoms resembling dissociative states. Furthermore, it is hypothesized that the dissociation-like state can be induced by the administration of ketamine or phencyclidine in mice. Further evaluation of specific brain structures has shown that the dissociative process may be related to environmental stress and increased glutamatergic activity. In addition, this debate suggests that the level of NMDA receptor blockade may have therapeutic or aggravating effects on pathology. This is particularly relevant because recent studies have found a positive effect between the administration of ketamine and decreased symptoms of depression and PTSD. Further investigation of the molecules with similar effects in complex dissociative disorders should focus predominantly on specific neurobiological mechanisms. Bradley et al. have suggested that the possible contributions of hyperglutamatergic states to the acute and long-term consequences of exposure to traumatic stress, drugs that reduce glutamate release, may have therapeutic and neuroprotective potential in traumatized individuals with dissociative symptoms [27]. The observations and studies in animals and humans that dissociation and related other mental states are associated with altered reactions to environmental factors that produce stress suggest that brain processes may influence the onset and course of complex disorders in which the basic evolutionary mechanisms play a prominent role. As a specific treatment approach should focus on these underlying neurological mechanisms, the role of interacting biological systems, stress response, NMDA receptors, and traumatic experiences may also be further clarified.

References 1. Scaer RC.  The neurophysiology of dissociation and chronic disease. Appl Psychophysiol Biofeedback. 2001;26:73–91. 2. Nijenhuis ERS, Vanderlinden J, Spinhoven P.  Animal defensive reactions as a model for trauma-induced dissociative reactions. J Trauma Stress. 1998;11:243–60.

132 3. Ferdowsian H, Merskin D.  Parallels in sources of trauma, pain, distress, and suffering in humans and nonhuman. Animals. 2012;13:448–68. https://doi.org/10.1080/15299732.2011.652346. 4. Chambers RA, Bremner JD, Moghaddam B, Southwick SM, Charney DS, Krystal JH.  Glutamate and post-traumatic stress disorder: toward a psychobiology of dissociation. Semin Clin Neuropsychiatry. 1999;4:274–81. 5. Vesuna S, Kauvar IV, Richman E, et al. Deep posteromedial cortical rhythm in dissociation. Nature. 2020;586:87–94. 6. Hofer MA.  Cardiac and respiratory function during sudden prolonged immobility in wild rodents. Psychosom Med. 1970;32:633–47. 7. Richter CP.  On the phenomenon of sudden death in animals and man. Psychosom Med. 1957;19:191–8. 8. van der Kolk BA.  The compulsion to repeat the trauma: re-­ enactment, revictimization, and masochism. Psychiatr Clin N Am. 1989;12:389–411. 9. Corriger A, Pickering G.  Ketamine and depression: a narrative review. Drug Des Devel Ther. 2019;13:3051–67. 10. Feder A, Costi S, Rutter SB, et al. A randomized controlled trial of repeated ketamine administration for chronic posttraumatic stress disorder. Am J Psychiatry. 2021;178:193–202. 11. Vyklicky V, Korinek M, Smejkalova T, et  al. Structure, function, and pharmacology of NMDA receptor channels. Physiol Res. 2014;63:191–203. 12. Krystal JH, Karper LP, Seibyl JP, Freeman GK, Delaney R, Bremner JD, Heninger GR, Bowers MB, Charney DS. Subanesthetic effects of the noncompetitive NMDA antagonist, ketamine, in humans. Psychotomimetic, perceptual, cognitive, and neuroendocrine responses. Arch Gen Psychiatry. 1994;51:199–214. 13. Chen F, Ye Y, Dai X, Zheng Y, Fang S, Liao L. Metabolic effects of repeated ketamine administration in the rat brain. Biochem Biophys Res Commun. 2020;522:592–8. 14. Morgan CJA, Muetzelfeldt L, Curran HV. Consequences of chronic ketamine self-administration upon neurocognitive function and psychological wellbeing: a 1-year longitudinal study. Addiction. 2010;105:121–33. 15. Edward Roberts R, Curran HV, Friston KJ, Morgan CJA. Abnormalities in white matter microstructure associated with chronic ketamine use. Neuropsychopharmacology. 2014;39:329. 16. Bagley J, Moghaddam B.  Temporal dynamics of glutamate efflux in the prefrontal cortex and in the hippocampus following

H. Belli repeated stress: effects of pretreatment with saline or diazepam. Neuroscience. 1997;77:65–73. 17. Gresch PJ, Sved AF, Zigmond MJ, Finlay JM. Stress-induced sensitization of dopamine and norepinephrine efflux in medial prefrontal cortex of the rat. J Neurochem. 1994;63:575–83. 18. Bradshaw GA, Capaldo T, Lindner L, Grow G. Building an inner sanctuary: complex PTSD in chimpanzees. J Trauma Dissociation. 2008;9:9–34. 19. Brüne M, Brüne-Cohrs U, McGrew WC, Preuschoft S. Psychopathology in great apes: concepts, treatment options and possible homologies to human psychiatric disorders. Neurosci Biobehav Rev. 2006;30:1246–59. 20. Siegmund A, Wotjak CT.  Toward an animal model of posttraumatic stress disorder. Ann N Y Acad Sci. 2006;1071: 324–34. 21. Cohen H, Matar MA, Richter-Levin G, Zohar J. The contribution of an animal model toward uncovering biological risk factors for PTSD. Ann N Y Acad Sci. 2006;1071:335–50. 22. Brüne M. Textbook of evolutionary psychiatry and psychosomatic medicine. 2015: 1:220–221. 23. Cantor C. Post-traumatic stress disorder: evolutionary perspectives. Aust N Z J Psychiatry. 2009;43:1038–48. 24. Chris C. Evolution and posttraumatic stress: disorders of vigilance and defence. 2005. 25. Boonstra R.  Reality as the leading cause of stress: rethinking the impact of chronic stress in nature. Funct Ecol. 2013;27: 11–23. 26. Latham NR, Mason GJ. Maternal deprivation and the development of stereotypic behaviour. Appl Anim Behav Sci. 2008;110:84–108. 27. Bradley SR, Uslaner JM, Flick RB, Lee A, Groover KM, Hutson PH.  The mGluR7 allosteric agonist AMN082 produces antidepressant-­like effects by modulating glutamatergic signaling. Pharmacol Biochem Behav. 2012;101:35–40. Hasan Belli  MD is an Associate Professor of Psychiatry at the Health Sciences University at the Bagcilar Training and Research Hospital (Turkey); he has worked in the area of treatment of persons with schizophrenia, personality disorders, and dissociative disorders for 20 years. Dr. Belli has written dozens of papers in the field of schizophrenia, personality disorders, consultation-liaison psychiatry, and dissociative disorders.

Genetics and Dissociative Identity Disorder (DID)

22

Nana Bonsu, Venkatesh Sreeram, and Faiz M. Hasan

Dissociative identity disorder (DID) is a type of dissociative disorder that is recognized in DSM V. It is a rare psychiatric disorder that is diagnosed in approximately 1.5% of the world’s population [1]. Higher rates occur in people seeking treatment for other psychiatric disorders and in groups that have been exposed to trauma [2]. Dissociative disorders are best described as a “disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” [3]. DID is a condition in which the individual’s consciousness is split into two or more discrete dissociative states [4]. The exact etiology of DID is not fully understood and some have deemed it to be multifactorial in nature [5]. Environment can play a role in inhibiting an integrated sense of personalities and the etiology of dissociation is most associated with environmental influences [6, 7]. There has not been any thorough analysis of genetics has occurred in DID at this time [5]. However, there has been research regarding the genetics of dissociative disorders in general. Childhood trauma has also been documented to be related to dissociation in adulthood [8]. However, genetic causes have been postulated as well. Dissociation has been found to be a frequent, but not a universal response to trauma. For instance, about 20–25% of persons exposed to a disaster may experience transient dissociative symptoms, but only a low amount of these individuals will fulfill criteria for a later dissociative disorder [9]. A comparable study of women who had been held captive and subjected to sexual violence by a militant group found that only 41% met the criteria for a dissociative disorder [10]. These findings would indicate that dissociation is not an invariable result of traumatic stress, even when it is serious and persistent. This suggests that N. Bonsu (*) Emory School of Medicine, Atlanta, GA, USA V. Sreeram Baylor College of Medicine, Houston, TX, USA F. M. Hasan Dartmouth Hitchcock Medical Center, Lebanon, NH, USA

some of this disparity is due to an inherent predilection that is at least partly genetic in origin [11, 12]. Twin studies have also supported the hypothesis that dissociative disorders have a heritable component [7, 13]. Some individuals have been described as having a “natural, inborn capacity to dissociate” [14], and some authors have postulated that there is a biological capacity to dissociate [15]. UP to 90% of persons may experience some form of dissociative phenomena at some point in their lives [16] and this has been linked to many different psychiatric conditions [17, 18]. Additive genetic influences accounted for 48% and 55% of the variance in scales measuring pathological and nonpathological dissociative experiences, respectively. This suggests that there are common genetic factors underlying pathological and nonpathological dissociative capacity. When familial patterns have been observed for dissociative disorders, they have usually been described as occurring solely on the basis of psychological mechanisms, such as exposure to trauma or learned behavior [19]. Studying molecular patterns will allow for a more accurate understanding of the place that dissociative disorders hold in psychiatric classification. Research has shown that there is some preliminary evidence which shows an association between dissociative symptomatology and variations in individual genes. The genes that have been linked are related to neural plasticity (BDNF), the regulation of the hypothalamic–pituitary–adrenal axis (FKBP5), monoaminergic transmission (5-HTT, COMT), and neuropeptide receptors (OXTR). Though the findings have not always been constant, these genes have often been linked with other stress- and trauma-related symptoms and disorders [20– 23]. Dissociative symptoms have been linked with a poorer response to serotonergic antidepressants in patients being treated for other disorders [24, 25]. It has also been noted that the pharmacological manipulation of serotonergic transmission can induce dissociative symptoms [26]. Research has shown that increased levels of noradrenaline and dopamine are found in certain dissociative states [27]. Dissociative disorders, in general, are associated with higher levels of oxytocin

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_22

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3. Stein DJ, Craske MA, Friedman MJ, Phillips KA.  Anxiety disorders, obsessive-compulsive and related disorders, traumaand stressor-related disorders, and dissociative disorders in DSM-5. Am J Psychiatry. 2014;171:611–3. 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC: Author; 2013. 5. Sar V, Dorahy M, Krüger C. Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychol Res Behav Manag. 2017;10(10):137–46. https://doi.org/10.2147/ prbm.s113743. 6. McGuffin P, Rijsdijk F, Andre M, et al. The heritability of bipolar affective disorder and the genetic relationship to unipolar depression. Arch Gen Psychiatry. 2003;60:497–502. 7. Becker-Blease K, Deater-Deckard K, Eley T, Freyd J, Stevenson J, Plomin R.  A genetic analysis of individual differences in dissociative behaviors in childhood and adolescence. J Child Psychol Psychiatry. 2004;45:522–32. 8. Irwin HJ. Proneness to dissociation and traumatic childhood events. J Nerv Ment Dis. 1994;182:456–60. 9. Canan F, North CS. Dissociation and disasters: a systematic review. World J Psychiatry. 2019;9:83–98. 10. Kizilhan JI, Steger F, Noll-Hussong M.  Shame, dissociative seizures and their correlation among traumatised female Yazidi with experience of sexual violence. Br J Psychiatry. 2020;216:138–43. 11. Mai FM. “Hysteria” in clinical neurology. Can J Neurol Sci. 1995;22:101–10. 12. Palomo T, Kostrzewa RM, Beninger RJ, Archer T. Genetic variation and shared biological susceptibility underlying comorbidity in neuropsychiatry. Neurotox Res. 2007;12:29–42. 13. Jang KL, Paris J, Zweig-Frank H, Livesley WJ. Twin study of dissociative experience. J Nerv Ment Dis. 1998;186:345–51. 14. Braun BG, Sachs RG. The development of multiple personality disorder: predisposing, precipitating and perpetuating factors. In: Kluft RP, editor. Childhood antecedents of multiple personality disorder. Washington, DC: American Psychiatric Press; 1985. p. 37–64. 15. Kluft RP. An introduction to multiple personality disorder. Psychiatr Ann. 1984;14:19–24. 16. Atchison M, McFarlane A. A review of dissociation and dissociative disorders. Aust N Z J Psychiatry. 1994;28:591–9. 17. Dunn G, Ryan J, Paolo A, Van Fleet J. Comorbidity of dissociative disorders among patients with substance use disorders. Psychiatr Serv. 1995;46:153–6. Conclusion 18. Feeny N, Zoellner L, Fitzgibbons L, Foa E.  Exploring the role of emotional numbing, depression and dissociation in PTSD.  J Trauma Stress. 2000;13:489–98. Despite there being a relatively low amount of research in 19. Harkness D. Testing Cernak’s hypothesis: is dissociation the medithis area, there appears to be some linkage between “stress-­ ating variable that links substance abuse in the family of origin with related” neural mechanisms and novel genetic loci of interoffspring codependency? J Psychoactive Drugs. 2001;33:75–82. est. These results will hopefully provide a foundation that 20. Rasmusson AM, Pineles SL. Neurotransmitter, peptide, and steroid will allow a better understanding of dissociative disorders. hormone abnormalities in PTSD: biological Endophenotypes relevant to treatment. Curr Psychiatry Rep. 2018;20:52. However, it is important to note that these findings are lim21. Navarro-Mateu F, Escámez T, Koenen KC, Alonso J, Sánchez-­ ited. More genetic research regarding DID would further Meca J. Meta-analyses of the 5-HTTLPR polymorphisms and post-­ illuminate the interaction of the individual with environmentraumatic stress disorder. PLoS One. 2013;8:e66227. tal stress. 22. Suliman S, Hemmings SM, Seedat S. Brain-derived neurotrophic factor (BDNF) protein levels in anxiety disorders: systematic review and meta-regression analysis. Front Integr Neurosci. 2013;7:55. 23. Mendonça MS, Mangiavacchi PM, Rios Á. Regulatory functions References of FKBP5 intronic regions associated with psychiatric disorders. J Psychiatr Res. 2021;143:1–8. 1. Mitra P, Jain A.  Dissociative identity disorder. [Updated 2022 24. Gulsun M, Doruk A, Uzun O, Turkbay T, Ozsahin A.  Effect of May 17]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls dissociative experiences on drug treatment of panic disorder. Clin Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/ Drug Investig. 2007;27:583–90. NBK568768/ 25. Bob P, Susta M, Gregusova A, Jasova D, Raboch J, Mishara 2. Rajkumar RP. The molecular genetics of dissociative symptomatolA. Traumatic stress, dissociation, and limbic irritability in patients ogy: a transdiagnostic literature review. Genes. 2022;13(5):843. with unipolar depression being treated with SSRIs. Psychol Rep. https://doi.org/10.3390/genes13050843. 2010;107:685–96.

and prolactin and decreased levels of tumor necrosis factoralpha [28]. Cortisol secretion is altered in both pathological and nonpathological dissociative experiences [29]. One study has shown the interaction between physical neglect and the S/S genotype of the 5-HTT gene to significantly predict dissociation symptom severity [28]. Additional outcomes include differences in dissociative symptoms between different single nucleotide polymorphisms (SNPs), a report on dissociative symptoms to correlate most strongly with five SNPs on chromosome 8 in the adenylyl cyclase8 (ADCY8) gene, and another SNP correlating with dissociative symptoms on chromosome 7  in the dipeptidyl-peptidase 6 (DPP6) gene, which was gender dependent and an association between lower levels of dissociation and low-activity of the “Met allele” of the BDNF-­ Val66Met polymorphism [30–32]. Studies related to genome-wide association have shown that loci within the ADYC8, DPP6, and APBB2 genes are connected to dissociative disorders. These loci have been linked to trauma-related alterations in brain development [2]. Some study designs have noted that interleukin-6 (IL-6) is elevated in individuals who are experiencing dissociative symptoms in depression and other trauma spectrum disorders [33, 34]. It is important to note that these findings provide a certain degree of biological acceptability to the results of single-­ gene association studies; it is also important to note that these findings have not been duplicated reliably and that these loci were identified as being unrelated to, or only slightly associated with, dissociation in a genome-wide analysis [2].

22  Genetics and Dissociative Identity Disorder (DID) 26. Lacy T, Mathis M.  Dissociative symptoms from combined treatment with sertraline and trazodone. J Neuropsychiatr Clin Neurosci. 2003;15:241–2. 27. Kawai N, Honda M, Nakamura S, Samatra P, Sukardika K, Nakatani Y, Shimojo N, Oohashi T.  Catecholamines and opioid peptides increase in plasma in humans during possession trances. Neuroreport. 2001;12:3419–23. 28. Roydeva MI, Reinders AATS.  Biomarkers of pathological dissociation: a systematic review. Neurosci Biobehav Rev. 2021;123:120–202. 29. Boulet C, Lopez-Castroman J, Mouchabac S, Olié E, Courtet P, Thouvenot E, Abbar M, Conejero I. Stress response in dissociation and conversion disorders: a systematic review. Neurosci Biobehav Rev. 2022;132:957–67. 30. Tadić A, Baskaya Ö, Victor A, Lieb K, Höppner W, Dahmen N.  Association analysis of SCN9A gene variants with borderline

135 personality disorder. J Psychiatr Res. 2008;43(2):155–63. https:// doi.org/10.1016/j.jpsychires.2008.03.006. 31. Wolf EJ, Rasmusson AM, Mitchell KS, Logue MW, Baldwin CT, Miller MW.  A genome-wide association study of clinical symptoms of dissociation in a trauma-exposed sample. Depress Anxiety. 2014;31(4):352–60. https://doi.org/10.1002/da.22260. 32. Savitz JB, van der Merwe L, Newman TK, Solms M, Stein DJ, Ramesar RS. The relationship between childhood abuse and dissociation. Is it influenced by catechol-O-methyltransferase (COMT) activity? Int J Neuropsychopharmacol. 2007;11(02) https://doi. org/10.1017/s1461145707007900. 33. Bob P, Raboch J, Maes M, Susta M, Pavlat J, Jasova D, Vevera J, Uhrova J, Benakova H, Zima T.  Depression, traumatic stress and interleukin-6. J Affect Disord. 2010;120:231–4. 34. Hori H, Kim Y.  Inflammation and post-traumatic stress disorder. Psychiatry Clin Neurosci. 2019;73:143–53.

Dissociative Identity Disorder and the Human Brain; Neuroanatomy

23

Faiz M. Hasan, Nana Bonsu, and Venkatesh Sreeram

Introduction You are not multiple personalities when you experience DID. You are fragmented versions of yourself. The reason that the brain splits in this regard, it’s always a protective mechanism.— Mental Health: Multiple Personality Disorder, 2020 [1]

In this chapter, we explore dissociative identity disorder and its link to neuroscience. The hallmark of DID suggests the presence of multiple personalities within an individual, where periods of dissociation disrupt the normal mental processes and one’s environment. There is limited evidence regarding brain changes in patients with DID, but several studies and research propose that patients suffering from the disorder have a cortico-limbic disconnect. The brain structures responsible for producing symptoms consistent with DID (i.e., amnesia, blurred sense of identity & reality, detachment from self-regulation, emotional stress burden, etc.) include but are not limited to the orbitofrontal cortex, amygdala, anterior cingulate cortex, and so forth. Vastly, as similarly and consistently demonstrated through the studies of viral pathologic disease wherein the blood-brain barrier is infiltrated, the brain system remains vulnerable. In this disorder, the aforementioned regions of the brain interfere with one’s ability to process and perceive. Many studies debate the neuroanatomical changes observed in DID with a strong correlation. Some hypothesized developments have demonstrated consistent similarities in the belief, particularly as the disorder is directly a result of childhood trauma. This suggests that there is most likely involvement of the amygdala as a result. Another theory is the implication of hippocampal involvement subsequently causing memory impairment [2]. F. M. Hasan (*) Dartmouth-Health, Geisel School of Medine, Lebanon, NH, USA N. Bonsu Emory School of Medicine, Atlanta, GA, USA V. Sreeram Baylor College of Medicine, Houston, TX, USA

Furthermore, alterations of glucose metabolism in the temporal and parietal lobes in DID play a role in loss or altered consciousness and shifting personalities. Due to a lack of understanding and validity regarding the etiopathology of DID, many psychiatrists and researchers consider DID a severe form of childhood-onset post-traumatic stress disorder (PTSD) because it is nearly impossible to find a patient without a history of PTSD [3]. In addition, DID shares common features with PTSD such as identity disruption in two or more distinct personalities.

Discussion Neuroimaging Evidence supporting the brain changes observed in patients with DID is limited. However, several studies have proposed structural alterations in components of the cortico-limbic system and blood flow to the cerebral structures [4]. To the present day, though the accurate neurobiological underpinnings of dissociation remain inconclusive, there is an increasing number of neuroimaging studies in persons with DID and PTSD, which attribute dissociative symptoms in brain function to structural alterations. One of the most important tools of clinical neurobiology is the use of neuroimaging techniques, such as positron emission tomography (PET), magnetic resonance imaging (MRI), diffuse tensor imaging (DTI), and MR spectroscopy (MRS) [5]. PET scans provide pivotal information in the detection of glucose metabolism. Also, the detection of blood-oxygen-­ level changes provides a measure of brain activity when observed at rest versus task states. MRS imaging provides neurochemical metabolites like glutamate, choline, or lactate in the brain. Structural and anatomical abnormalities in gray or white matter volume can be demonstrated using MRI and DTI methods. These are some studies utilized to detect abnormalities in the brain.

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Cortico-Limbic Disconnect Model

activity in the occipitotemporal cortex, ACC, and insula in comparison to OCD and HC subjects. The insula serves a In 1998, Sierra et al. postulated that depersonalization symp- vital role in modulating attention, negative emotions, pain, toms are likely correlated with disconnection of the cortico-­ and awareness of stimuli, and reduced volume in this area limbic brain network, involving the prefrontal region, reflects reduced interoceptive awareness in depersonalization amygdala, and anterior cingulate cortex (ACC). This model disorder, supporting the notion of neuroanatomical changes described depersonalization as a state of subjective detach- observed in this condition. Further investigations are necesment manifesting as empty thoughts, emotional numbing, sary for this under-researched psychiatric disorder (Fig. 23.1). analgesia, and hypervigilance [2]. Given these symptoms, it Another notable study conducted by Vermetten and colwas proposed that increased activity in the medial prefrontal leagues [8] compared hippocampal and amygdala volumes and dorsolateral prefrontal cortex – regions responsible for in female patients suffering from DID versus healthy subattention, arousal, and cognitive modulation – were associ- jects. The aim of this study postulated that stress-related psyated with the findings. As recruitment in the prefrontal cortex chiatric conditions, such as post-traumatic stress disorder, increased, this led to a downstream effect in the amygdala childhood trauma, depression in the context of abuse, and with marked attenuation of automatic responses. There is borderline personality disorder, demonstrate a smaller volwell-known fundamental involvement of the amygdala in the ume in the hippocampal and amygdala regions. Volumetric salience network detection and processing of emotions such measurements in the two groups were compared where there as inception of fear and stress responses. Thus, this may be was a reduction in hippocampal and amygdala volumes by associated with reduced reaction in this area during detach- 19.2% and 31.6%, respectively, in patients with DID when ment states. compared to healthy individuals. An investigation conducted by Phillips et  al. [6] studied brain activity using functional magnetic resonance imaging (fMRI). This study measured brain activity while presenting Brain Networks aversive versus neutral images in patients with chronic depersonalization disorder had compared them with patients with The cortico-limbic brain network as demonstrated consists obsessive-compulsive disorder (OCD), and healthy controls of the prefrontal cortices, hippocampus, and amygdala. (HC). In feedback to aversive images, subjects with deper- These structures in combination integrate cognition with sonalization disorder exhibited less arousal with diminished emotion, producing a behavioral output that is flexible based

Prefrontal cortical structures Goal-directed behavior, cognitive control, regulation of impulses and emotions

Anterior Cingulate arousal modulation, emotion processing, inhibitory control

Inferior frontal gyrus Inhibitory control, attention, language processing

Fusiform gyrus Visual processing, language processing Lingual gyrus Visual processing, language, attention

Posterior cingulate Precuneus

lnsula

Self-referential processing

Salience detection, bodily awarenes

Amygdala Emotion processing, Initiation of stress and fear responses, salience detection Salience and emotion prosessing

Hippocampus Memory, stress responses Self-referential processing

Thalamus Sensory relay station

Fig. 23.1  Illustrates the brain regions and their functions [7]

Superior temporal gyrus Social cognition, memory

23  Dissociative Identity Disorder and the Human Brain; Neuroanatomy

on the environmental circumstances and plays a role in addressing pain, both adaptive and maladaptive. In DID, the patients have a strong history linked with emotional pain and trauma. Evidence supports that genetic factors may also contribute to personality disorders. Though general symptoms of personality disorders are ego-syntonic, patients with personality disorders are associated with a wide range of problems in social and educational functioning but there is no evidence of the difference in education levels when compared to those without personality disorders. The prefrontal cortex (PFC) plays a key role in cognitive control modulated by dopamine. This influences attention, impulse inhibition, expected memory, and flexibility of cognition. Imbalance in PFC functioning is commonly observed in DID. Given the mentioned structures, we can understand how shifting personalities create a new genre or “character” an individual may encounter. One personality, or split personality, may demonstrate little to no recollection of memories saved by the host personality. Furthermore, PFC connection with hippocampal structures plays a major role in memory and learning. The hippocampus is a relatively complex brain. structure embedded deep into the temporal lobes bilaterally. Dysfunction in the hippocampus is thought to result in reduced memory encoding, spatial navigation, and consolidation of memory as seen with DID. Involvement of the parieto-occipitotemporal cortex of the nondominant hemisphere influences one’s ability to read, perform mathematical operations, and think through logical problems. Psychological studies in patients with such damaged regions suggest that this hemisphere is quintessential for comprehending nonverbal visual experiences, spatial relationships between the person and their surroundings, intonations of people’s voices, and potentially many somatic-­ related experiences pertaining to the use of hands and limbs. As the disruption is discussed in DID, we can illustrate the pathological consequences of dysregulation within this network. As a result, patients of DID may also experience depersonalization and derealization symptoms, and it is hypothesized that the cause is related to a disturbance in the occipitoparietal region of the brain. Few research studies aimed to investigate the characteristics of regional cerebral blood flow (rCBF) in dissociative identity disorders. Reinders et al. [3] compared the neutral personality state (NPS) and traumatic personality states in patients with DID by measuring rCBF. The method of this study subjected patients to listening to a memory script, and interestingly, there was no change observed between the NPS and TPS patients whilst hearing the neural script, nor was there a difference in the neutral or traumatic scripts for NPS subjects. However, when the traumatic script was induced during NPS, they found observable deactivation brain patterns. The findings concluded that patients with

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DID possess a contrasting autobiographical sense of self. Other findings of this study demonstrated a reduction in the medial prefrontal cortex, thus illustrating an opinion regarding the involvement of the orbitofrontal cortex seen in DID.  Several prior studies and authors suggested the OFC involvement in this condition.

Glutamate’s Role in Neurotransmission Glutamic acid or glutamate as known in its ionic form, is an alpha-amino acid used by almost all living beings in the biosynthesis of proteins. It is the most abundant excitatory neurotransmitter in the central nervous system and serves as the precursor for the synthesis of gamma-aminobutyric acid (GABA). Within the nervous system, glutamate’s neurotransmitter role in synaptic plasticity is involved in cognitive functions including learning and memory formation in the brain. This long-term potentiation is a form of neuronal plasticity – and takes place at the glutamatergic synapses located in the hippocampus, limbic system, and other brain regions. The N-methyl-D-aspartate receptor, more commonly known as NMDA receptor, is activated upon the binding of glutamate. Similarly, Ketamine is a well-known, well-controlled substance primarily used to induce and maintain anesthesia. The mechanism of action is through antagonism of the NMDA receptor, which accounts for most of its anesthetic and dissociative effects except as an anti-depressive agent – at significantly lower sub-threshold anesthetic doses; Ketamine is used in patients with treatment-resistant depression. However, a commonly understood and clinically evident phenomenon of Ketamine is its ability to induce dissociative anesthesia, creating a trance-like state in its patients while providing sedation, pain relief, and amnesia. Ketamine is also used for recreational purposes, often referenced as “Special K” for its dissociative and hallucinogenic accouterments. In DID, patients experience similar, if not identical, symptoms to that of Ketamine administration – via NMDA-receptor modulation. Therefore, is DID an indirect result of NMDA blockade? One cannot simply ignore the correlation of effects, and it is note-worthy for further investigative research.

Conclusion Dissociative identity disorder is a neuropsychiatric and pathophysiological disorder that is a highly understudied topic in mental health. The precise neurobiological underpinnings of dissociative identity disorder remain inconclusive, but there is evidence supporting the link between dissociative states and potential neuro-alterations. Current

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research suggests these specific areas regulate memory and emotional processing data, along with arousal modulation, which is altered in their functions. The involvement in vast areas of the limbic system and PFC explain dissociative symptoms as a direct result of both short and long-term memory impairment. Like the effects of Ketamine regulated via NMDA receptors, DID patients experience identical effects of this drug. This creates the question of NMDA regulatory agents as potential treatment options. An option is the measurement of glutamate levels in persons with DID. Should levels be found to be elevated, one may consider glutamate blockade as a viable treatment intervention in patients with DID, but further research is required prior to this premature ideation. Future studies may indicate how these brain changes during dissociative states cause the disruption of cognitive functioning and distorted reality. Many researchers and scholars propose that dissociation stems from some form of trauma with a decreased recollection of the trauma-related information. Further neuroimaging research investigations are required and tasked to better understand the correlation between dissociation and cognition.

References 1. Thompson JM, Neugebauer V. Cortico-limbic pain mechanisms. Neurosci Lett. 2019;29;702:15−23. https://doi.org/10.1016/j.neulet.2018.11.037. Epub 2018 Nov 29. PMID: 30503916; PMCID: PMC6520155.

F. M. Hasan et al. 2. Blihar D, Crisafio A, Delgado E, Buryak M, Gonzalez M, Waechter R.  A meta-analysis of hippocampal and amygdala volumes in patients diagnosed with dissociative identity disorder. J Trauma Dissociation. 2021;22(3):365–77. https://doi.org/10.1080/1529973 2.2020.1869650. Epub 2021 Jan 12. PMID: 33433297 3. Reinders AATS, Veltman DJ. Dissociative identity disorder: out of the shadows at last? Br J Psychiatry. 2021;219(2):413–4. https:// doi.org/10.1192/bjp.2020.168. PMID: 33023686 4. Rutkofsky I, Khan A, Sahito S, Aqeel N, Tohid H. The neuropsychiatry of dissociative identity disorder: why split personality patients switch personalities intermittently? Cell Sci Ther. 2017;08 https:// doi.org/10.4172/2157-­7013.1000267. 5. Le C, Smith J, Cohen L.  Mirror writing and a dissociative identity disorder. Case Rep Med. 2009;2009:814292. https://doi. org/10.1155/2009/814292. Epub 2009 Oct 26. PMID: 19865491; PMCID: PMC2766827 6. Phillips ML, Medford N, Senior C, Bullmore ET, Suckling J, Brammer MJ, Andrew C, Sierra M, Williams SC, David AS.  Depersonalization disorder: thinking without feeling. Psychiatry Res. 2001;108(3):145–60. https://doi.org/10.1016/ s0925-­4927(01)00119-­6. PMID: 11756013 7. Krause-Utz A, Frost R, Winter D, Elzinga BM.  Dissociation and alterations in brain function and structure: implications for borderline personality disorder. Curr Psychiatry Rep. 2017;19(1):6. https://doi.org/10.1007/s11920-­017-­0757-­y. PMID: 28138924; PMCID: PMC5283511 8. Vermetten E, Schmahl C, Lindner S, Loewenstein RJ, Bremner JD. Hippocampal and Amygdalar volumes in dissociative identity disorder. Am J Psychiatry. 2006;163:630–6.

Pathophysiology of Dissociative Identity Disorder

24

Justin Mark, Qaas Shoukat, Jack Bayer, and Emily Harris

Big Picture: Dissociation → Conversion Dissociative identity disorder (DID) is characterized by the DSM V by two or more distinct personality states, which may be described by some cultures as an experience of possession. In the dissociated state, there is a marked discontinuity in the sense of self. This marked discontinuity leads to alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. The affected individual may notice these signs and symptoms; however, more commonly, the dissociated episodes are observed by other individuals due to the affected patient’s complete lack of recall during the dissociative episode.

Impairment of Daily Living The gaps in recall of everyday events and important personal information are clinically significant and are inconsistent with ordinary forgetfulness. These symptoms are likely to cause significant distress and/or impairment in social, occupational, or other important areas of functioning. In order to be consistent with the DSM V criteria, the disturbance of a dissociative episode is not a normal part of a broadly accepted cultural or religious practice. Certain groups including those in rural areas, certain religious practices, people in the developing world, etc., may be more likely to take on possessed J. Mark (*) University of Miami Miller School of Medicine, Fort Lauderdale, FL, USA e-mail: [email protected] Q. Shoukat HCA Florida Aventura Hospital, Aventura, FL, USA e-mail: [email protected] J. Bayer Morristown Medical Center, Morristown, NJ, USA e-mail: [email protected] E. Harris HCA Florida St. Lucie Hospital, Port St. Lucie, FL, USA

states such as demons, animals, or spirits and the symptoms caused by these dissociative episodes would not constitute normal religious practices. There are several substances and medical conditions that produce effects similar to a dissociative episode. An example is severe intoxication with alcohol that may significantly alter a person’s personality and recall during the intoxicated state, or a complex partial seizure that produces a postictal state and loss of recall of the seizure episode. To be consistent with the DSM V diagnosis of DID, the dissociative episodes are not attributable to the effects of a substance or another medical condition.

What Causes DID? The answer to this question is quite complex; however, the general consensus points to severe physical and/or sexual trauma in early childhood being the main contributing and inciting factor. Children are more likely to lack the coping mechanisms necessary to appropriately handle the severe stress. Trauma occurring in the stage of life when having imaginary companions is considered normal may lead to an elaborate form of denial where the child at first believes the traumatic events are happening to someone else. Putnam et al. stated, “alternate identities result from the inability of many traumatized children to develop a unified sense of self that is maintained across various behavioral states, particularly if the traumatic exposure first occurs before the age of 5.” This combined with the child’s shame and lack of ability to adequately inform authority figures to get the help they need leads to compartmentalizing the trauma in an effort to escape from their memory. The overwhelming need to forget has the potential to lead to a dissociative break. DID is a highly controversial pathology, and further research is necessary to clarify the extent to which dissociative episodes are attributable to defensive neurologic functions, or to the neurotoxic effects of traumatic stress. Neurochemically, it has been suggested that glutamate release in the corticolimbic area may contribute to symptoms of dissociation.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_24

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 roposed Etiology of Dissociative Identity P Disorder Current Focus in Research A current focus in DID research is mapping brain activity. Scientists are currently studying the effects that prolonged trauma has on the brain activity of animal models. Human trials are being conducted as well by mapping and comparing the brain activity in individuals during different personality states as well as comparing the brain activity of DID patients to healthy controls. Studies have suggested that stress increases the release of glutamate by the cortico-­limbic area of the brain. In animal models, the glutamate released during stress produces a vast array of changes in neural plasticity, leading to potentially long-lasting effects on behavior and brain functioning as well as eventual neural toxicity with prolonged glutamate release. In human trials, antagonists of the N-methyl-D-aspartate subtype of glutamate receptors transiently stimulate glutamate release, and symptoms resembling dissociative states are produced. True DID is rare, leading to a sparsity of adequate trials. However, with the continued improvement and increasing utilization of brain mapping in recent years, scientists are getting closer to determining whether the structural/ functional changes in brain activity are the causes or consequences of DID. With no FDA-approved pharmacologic inter-

J. Mark et al.

vention for DID, continued research on brain activity in DID patients is essential in improving our understanding of the disorder as well as discovering new treatments. Areas of Impact Several modalities are improving our understanding of the pathophysiologic effects on brain structure, function, and neuro-hormonal activity in patients with DID. These important modalities include functional magnetic resonance imaging (fMRI), positron emission tomography (PET), single-photon emission computerized tomography (SPECT), event-related potentials, and electroencephalogram (EEG).

fMRI MRI utilizes the phenomenon of nuclear magnetic resonance (NMR), in which the hydrogen nuclei generate a signal through manipulation that is utilized to generate an image that can be mapped. The fMRI analyzes the increased/ decreased blood flow to certain areas of the brain that are more or less active in patients during certain activities and mental states. Its use in studying DID patients has demonstrated that various identities or categories of identities have different brain activation patterns (parahippocampal gyrus vs. brainstem/motor-related areas) when presented with the same stimulus. These unique brain activity patterns observed in DID patients were not found in control patients.

24  Pathophysiology of Dissociative Identity Disorder

PET Scan A PET scan utilizes imaging that reveals biochemical or metabolic function of tissues and organs. It does this by injecting a radioactive tracer that will reveal both normal and abnormal metabolic activity. Studies that have focused on trauma/defensive operations showed that DID patients had increased cerebral blood flow in the amygdala, insular cortex, somatosensory areas in the parietal cortex, and the basal ganglia, as well as in the occipital and frontal regions and anterior cingulate when compared to the same patients when focusing on tasks of daily living. The patterns in these studies were not reproducible in healthy controls, simulating distinct dissociative identities. SPECT SPECT neuroimaging assesses cerebral blood flow utilizing a lipophilic, radiotracer (most commonly technetium99  m-hexamethylpropyleneamine oxime (HMPAO) and ­ 99m Tc-ethylene cysteine diethylester [ECD], with a half-life of 6.02 h) that emits gamma rays after being injected to the patient and crossing the blood-brain barrier. Gamma detectors create a 3-D image from the emission. SPECT scans in DID patients while in the mental state of non-host identities have shown decreased perfusion in orbitofrontal regions and hyperperfusion in prefrontal/occipital regions in comparison to “host” identities. Additionally, increased perfusion in the left lateral temporal region of DID patients in host identities compared to healthy controls has been observed. EEG EEG assesses the electrical activity of the brain with use of electrodes placed on a patient’s scalp. It has been used to demonstrate variability between various identities of DID patients. EEG results have shown differences in beta activity in frontal and temporal lobes, as well as lower-alpha coherence on QEEG in temporal, frontal, parietal, and central regions for patients in non-host identities vs. host identities. These findings suggest that cortical changes may be associated with the development of multiple identities and personalities in these patients and may serve as a useful tool for elucidating these differences.

Affected Functions in D.I.D.

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Identity The foundation of a DID diagnosis is the presence of dissociated identities in the patient, each of which has a separate organized system of functioning with its own first-person perspective of the world, a unique sense of self (including a sense of personal will and agency), a distinct set of memories and experiences, all of which appear to coexist within the individual and which reportedly are unaware of each other. The formation of these various identities is caused by multiple events. First, severe adverse childhood experiences (physical/sexual abuse) cause the child to be unable to maintain a unified sense of self and are a result of an elaborate version of trauma-related mental intrusions and avoidance. Essentially, creating new identities that are unaware of each other can help the individual cope with trauma experienced in the unaltered state [2]. Milder presentations of DID are sometimes associated with less severe traumatization, e.g., enduring severely dysfunctional communication and relationship styles in family members, including subtle forms of emotional neglect [3]. Some data suggest that a disorganized attachment style (inadequate care-seeking interactions with primary caregivers) can lead to the development of multiple internal representations of self and later be associated with the development of DID.  Disorganized attachment to primary caregivers in which the caregiver is unable to provide the safety and comfort that a child needs can impede the child’s connection to the caregiver, thereby leading to the creation of internal sources of comfort and soothing that manifests as multiple internal representations of self [4]. Childhood abuse and neglect may activate feelings of alienation, isolation, and loneliness, and in the absence of necessary emotional support, a child may be unable to process adverse events, and their ability to make sense of these events in the context of other life events may be impeded. As a result, these adverse experiences may remain isolated from integration within the child’s sense of self, and with subsequent events, a child may not be able to develop an ordinary sense of self-in-relation-to-others that includes those adverse events, leading to a fractured self-identity from which multiple dissociated identities may form.

Memory

Consciousness

Evidence suggests memory lapses may be due to encoding failure while the individual is in a traumatic, altered state. Individuals may unconsciously block the retrieval of painful memories later on. If memories do get retrieved, they are more likely to experience higher levels of traumatic symptoms regarding the event when placed in a similar state, a phenomenon known as state-dependent memories [1]. Evidence also suggests that certain specific memories differ across the various personalities in DID.

Consciousness is predicated on an awareness of oneself and of the stimuli in one’s surroundings [5]. In DID, the action of encoding experienced events and perceiving ownership of those events as part of one’s autobiographical experience is divided amongst multiple personalities, and the different identities have different awareness/memories/perceptions of events that occur. Based on this notion, consciousness in DID is intact within the context of an alter-identity but not between various identities, indicating that the unique person-

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alities are unaware of one another as there is a disconnection and amnesia between them.

Perception Similar to consciousness, one’s perception of life events in DID is preserved within an identity, but skewed heavily across identities. One’s perception of time, may especially be skewed, as periods spent in some identities may not be recalled by others, leading to amnesia of certain events. State-dependent memory may lead to inter-identity amnesia, although evidence of whether this is a true phenomenon or one that is a deliberate attempt to misremember or refuse to recall events is incomplete [6].

Conclusion Dissociative Identity Disorder often stems from unresolved childhood trauma resulting in impairment of activities of daily living [7]. Patients also demonstrate altered memory, identity formation, consciousness, and perception difficulties that impair their ability to live normally and fulfill meaningful relationships with others [8–15]. Patients also often exhibit a pervasive pattern of behavior and poor coping mechanisms that predispose them to developing other psychiatric comorbidities [12–15]. Advances in neuroimaging have provided useful tools to characterize and further study the macroscopic changes to the brain and associated functional impairments.

References 1. Bonanno GA, Noll JG, Putnam FW, O’Neill M, Trickett PK.  Predicting the willingness to disclose childhood sexual abuse from measures of repressive coping and dissociative tendencies. Child Maltreat. 2003;8:302–18. https://doi. org/10.1177/1077559503257066. 2. Şar V, Dorahy MJ, Krüger C.  Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective.

J. Mark et al. Psychol Res Behav Manag. 2017;10:137–46. Published 2017 May 2. https://doi.org/10.2147/PRBM.S113743. 3. Sar V, Akyuz G, Kugu N, Ozturk E, Ertem-Vehid H.  Axis I dissociative disorder comorbidity in borderline personality disorder and reports of childhood trauma. J Clin Psychiatry. 2006;67(10):1583–90. 4. Main M, Hesse E.  Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: is frightened or frightening parental behavior the linking mechanism? In: Greenberg M, Cicchetti C, Cummings EM, editors. Attachment in the preschool years. Chicago, IL: University of Chicago Press; 1990. p. 161–82. 5. Monjaraz Fuentes P, Rojas Hernández MDC, Santasilia S, Monjaraz FF. The body as constitutive element phenomenology and psychoanalysis on our view of ourselves and others. Life Sci Soc Policy. 2017;13(1):6. https://doi.org/10.1186/s40504-­017-­0051-­0. 6. Kong LL, Allen JJB, Glisky EL. Interidentity memory transfer in dissociative identity disorder. J Abnorm Psychol. 2008;117(3):686– 92. https://doi.org/10.1037/0021-­843X.117.3.686. 7. Dissociative Identity Disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis - UpToDate (n.d.) 8. Mitra P, Jain A.  Dissociative identity disorder. [Updated 2021 May 18]In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. p.  2021. https://www.ncbi.nlm.nih.gov/books/ NBK568768/ 9. Ashraf A, Krishnan R, Wudneh E, Acharya A, Tohid H. Dissociative identity disorder: a pathophysiological phenomenon. J Cell Sci Ther. 2016;7:251. https://doi.org/10.4172/2157-­7013.1000251. 10. Allen JJ, Movius HL 2nd. The objective assessment of amnesia in dissociative identity disorder using event-related potentials. Int J Psychophysiol. 2000;38(1):21–41. https://doi.org/10.1016/ s0167-­8760(00)00128-­8. 11. Renard SB, Huntjens RJ, Lysaker PH, Moskowitz A, Aleman A, Pijnenborg GH.  Unique and overlapping symptoms in schizophrenia Spectrum and dissociative disorders in relation to models of psychopathology: a systematic review. Schizophr Bull. 2017;43(1):108–21. https://doi.org/10.1093/schbul/sbw063. 12. Reinders AATS, Chalavi S, Schlumpf YR, Vissia EM, Nijenhuis ERS, Jäncke L, Veltman DJ, Ecker C.  Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder. Acta Psychiatr Scand. 2018;137(2):157–70. https://doi. org/10.1111/acps.12839. Epub 2017 Dec 27. PMID: 29282709 13. Foote B, Park J. Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues. Curr Psychiatry Rep. 2008;10(3):217–22. https://doi.org/10.1007/s11920-­008-­0036-­z. 14. Gleaves DH.  The sociocognitive model of dissociative identity disorder: a reexamination of the evidence. Psychol Bull. 1996;120(1):42–59. 15. Putnam FW. Dissociation in children and adolescents: a developmental perspective. New York, NY: Guilford Press; 1997.

Risk Factors of Dissociative Identity Disorder

25

Neena E. Thomas

Dissociative Identity Disorder is characterized by a disruption in an individual’s sense of identity, memory, emotions, and consciousness. This disruption results in more than one personality in an individual. Physical abuse, sexual abuse, and neglect are risk factors that contribute to the development of Dissociative Identity Disorder. More than one personality is thought of as a way to cope with the stress of prolonged trauma. This chapter further examines some of these risk factors and how they contribute to the biopsychosocial profile of those diagnosed with Dissociative Identity Disorder. Approximately 1% of the general population is affected with Dissociative Identity Disorder [1]. Like most Psychiatric Disorders, biopsychosocial factors contribute to a diagnosis of DID.  The psychopathology most responsible for Dissociative Identity Disorder is developmental trauma, which often occurs in childhood. However, it is also possible for patients to develop DID later in adulthood. The most common risk factors for Dissociative Identity Disorder in adolescence and adulthood are prolonged exposure to physical abuse, sexual abuse, and neglect, ultimately leading to trauma. The existence of dissociative psychopathology was known to clinicians as early as the nineteenth century. Clinicians observed dissociation was linked to a history of physical and sexual abuse in childhood [2]. A renewed interest in DID research resurfaced in the 1980s and documented that adults who were exposed to severe sexual and physical abuse presented with Dissociative Identity Disorder [3]. A more recent study in the Canadian Journal of Psychiatry found that 90.2% of individuals had been sexually abused, and 84.2% had been physically abused by age 5. Of those participants, 95.1% also reported experiencing both forms of abuse by age 5 [4]. Currently, there are three theories on how developmental trauma leads to DID. The first theory, developed by Van Der N. E. Thomas (*) Pontiac General Hospital, Pontiac, MI, USA

Hart, Nijenhuis, and Steele, is the structural dissociation model. The theory proposes that during trauma, the brain’s adaptive system and defensive system become disconnected. With more exposure to trauma, the personality is split into further fragments called secondary and tertiary dissociation [5]. Other clinicians believe this theory follows a lack of “developmental integration” rather than “splitting” [6]. A second theory is that shame underlies severe dissociative pathology. A child who has experienced sexual abuse may avoid the pain of shame by adopting a different self-­ conception [7]. Without support, children and adolescents may incorporate shame-based concepts of self, leading to a different self-concept [8]. The last theory proposes that a constant traumatic environment causes a child to remain in rigid and impermeable states [9]. Children and adolescents who grow up with attentive and loving parents allow a child to self-regulate independently. There is also additional research that suggests a childhood history of neglect contributes to dissociation symptoms. One longitudinal study has found that disorganized attachment styles between children and parents can predict dissociation in teenagers [10]. It is unclear if there are genetic factors that contribute to Dissociative Identity Disorder. One study in dizygotic and monozygotic twins had shown that heritability had no effect and that variability in shared and non-shared environments was responsible [11]. However, another study with adopted siblings and twin pairs used objective ratings of non-­ pathological dissociation and found that shared environmental factors had little effect. It was noted in the study that dissociative behavioral correlations of r = 0.21 for fraternal twins and r = 0.60 for identical twins imply that there may be a genetic component in developing dissociative symptoms [12]. Overall, both studies suggest further investigation into genetics in individuals diagnosed with Dissociative Identity Disorder. In summary, a past history of trauma in childhood is a well-known contributor to the Development of Dissociative Identity Disorder. In particular, a history of childhood sexual

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abuse, physical abuse, and neglect are risk factors that significantly contribute to DID. Theories described in this chapter may explain disruptions in a personality that result in more than one personality. Lastly, it is also possible that a genetic predisposition to Dissociative Identity Disorder may exist and needs to be further evaluated.

References 1. Şar V.  Epidemiology of dissociative disorders: an overview. Epidemiol Res Int. 2011;2011(8):Article ID 404538. 2. Putnam FW.  Dissociative phenomena. In: Tasman A, Goldfinger SM, editors. American psychiatric press review of psychiatry, vol. 10. Washington, DC: American Psychiatric Association; 1991. p. 145–60. 3. Ross CA, Miller SD, Bjornson L, Reagor P, Fraser GA, Anderson G.  Abuse histories in 102 cases of multiple personality disorder Lewis, Michael. Handbook of developmental psychopathology, 3rd edition, Springer, 2014: 761. 4. Ross CA, Miller SD, Bjornson L, Reagor P, Fraser GA, Anderson G. Abuse histories in 102 cases of multiple personality disorder. Can J Psychiatry. 1991;36(2):97–101.

N. E. Thomas https://doi.org/10.1177/070674379103600204. https://journals. sagepub.com/doi/abs/10.1177/070674379103600204. 5. Van Der Hart O, Nijenhuis ERS, Steele K. The haunted self: structural dissociation and the treatment of chronic traumatization. New York: W. W. Norton; 2006. 6. Lewis M. Handbook of developmental psychopathology, third edition. Springer; 2014. p. 763. 7. Lewis M.  Shame: the exposed self. New  York: The Free Press; 1992. 8. Feiring C, Taska L, Lewis M. A process model for understanding adaptation to sexual abuse: the role of shame in defining stigmatization. Child Abuse Negl. 1996;20(8):767–92. 9. Putnam FW. Dissociation in children and adolescents: a developmental approach. New York: Guilford; 1997. 10. Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egeland B.  Development and the fragmented self: longitudinal study of dissociative symptomatology in a non-clinical sample. Dev Psychopathol. 1997;9:855–979. 11. Waller N, Ross C.  The prevalence and biometric structure of pathological dissociation in the general population: Taxometric and behavior genetic findings. J Abnorm Psychol. 1997;106(4):499–510. 12. Becker-Blease K, Deater-Deckard K, Thalia Eley E, Freyd J, Stevenson J, Plomin R. A genetic analysis of individual differences in dissociative behaviors in childhood and adolescence. J Child Psychol Psychiatry. 2004;45(3):522–32.

Causes of Dissociative Identity Disorder

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Aaron Marbin, Nadia Obaed, James Allen Mcalister III, and Emanuella Brito

Introduction Dissociative Identity Disorder is believed to have stemmed from traumatic experiences from early childhood, despite the fact that in most cases, DID appears in adulthood [1]. There are two separate main models contributing to the developement of DID: Trauma and Fantasy. In the trauma model, it is posited that repetitive experiences of abuse and neglect can lead to development. On the other hand, the fantasy model states that an individual mostly confabulates experiences such as trauma and neglect [2]. These theories are discussed in detail, as well as how to detect early markers in the development of DID.

grow separately and be recognized as alters (multiple personalities) that people dissociate into when facing memories, thoughts or feelings of the trauma. Trauma undoubtedly has a role in the genesis of dissociation as people with DID often report a history of childhood trauma, but whether it is centrally causal to DID development is still debated [5]. Studies examining the correlation between trauma and dissociation vary widely in methodology (blindness among researcher and participant), magnitude of correlation, effect size, population size, measures, and definitions of trauma. Thus, more studies are necessary to determine the validity of the trauma model.

Fantasy Model The fantasy model (FM) is characterized by a person’s intrinRelevant Models and Theories sic qualities such as high-suggestibility, fantasy proneness, and executive dysfunction [6]. The FM upholds these qualiTrauma Model ties as the central etiology of DID by yielding confabulated The trauma model (TM) posits that DID stems from early and false memories of experiences like trauma. Proponents childhood experiences of severe and chronic physical, sex- of the fantasy model argue that dissociation is a psychologiual, and emotional abuse or chronic neglect [3]. The mani- cal process unrelated to traumatic or stressful events. It posfestations of the disorder serve as a protective response to its that the trauma histories reported by individuals with help compartmentalize the trauma itself and the trauma-­ dissociative experiences are largely confabulations or exagassociated thoughts and emotions. Not having the chance to gerations resulting from fantasy proneness, suggestion, and properly heal or understand their trauma given the lack of cognitive distortions. Fantasy model theorists suggest that appropriate childcare and young age, this model poses DID dissociation overlaps with or gives rise to fantasy proneness, as a defensive mechanism that children may develop in suggestibility, or cognitive distortion, which in turn heightefforts to avoid what would be an expected severe psychiat- ens trauma reporting. Essentially, dissociation leads to ric breakdown following severe trauma. Another part of this trauma reporting via various biopsychological mediator and trauma model is the theory that people are not born with a moderator variables [6]. single unified personality. Different personality states are thought to exist for different emotions and states of being like happiness or hunger [4]. If trauma prohibits the integra- Relation to Other Pathology tion of these states into a cohesive sense of self, these can Dissociative Identity Disorder has been linked to Post-­ Traumatic Stress Disorder since DID patients often have sufA. Marbin (*) fered trauma as well, but typically before the age of 10 years HCA Aventura Hospital, Aventura, FL, USA old [7]. When DID is recognized as a defense syndrome, the N. Obaed · J. A. McalisterIII · E. Brito close relationship to PTSD becomes more clear. The altered Nova Southeastern University, Fort Lauderdale, FL, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_26

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states of DID can be considered an elaborated version of the mental intrusion and avoidance experienced in PTSD [7].

Early Markers for Predicting DID Development Children start to develop a sense of self around the age of 2-years-old. Their self-descriptions become more concrete, and their autonomy grows with their self-awareness [8]. One significant challenge in their development towards a strong sense of self is the addition of the school setting. Children must begin to explore group dynamics and unfamiliar surroundings apart from the comfort of home when beginning school. Therefore, it also presents as a crucial time in a child’s psyche. Children will go through bouts of demanding attention, reluctance to leave home, competitiveness, learning responsibility, bullying, gaining attention by excelling in unique interests or aptitudes, insecurity, and friendship for a start. When children have lived in the absence of a supportive and nurturing household, the development of inferiority and inadequacy can grow, deepen, and be overwhelming without the proper ability to adapt to a new environment. Children may begin to dissociate–perceiving external and internal stimuli differently than most people–-in efforts to cope with their new surroundings and experiences [8]. Research studies conducted on DID development have noted the possibilities of early markers for predicting DID. One such marker is the presence of imaginary characters as a coping mechanism for stressful experiences [8]. Distinguishing between imaginary playmates and dissociated self-states in children is difficult. There are differing theories as to the development of imaginary playmates revolving around the ideas of isolation, abuse, or neglect, which are also commonly present in the histories of patients with DID. Indicators that imaginary companions may actually be suggesting more psychopathology consist of age greater than 8, number of companions in which the average in a normal child can be up to 3, and the nature of the imaginary friends. Other possible predictors include referring to self in third-person, responding to internal voices, and extreme shifts in mood and behavior that are uncharacteristic of the usual self and subsequently denying the event’s occurrence. Referencing oneself in the third person can express an awareness of one's internal fragmentation. An all-night polysomnography study showed that patients with insomnia experienced elevated dissociative symptoms [9]. The REM sleep period is critical for memory consolidation; thus, longer REM sleep periods and out-of-phase REM sleep can be predictive of DID.  Rapid and extreme shifts in mood that tend to disrupt the normal routine of the usual self and con-

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tradict the usual self-behavior that can later even be denied by the person in question, although not a specific indicator for DID, does prompt further consideration into a possible mental health disorder. These self-shifts may be preceded by stressful or special experiences that may upset their subconscious. Regressed behavior and amnesia are other early signs of DID [10]. The earlier that such signs are noticed and yield a DID diagnosis, then the better the prognosis of DID is with treatment at a younger age.

Role of Trauma in DID Development Interpersonal Stressors In general, stress produces physiologic changes in our bodies. Interpersonal stress can be defined as the physical and mental responses to overwhelmingly difficult episodes that a person faces in communication and relationships, which in turn threaten one’s well-being. The amygdala, responsible for fear conditioning and emotions, and the hippocampus, responsible for memory and learning, are both part of the limbic system [11]. This system maintains an integral role in the stress response. The significance of stress in patients with DID is exemplified by the significantly reduced size of the amygdala and hippocampus [11].

Environmental Stressors Childhood trauma is one of the main environmental stressors linked to DID, and it has become increasingly common worldwide. It has been theorized that childhood trauma is associated with more intense reactions to daily life stressors in adulthood. There are more intense negative emotions to minor stressors, as well as increased levels of perceived stress. Childhood abuse and trauma are thought to cause neurobiological changes in the stress response systems, including hypothalamic–pituitary–adrenal axis, and the sympathetic and parasympathetic nervous systems. Repeated instances of assault, sexual abuse, physical abuse, emotional abuse, neglect, and mistreatment all contribute to environmental factors that can ultimately cause DID to manifest. Repeated environmental events bring about traumatic complexities that arise into ongoing issues seen in subsequent years like depression, emotional dissociation, character changes, and aggressive/destructive behaviors. These environmental events can lead to dissociative symptoms such as depersonalization, derealization, amnesia, identity confusion, or identity alteration.

26  Causes of Dissociative Identity Disorder

Impact of Childhood Trauma One avenue of exploration that has yielded insights into the development and nature of DID is the phenomenon of imaginary companions. While imaginary companions are a common feature of childhood development, the cognitive processes that underlie them and the nature of the imaginary friends themselves have implications for the study of DID. Imaginary companions may also serve as an outlet for children to displace their own failings and vulnerabilities and thus may serve as a coping mechanism. In this latter case, the imaginary companion may fluctuate between being externalized and internalized, with the child assuming some qualities of the imaginary companion [6]. It is apparent that in cases where the child internalizes the imaginary companion, it begins to resemble an altered state, as in DID.  Some definitions of imaginary companions attempt to differentiate the two by making imaginary companions a voluntary creation while alters are involuntary. A true imaginary companion would serve a specific function such as an outlet for anger or simply as a company to pass the time with. Nonetheless, research has demonstrated that alters and imaginary companions are more connected than this definition would seem to suggest. One study found that 74% of those suffering from DID remain in contact with their imaginary companions [12]. Findings such as this have led to an ongoing debate about the true nature of imaginary companions and their relation to altered personality states. A three-stage theory has developed which attempts to describe the evolution from imaginary companion to alter. This evolutionary process begins with a child who, by biological nature, has a baseline tendency towards the development of DID. The trauma must also occur within an identified “developmental window,” which generally occurs from age 2 to 8. Past this time, the child is better able to reason abstractly and has a more concrete sense of self, making DID less likely [13]. If the child is subject to repeated trauma without an appropriate outlet such as a caregiver, then the child may resort to creating an imaginary friend upon which to project their negative emotions. The process may be terminated or changed if the child is able to receive appropriate help. In this case, the child may develop another condition such as PTSD or borderline personality disorder but not DID [13]. The following second stage occurs when the child begins to associate the imaginary companion with specific states of feeling. A child who experiences multiple different types of repeated trauma may create an imaginary companion for each state. The imaginary companion will emerge in response to the trauma for which it is created. For example, if the child is being verbally abused, a specific imaginary companion linked to verbal abuse will appear as a means of coping [13]. Stage three is unique in that it occurs after the developmental window for DID.  It is during adolescence that the

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imaginary companion completes its final transformation into a distinct personality state. A key component of adolescence is the development of a child’s distinct identity, and as the child forms an identity for themself and a role within the world, so too will the imaginary companions, with the most powerful ones being those created to cope with the worst traumas [13]. Sexual abuse has been identified as one of the most likely [14]. The end result is the formation of multiple distinct personalities that vie for existence. They will tend to appear in response to stimuli similar to that which created them. For example, one created as an imaginary companion to deal with verbal abuse in childhood might appear in adulthood in response to being called names. This process is still being debated with lingering questions about why altered personality states can appear independently of a predecessor’s imaginary companion in some instances. There is, however, a strong link in many cases of altered personality states resulting from a previous imaginary companion.

Schneiderian Symptoms in Trauma Model People with schizophrenia and DID both have disruptions in perception. Dr. Kurt Schneider was a German psychiatrist who proposed a conglomerate of symptoms in 1938 that were either indicative (first-rank symptoms) or associated but not specific to (second-rank) schizophrenia. There were 11 symptoms that were described as classic to schizophrenia: audible thoughts, voices arguing, voices commenting, somatic passivity, thought withdrawal, insertion, broadcasting, delusion perception, made feelings, made actions, and made impulses. Throughout the years, the criteria were deemed invalid in schizophrenia diagnosis and actually more relevant to other mental illnesses, specifically DID.  The Schneiderian symptoms that are seen in DID include auditory hallucinations and non-bizarre delusions of control and thought withdrawal/ insertion [9]. Auditory hallucinations are found in 47% to 90% of patients with dissociative disorders. Patients with DID have also reported 2.7–5.5 more first rank symptoms than those with schizophrenia, supporting the closer association of Schneiderian symptoms in dissociative pathology [9].

 ociocognitive or Non-Trauma-Related S Model The Fantasy Model of DID can also be described as the Sociocognitive or Non-Trauma-Related Model. This approach defines DID as a creation of psychotherapy and the media, and addresses high fantasy proneness to four distinct causes: enactment, sleep disturbances, suggestive psychotherapy, and sociocultural influences [15].

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Causes Related to High Fantasy Proneness Enactment Confabulation of trauma due to fantasy proneness, suggestion, and role-playing are according to the FM model, evidence that DID has no trauma-related origin. According to Spanos (1994), who first defined the Sociocognitive Model, multiple identity enactment is the principle psychopathology of DID. This enactment is explained by the histrionic personality of patients diagnosed with DID.  A diagnosis of DID, which is known to receive more attention than other psychopathologies due to its controversy, would explain why attention-­seeking patients find it rewarding to stimulate the disorder [16]. Sleep Disturbances DID symptoms have been correlated with sleep disturbances. It has been hypothesized that “dreamlike mentation conquers the waking state.” Hypnagogic hallucinations, nightmares, waking dreams, and lucid dreams have been linked to cognitive failure, which decreases a person’s attention control and memory, inciting “imaginative mentation.” The FM supports the statement that sleep disturbances might be a necessary antecedent for DID [17]. Suggestive Psychotherapy For those who support the Sociocognitive Model, DID has been characterized as an iatrogenic artifact of psychotherapy, in which psychotherapists reinforce patients’ symptoms. They do so by legitimizing the concept of multiplicity and modeling patients’ behavior through differential reinforcement. Proponents of the FM model argue that as therapists ask patients to retrieve childhood memories, they incite high fantasy proneness of patients, leading to false memories [16]. Sociocultural Influences The FM model suggests that the media has also played a role in validating DID among society. For instance, Hollywood productions that date back to the 1950s until current days have provided content to support the creation and explanation of the symptomatology of DID to the general public. The broad range of content on DID available in the media has influenced the misdiagnosis of this condition, as patients who identify themselves with the disorder, eventually report symptoms of DID in a convincing manner[16].

 imilarities between the Trauma and Fantasy S Model The TM and FM models can be thought of as theories proposing external experiences versus intrinsic individual qualities, respectively, that lead to DID development. Theorists

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of both models tend to de-emphasize the causality or centrality of the opposing role of fantasy-proneness or trauma in efforts to explain DID. Although, both TM and sugg FM theorists believe that role-enactment contributes to the idea of believing in multiple disparate identities within a single individual.

 eurobiologic Correlation in DID N Development  ippocampal Volume and Changes in Brain H Morphology Hippocampal and amygdalar volume have been shown to change in a number of psychiatric pathologies and DID is no different in this regard [11]. These two structures are involved in both the formation of memories and in stress responses. Individuals subject to severe stress and trauma in childhood often suffer from permanent derangements in these key structures [11]. For example, individuals suffering from PTSD in particular have been shown to have reduced volume in both the hippocampus and amygdala. In populations screened for both childhood trauma and DID, it has been shown that the left and right hippocampus may decrease in volume by 19.2% when compared to healthy patients. Similarly, the left and right amygdalar volume may drop by 31.2% [11]. The underlying causes of these volume shifts are unclear. It is possible that the observed changes in volume are the result of a genetic predisposition to these pathologies and not a change caused by environmental exposure. It is also possible that derangements in neurotransmission involving glutamate, serotonin, and endogenous opiates could lead to the observed changes [11]. These two regions of the brain are less susceptible to the influence of glucocorticoids, making this less likely. Of note, the size reductions seen in the amygdala are more significant than those seen in the hippocampus. This observation could aid in future diagnostic efforts and in detecting individuals susceptible to developing DID.

Brain Activation Studies The past couple of decades have yielded multiple brain activation studies validating the DSM-5 diagnostic criteria for dissociative identity disorder [17]. One of the first studies used functional neuroimaging in patients with DID and demonstrated that multiple distinct mental states had unique signatures of localized brain activity and cerebral blood flow patterns. Another study monitored brain activation through positron emission tomography to show that the emotional modulation in DID relates to PTSD, such that both share hyper- and hypo-arousal states [18].

26  Causes of Dissociative Identity Disorder

According to the Theory of Structural Dissociation of Personality, there is both an “Emotional Part” (EP) subsystem and an “Apparently Normal Part” (ANP) subsystem to personality that reacts differently to trauma-related cues. One study investigated these subsystems’ perfusion patterns using arterial spin labeling perfusion MRI [19].  The ANP showed elevated perfusion bilaterally in the thalamus, while EP had elevated perfusion in the dorsomedial prefrontal cortex, primary somatosensory cortex, and motor-related areas [19]. The findings contradict the Fantasy model such that actors were shown to have different ANP and EP perfusion patterns compared to tested DID patients.

Conclusion The causes of DID is still a topic of debate today. There are a number of theories as to what exactly causes an individual to develop multiple distinct personalities. The two main theories were discussed, as well as what the main influences are in each. Despite the fact that most cases are diagnosed in adulthood, it is highly suggestive that events experienced in early childhood are the cause. The trauma model states that early childhood abuse and neglect contribute to the development of DID, whereas the fantasy model states that individuals with proneness to confabulating false memories and experiences such as trauma lead to the development of DID.

References 1. Reinders AATS, Veltman DJ. Dissociative identity disorder: out of the shadows at last? Br J Psychiatry. 2021;219(2):413–4. https:// doi.org/10.1192/bjp.2020.168. 2. Conway J.  The role of environmental stressors experienced during childhood in the development of dissociative identity disorder. PCOM Capstone Projects. 2021; 32. https://digitalcommons.pcom. edu/capstone_projects/32. 3. Vissia EM, Giesen ME, Chalavi S, Nijenhuis ERS, Draijer N, Brand BL, Reinders AATS. Is it trauma-or fantasy based? Comparing dissociative identity disorder, post-traumatic stress disorder, stimulators, and controls. Acta Psychiatr Scand. 2016;134:111. https://doi. org/10.1111/acps.12590. 4. Apter C. Denying the traumatic origin of dissociative identity disorder denies those who live with it a recovery. Ment Health Today. 2019. https://www.mentalhealthtoday.co.uk/blog/teach-me-well/ denying-the-traumatic-origin-of-dissociative-identity-disorderdenies-those-who-live-with-it-a-recovery.

151 5. Lynn SJ, Lilienfeld SO, Merckelbach H, Giesbrecht T, McNally RJ, Loftus EF, Bruck M, Garry M, Malaktaris A. The Trauma Model of Dissociation: inconvenient truths and stubborn fictions. Comment on Dalenberg et al. (2012). Psychol Bull. 2014;140(3):896–910. https://doi.org/10.1037/a0035570. 6. McLewin LA, Muller RT. Childhood trauma, imaginary companions, and the development of pathologic dissociation. Aggress Violent Behav. 2006;11(5):531–45. https://doi.org/10.1016/j. avb.2006.02.001. 7. Soibelman A. The correlation between stress and the development of dissociative identity disorder. Sci J Lander College Arts Sci. 2017;11(1). https://touroscholar.touro.edu/sjlcas/vol11/iss1/9 8. Sar V.  The many faces of dissociation: opportunities for innovative research in psychiatry. Clin Psychopharmacol Neurosci. 2014;12(3):171–9. https://doi.org/10.9758/cpn.2014.12.3.171. 9. Renard SB, Huntjens RJ, Lysaker PH, Moskowitz A, Aleman A, Pijnenborg GH.  Unique and overlapping symptoms in schizophrenia spectrum and dissociative disorders in relation to models of psychopathology: a systematic review. Schizophr Bull. 2017;43(1):108–21. https://doi.org/10.1093/schbul/sbw063. 10. Allen JJ, Movius HL 2nd. The objective assessment of amnesia in dissociative identity disorder using event-related potentials. Int J Psychophysiol. 2000;38(1):21–41. https://doi.org/10.1016/s01678760(00)00128-8. 11. Vermetten E, Schmahl C, Lindner S, Loewenstein RJ, Bremner JD.  Hippocampal and amygdalar volumes in dissociative identity disorder. Am J Psychiatry. 2006;163(4):630–6. https://doi. org/10.1176/ajp.2006.163.4.630. 12. Sanders B. The imaginary companion experience in multiple personality disorder. Dissociation. 1992;5:159–62. 13. Pica M.  The evolution of alter personality states in dissociative identity disorder. Psychotherapy. 1999;36(4):404–15. https://doi. org/10.1037/h0087838. 14. Kisiel CL, Lyons JS. Dissociation as a mediator of psychopathology among sexually abused children and adolescents. Am J Psychiatry. 2001;158:1034–9. 15. Gleaves DH.  The sociocognitive model of dissociative iden tity disorder: a reexamination of the evidence. Psychol Bull. 1996;120(1):42–59. https://doi.org/10.1037/0033-2909.120.1.42. 16. Spanos NP. Multiple identity enactments and multiple personality disorder: a sociocognitive perspective. Psychol Bull. 1994;116(1): 143–65. https://doi.org/10.1037/0033-2909.116.1.143. 17. Reinders AA, Nijenhuis ER, Paans AM, Korf J, Willemsen AT, den Boer JA. One brain, two selves. Neuroimage. 2003;20(4):2119–25. https://doi.org/10.1016/j.neuroimage.2003.08.021. 18. Reinders AA, Willemsen AT, den Boer JA, Vos HP, Veltman DJ, Loewenstein RJ.  Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder: a PET study and neurobiological model. Psychiatry Res. 2014;223(3):236–43. https://doi.org/10.1016/j.pscychresns.2014.05.005. 19. Schlumpf YR, Reinders AA, Nijenhuis ER, Luechinger R, van Osch MJ, Jäncke L. Dissociative part-dependent resting-state activity in dissociative identity disorder: a controlled FMRI perfusion study. PloS one. 2014;9(6):e98795. https://doi.org/10.1371/journal. pone.0098795.

27

DID and Diagnosis Shivani Kaushal, Jordan Calabrese, Anam Roy, and Jose Isaac Reyes

Intro/Diagnostic Criteria Dissociative Identity Disorder (DID) has long fascinated psychiatrists, therapists, and the general public, with much debate centered around the recognition and establishment of its defining features and diagnostic criteria. This struggle to define and reliably diagnose DID arises from many unique aspects of the disorder, from the heterogeneous span of symptoms it encompasses to the closely integrated relationship of DID to patients’ social contexts and personal trauma, which can evade representation by systematized criteria [1]. Thus, factors such as these have contributed to the dynamic history of DID and the many evolutions of its standing in medicine and the general population. Investigations establishing empirical data have guided the field of psychiatry to its current diagnostic criteria for DID, delineated in the fifth and most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. These criteria include distress or functional impairment with disruption of identity caused by the presence of the following: (1) at least two distinct identities or “personality states” with accompanying changes in behavior, memory, and thinking, and (2) recurrent gaps in memory of everyday events, personal information, and/or past trauma. Such features must not be a normal element of a broadly accepted cultural or religious practice, a refinement added in the DSM-5 to avoid the pathologization of common traditions observed by different cultures and religions [2, 3]. However, current criteria for DID do differ slightly: the 10th revision of the International

S. Kaushal Dr. Kiran C. Patel College of Allopathic Medicine, Grand Blanc, MI, USA J. Calabrese (*) Aventura Hospital and Medical Center, Overland Park, KS, USA A. Roy Windsor University School of Medicine, Santa Fe, NM, USA J. I. Reyes Saint George’s University School of Medicine, Miramar, FL, USA

Classification of Diseases (ICD-10) also lists identity alteration and amnesia in its diagnostic code for DID but excludes the confusion of one’s identity as a criterion. The 2022 publication of the ICD-11 will introduce various changes to the naming and criteria for DID and dissociative disorders. For DID in particular, a major addition is the use of the diagnosis “partial dissociative identity disorder” to categorize cases of DID in which non-dominant personality states do not recurrently take executive control of the patient’s consciousness and functioning [4]. Examining the progression of how DID has been recognized and diagnosed in the past can aid current understanding of, and development of future improvements in, assessing patients for DID so that they can receive the treatment they need. As evidenced by the refinements that are still being made to the definition of DID, more information is still being gathered in order to establish the most reliable practices to recognize and diagnose the condition. This chapter will discuss the path of DID diagnosis to where it is today, as well as recent research developments aimed at better understanding and addressing the shortcomings that remain.

History of DID Diagnosis DID is often known to the general public as “multiple personality disorder”, the medical term used in the past to describe symptoms that might now be recognized as dissociative. The name “multiple personality disorder” was used in psychiatry to refer to such symptoms until the 1994 publication of the DSM-IV established the name “Dissociative Identity Disorder” [5]. While there are various reasons posited for this change, a common explanation seems to emphasize the clarity the label of DID offers to clinicians and patients. Some posited that the name change could prevent reinforcement of patients’ subjective perceptions that they were collections of different people [6]. The previous use of “multiple personality disorder” reflects the common conception of dissociative symptoms as encompassing different

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personalities, as opposed to the current most widely accepted understanding that the symptoms more closely reflect different identities and personality states. Dissociative disorders in general were not widely acknowledged, and sometimes not well-understood, by the psychiatric community in the decades leading up to the designation of DID in the DSM-IV. A common feature in this grouping of disorders is disruption of the normal integration of identity, consciousness, memory, emotion, perception, body representation, motor control, and behavior [7]. Of course, this classification has arisen only after many years of confusion among terms attempting to describe the inner world of individuals suffering from mental illness. Pierre Janet, a French psychiatrist active in the early twentieth century, was the first individual to use the term “dissociation” to describe the perceived phenomenon of patients’ thought processes splitting their personality into distinct sectors. While many cases of dissociation and “multiple personality” were identified around this time, interest in dissociation diminished as it was overshadowed by the older and more widespread label of “hysteria.” Hysteria has a long history of use as a catch-all term in general society for misunderstood physical and behavioral aberrances in women, in the past sometimes even attributed to outlandish theories such as witchcraft and demonic possession. With this framing, and the evolution of women’s roles in society, “hysteria” became a label for behavior deemed “attention-seeking” [8]. The term was more formally solidified in the psychiatric field with Sigmund Freud’s establishment of the concept of hysterical conversion. The close association between DID and outdated, dismissive labels such as hysteria have persisted well into recent memory, even prompting the use of the term “pseudo-hysteria” to refer to cases in which someone with a legitimate presentation of DID is perceived to simply be putting on a hysterical, attention-seeking act [8]. Even as DID became more widely known in the modern era, skepticism of the source of patients’ presentations, and thus their diagnoses, remained. Combined with the continued practice of deeming aberrant thought patterns and behaviors as somewhat akin to hysteria, these criticisms led to a prevailing theory continuing into the 1990s that DID symptoms were simply a manifestation of patients’ conscious fantasies, created in part by suggestibility from therapists. Numerous psychiatrists espoused the “sociocognitive model” of DID, positing that patients developed the condition iatrogenically. This model theorized that DID was the effect of outside factors (including psychotherapists, media, and social exposure to DID), suggesting the concept of multiple personalities, inducing symptomatology, and reinforcing behaviors congruent to these beliefs [9]. This theory has been widely dismissed and refuted as the multifactorial etiology of DID has been explored, and little to no evidence has surfaced for iatrogenic processes in the disorder. Instead,

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growing evidence supports the post-traumatic model of DID, which explains the development of dissociative identities as a consequence of previous trauma and its subsequent effects on a patient’s emotions, relationships, cognitive processes, and neurobiology [10]. The extensive controversies surrounding DID have unfortunately led to missed and delayed diagnoses for patients who suffer from the condition. In various studies in the 1980s, patients with DID were shown to have spent an average of almost 7 years in mental health treatment before being diagnosed with the condition; little evidence suggests that this amount of time has been shortened in the intervening years, even with advancements in understanding of DID [11].

Diagnostic Tools The ongoing controversy surrounding the diagnosis of DID has contributed to a myth that the disorder is unable to be objectively assessed, or that measures of DID might not be accurate. While several measures and screening tools for DID do exist, it has been omitted from many larger psychiatric epidemiologic studies. Despite DID’s under-­representation in psychiatric research in the past, and possible mistrust of diagnostic accuracy, empirical data has established the validity of various diagnostic measures of DID. Extensive research has investigated the available empirical data that validates the diagnosis of DID. Dorahy et al. report evidence that DID demonstrates the core types of validity that must be established for all psychiatric disorders: content validity (consistent clinical presentation among independent researchers), criterion validity (testing data consistent with clinical presentation), and construct validity (ability to be distinguished from other disorders and simulation of the disorder). Regarding diagnosis of DID specifically, the core symptoms that distinguish DID from other DSM-5 disorders are identity confusion, identity alteration, and amnesia. Furthermore, derealization and depersonalization are not needed for diagnosis of DID, though they are common symptoms among individuals with the disorder. These symptoms persist in DID patients across different continents and cultures, supporting consistent diagnostic features [1].

Clinician-Administered Tools The vetting of DID diagnosis through empirical means has established the presence of reliable tools for diagnosing DID, despite past diagnostic controversies. The two clinician-­ administered diagnostic interviews for dissociative disorders, both of which have been deemed valid and reliable, are the Structured Clinical Interview for DSM-IV Dissociative

27  DID and Diagnosis

Disorders (SCID-D)/SCID-D-Revised and the Dissociative Disorders Interview Schedule (DDIS). Studies validating the DDIS have confirmed that this measure can differentiate DID as a discrete category apart from other dissociative disorders and several other psychiatric conditions [12]. This measure provides diagnostic information for the five dissociative disorders, somatization disorder, major depressive episode, and borderline personality disorder. It also gathers information about past history of abuse and various symptom clusters, including those ­surrounding substance abuse, schizophrenia, and paranormal experiences. The 16 symptom sections in the DDIS are listed below: Sections of the dissociative disorders interview schedule (DSM-5 version)   1. Somatic complaints (previously somatization disorder symptoms).   2. Substance abuse.   3. Psychiatric history.   4. Major depressive episode symptoms.   5. Schneiderian First-rank symptoms of schizophrenia.   6. Trances, sleepwalking, childhood companions.   7. Childhood abuse.   8. Features associated with dissociative identity disorder.   9. Supernatural/possession/extrasensory/paranormal experiences/ cults.  10. Borderline personality disorder criteria.  11. Dissociative amnesia.  12. Dissociative fugue.  13. Depersonalization/Derealization disorder.14. Dissociative identity disorder.  15. Criteria for other specified dissociative disorder or unspecified dissociative disorder (DSM-5); previously dissociative disorder not otherwise specified (DSM-IV DDNOS).    (a) E.g., trance-like states, derealization unaccompanied by depersonalization.  16. Concluding item (descriptive question, not scored): Did the subject display unusual, illogical, or idiosyncratic thought processes?

The DSM-5 criteria for DID are included in the DDIS in section 15 with the following questions [11]: Dissociative disorders interview schedule items covering DSM-5 criteria  1. Have you ever felt like there are two or more distinct personality states within yourself, which may be described in some cultures as an experience of possession? The personality states result in disruption in your sense of self accompanied by disruptions in feeling, behavior, consciousness, memory, perception, thinking, or sensation.  2. Have you experienced inability to recall important personal information or traumatic events that are too extensive to be explained by ordinary forgetfulness?  3. Have the symptoms caused significant distress or impairment in your social, occupational, or other areas of functioning?  4. Is the problem with different identities or personalities because of substance abuse (e.g., alcohol blackouts) or a general medical condition? Answer choices for the above items are yes, no, or unsure

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A statistical measure of the dissimilarity among groups, adjusted for intercorrelations among sections, is known as the Mahalanobis distance. This procedure was applied to the DDIS in one study, calculating the distance between diagnostic categories within the measure [12]. Diagnostic groupings were compared through analysis of the 16 symptom sections by which the DDIS was structured at the time of the study, before the publication of the DSM-5 (generally very similar to the list provided above). The study determined that DID was “further away” from all other diagnostic categories than those other categories were from each other, and was closest in distance to dissociative disorder not otherwise specified. These findings appear to suggest that the DDIS is effective at differentiating DID from other dissociative and psychiatric disorders. The DDIS also has good inter-rater reliability with clinical interview, the Dissociative Experiences Scale (DES) (a self-reported screening tool for DID), and the SCID-D [1]. The SCID-D, the other validated structured clinical interview through which DID can be diagnosed, assesses identity confusion, identity alteration, amnesia, depersonalization, and derealization (the five categories of dissociative symptoms). Duration, frequency, severity, and associated impairment of each of these symptoms are also assessed. SCID-D interview score and subscale scores significantly differentiated dissociative disorders from non-dissociative disorders in a recent meta-analysis, with the greatest effect size in the amnesia and identity alteration subscales [13]. The SCID-D has shown generally higher inter-rater reliability for DID than for other psychiatric disorders, good to excellent test-­ retest reliability, and good discriminant validity in the assessment of dissociative disorders and symptom severity [14]. In addition to reliably differentiating DID from other dissociative and psychiatric disorders, the SCID-D also aids in discriminating dissociative disorders from factitious dissociative symptoms and from dissociation better explained by other phenomena, such as traumatic brain injury and medical illness [1, 13, 15].

Self-Report Tools The Multidimensional Inventory of Dissociation (MID) is the only self-report measure used for the diagnosis of DID, with other self-reports used for screening only. This self-­ administered instrument contains 218 items that assess the subjective experiences of dissociation on a 0–10 Likert scale. According to the author of the MID, the instrument does not include a time frame in which the symptoms should have occurred due to the infrequency of amnesic episodes [16]. The MID is also meant to clarify diagnosis in patients exhibiting features typical of PTSD, DID, and borderline personality disorder (BPD). For example, one response

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categorization identifies aspects of BPD that may be mistaken for dissociative symptoms, such as the tendencies to report bizarre symptoms, feign illness, and seek attention in BPD.  Of course, BPD and DID can be comorbid, and the MID has been used to demonstrate severe dissociative symptoms in all DID diagnostic criteria categories in patients with both of these DSM diagnoses [17]. Convergent validity has been exhibited in the MID, with strong correlations to the SCID-D-R and three other self-report measures of dissociative symptoms (the Dissociative Experiences Scale [DES], Dissociation Questionnaire [DIS-Q], and Somatoform Dissociation Questionnaire-20 [SDQ-20]). The MID also showed discriminant validity, structural validity, and internal reliability [16]. As mentioned above, other self-report measures of dissociative symptoms exist for screening purposes in various psychiatric disorders, but are not solely used in diagnosing dissociative disorders. The DES assesses symptoms of derealization, depersonalization, absorption, and amnesia. It has been used to screen for these symptoms in patients with schizophrenia or other psychotic disorders [18]. The SDQ-­ 20 is a validated measure of somatoform dissociation, showing higher scores in patients with DID compared to those with DDNOS [19]. Finally, the DIS-Q has been used as a reliable and validated measure of dissociative symptoms in various psychiatric disorders [20].

Challenges in Diagnosis Several challenges remain in the diagnosis of DID, particularly regarding confusion with the term “conversion disorder.” Conversion disorders were considered interchangeable with dissociative disorders in the ICD-10, including conditions such as non-epileptic seizures (NES) and dissociative anesthesia and sensory loss, though the ICD-11 has removed the term “conversion” from the grouping of dissociative disorders. The DSM-IV listed conversion disorders under dissociative disorders, a categorization that has been changed in the DSM-5 with separate listings for conversion disorder, now also referred to as “functional neurological symptom disorder”, and dissociative disorders. Confusion surrounding these conditions remains, potentially complicated by the extensive comorbidity established between conversion disorder and dissociative disorders [7]. However, higher comorbidity has been established between conversion disorder and other psychiatric conditions, such as anxiety and somatoform disorders, de-emphasizing the role that comorbidity may play in diagnostic confusion with dissociative disorders. Individuals with conversion disorder do exhibit similar symptoms to those with dissociative disorders; for example, patients with conversion disorders have scored twice as high

on the DES than age-matched psychiatric patients [7]. Conversion seizures have been noted to commonly co-occur with dissociation following experiences of trauma, and some researchers posit that conversion is somatoform type or manifestation of dissociation [21, 22]. Unfortunately, medically unexplained symptoms are very common in both DID and somatization disorders; as always, careful psychiatric and neurological workup continue to be paramount. Despite large advances in diagnosing DID, it continues to be misdiagnosed, contributing to delayed appropriate treatment and poor prognosis [23]. Further clarification is needed to more definitively recognize DID, particularly when differentiating the symptoms of DID, BPD, schizophrenia, conversion disorder, and other diagnoses with overlapping symptoms and differing etiologies.

Future Directions in Diagnosis Researchers have explored some potential diagnostic methods for DID to complement extensive clinical interviews and questionnaires. A pattern of neuroimaging biomarkers has been proposed after they were able to accurately classify DID patients and healthy controls based on brain structure with high sensitivity and specificity [24]. However, a comprehensive literature review of neuroimaging in patients with dissociative experiences concluded that studies of differential brain activation in DID, rather than brain structure, may offer more promising results for future application to diagnosis [25]. Neural correlates of trauma-related dissociation have also been identified as possible opportunities for earlier intervention in patients, particularly those with persistent derealization [26].

Conclusion While challenges in diagnosing DID persist, much progress has been made to allow more accurate identification, and subsequent treatment, of the disorder. Future research on neuroimaging and neurological biomarkers of DID may be promising but are far from being clinically applied. Careful clinical interview, with appropriate credence to the contribution of trauma to etiology, remains our best tool for diagnosing DID and treating its underlying causes.

References 1. Dorahy, M. J., Brand, B. L., Sar, V., Krüger, C., Stavropoulos, P., Martínez-Taboas, A., Lewis-Fernández, R., and Middleton, W. (2014). Dissociative identity disorder: An empirical overview. Aust N Z J Psychiatry, 48(5), 402–417.

27  DID and Diagnosis 2. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™, vol. 5. 5th ed. American Psychiatric Publishing, Inc.; 2013. p. 5. 3. Wang P. What Are Dissociative Disorders? American Psychiatric Association. 2018, August. https://www.psyc h i a t r y. o r g / p a t i e n t s -­f a m i l i e s / d i s s o c i a t iv e -­d i s o r d e r s / what-­are-­dissociative-­disorders 4. Reed GM, First MB, Kogan CS, Hyman SE, Gureje O, Gaebel W, Maj M, Stein DJ, Maercker A, Tyrer P, Claudino A, Garralda E, Salvador-Carulla L, Ray R, Saunders JB, Dua T, Poznyak V, Medina-Mora ME, Pike KM, et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry. 2019;18(1):3–19. 5. Nakdimen K.  Renaming multiple personality disorder. Am J Psychiatry. 1995;152(7):1104. https://doi.org/10.1176/ ajp.152.7.1104a. 6. Waugaman RM.  Multiple personality disorder and one analyst’s paradigm shift. Psychoanal Inq. 2000;20(2):207–26. 7. Spiegel D, Lewis-Fernández R, Lanius R, Vermetten E, Simeon D, Friedman M.  Dissociative disorders in DSM-5. Ann Rev Clin Psychol. 2013;9:299–326. 8. Foote, B. (1999). Dissociative identity disorder and pseudo-­ hysteria. Am J Psychother, 53(3), 320–343. 9. Gleaves DH.  The sociocognitive model of dissociative identity disorder: a reexamination of the evidence. Psychol Bull. 1996;120(1):42–59. 10. Şar, V., Dorahy, M. J., and Krüger, C. (2017). Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychol Res Behav Manag, 10, 137–146. 11. Ross, C. A. (2015). When to suspect and how to diagnose dissociative identity disorder. J EMDR Pract Res, 9(2), 114–120. 12. Ross, C. A., and Ellason, J. W. (2005). Discriminating among diagnostic categories using the dissociative disorders interview schedule. Psychol Rep, 96(2), 445–453. 13. Mychailyszyn MP, Brand BL, Webermann AR, Şar V, Draijer N.  Differentiating dissociative from non-dissociative disorders: a meta-analysis of the structured clinical interview for DSM dissociative disorders (SCID-D). J Trauma Dissoc. 2021;22(1): 19–34. 14. Steinberg. Advances in the clinical assessment of dissociation: The SCID-DR. BULLETIN-­MENNINGER CLINIC. 2000. https://www.researchgate.net/profile/Marlene-­Steinberg/publication/12476744_Advances_in_the_clinical_assessment_of_dissociation_The_SCID-­D -­R /links/54832b300cf2f5dd63a90fcd/ Advances-­in-­the-­clinical-­assessment-­of-­dissociation-­The-­SCID-­ D-­R.pdf

157 15. Gleaves DH, May MC, Cardeña E.  An examination of the diagnostic validity of dissociative identity disorder. Clin Psychol Rev. 2001;21(4):577–608. 16. Dell PF.  The multidimensional inventory of dissociation (MID): A comprehensive measure of pathological dissociation. J Trauma Dissoc. 2006;7(2):77–106. 17. Korzekwa MI, Dell PF, Links PS, Thabane L, Fougere P. Dissociation in borderline personality disorder: a detailed look. J Trauma Dissoc. 2009;10(3):346–67. 18. Saggino A, Molinengo G, Rogier G, Garofalo C, Loera B, Tommasi M, Velotti P. Improving the psychometric properties of the dissociative experiences scale (DES-II): a Rasch validation study. BMC Psychiatry. 2020;20(1):8. 19. Nijenhuis ER, Spinhoven P, Van Dyck R, Van der Hart O, Vanderlinden J. The development and psychometric characteristics of the somatoform dissociation questionnaire (SDQ-20). J Nerv Ment Dis. 1996;184(11):688–94. 20. Matsui, Y., Naito, K., Matsuishi, K., Kato, H., Maeda, K., and Tanaka, K. (2011). Assessment of dissociation symptoms in patients with mental disorders by the dissociation questionnaire (DIS-Q). Kobe J Med Sci, 56(6), E263–E269. 21. Bowman, E.  S. (2006). Why conversion seizures should be classified as a dissociative disorder. Psychiatr Clin North Am, 29(1), 185–211, x. 22. Nijenhuis ER, van Dyck R, Spinhoven P, van der Hart O, Chatrou M, Vanderlinden J, Moene F.  Somatoform dissociation discriminates among diagnostic categories over and above general psychopathology. Aust N Z J Psychiatry. 1999;33(4):511–20. 23. Mitra P, Jain A.  Dissociative identity disorder. In StatPearls. Treasure Island, FL: StatPearls Publishing; 2021. 24. Reinders AATS, Marquand AF, Schlumpf YR, Chalavi S, Vissia EM, Nijenhuis ERS, Dazzan P, Jäncke L, Veltman DJ.  Aiding the diagnosis of dissociative identity disorder: pattern recognition study of brain biomarkers. Br J Psychiatry J Ment Sci. 2019;215(3):536–44. 25. Lotfinia, S., Soorgi, Z., Mertens, Y., and Daniels, J. (2020). Structural and functional brain alterations in psychiatric patients with dissociative experiences: a systematic review of magnetic resonance imaging studies. J Psychiatr Res, 128, 5–15. 26. Lebois LAM, Harnett NG, van Rooij SJH, Ely TD, Jovanovic T, Bruce SE, House SL, Ravichandran C, Dumornay NM, Finegold KE, Hill SB, Merker JB, Phillips KA, Beaudoin FL, An X, Neylan TC, Clifford GD, Linnstaedt SD, Germine LT, et  al. Persistent dissociation and its neural correlates in predicting outcomes after trauma exposure. Am J Psychiatry. 2022;179(9):661–72.

DID and Differential Diagnoses

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Shivani Kaushal, Jordan Calabrese, Anam Roy, and Jose Isaac Reyes

Introduction

DID and Other Dissociative Disorders

Controversy surrounding diagnosis is common to many psychiatric disorders, an expected issue when pathology is characterized by symptoms and signs reflecting an internal environment that cannot be seen with the human eye. Determining diagnostic criteria, number of symptoms, and other objective measures has presented persistent challenges in differentiating psychiatric conditions, even with the introduction of the revamped third and subsequent editions of the Diagnostic and Statistical Manual of Mental Disorders. Within this already challenging context, Dissociative Identity Disorder (DID) and other dissociative conditions are arguably some of the more difficult diagnoses to understand and distinguish from other psychiatric disorders. Patients with DID may exhibit many features common to other psychiatric diagnoses, making specific detection of DID difficult, while presentations of DID are often extremely heterogeneous and unique to each individual, adding another level of obfuscation to its diagnosis or concordance with generalized criteria. Such factors contribute to a broad differential diagnosis to consider in a patient presenting with dissociative symptoms, requiring a nuanced look at the current understanding of DID and its relationship with other dissociative disorders and non-dissociative psychiatric conditions.

In approaching the differential diagnosis of DID, it is helpful to start with the other disorders classified as “dissociative” alongside DID in the DSM-5. By definition, dissociative disorders involve disruption in integrating multiple cognitive processes, including consciousness, memory, identity, emotion, perception, motor control, body representation, and behavior [1]. The dissociative disorders in the DSM-5 include three groupings: DID, dissociative amnesia, and depersonalization/derealization disorder. Specific dissociative disorders are classified based on the primary aspects of normal cognition that are affected or compromised in the individual experiencing dissociation (particularly modified by positive and negative symptoms). In dissociative amnesia, for example, the ability to recall autobiographical information or integrate memories is lacking or compromised. Depersonalization/derealization disorders, on the other hand, involve added experiences of altered feeling and/or perception, including disconnection from one’s body, thoughts, or emotions; or appraisal of one’s surroundings as distorted, foggy, or surreal [2]. There are further classifications to more specifically pinpoint dissociative diagnoses and classify dissociative symptoms: a modifier for dissociative amnesia is “with dissociative fugue”, in which an individual’s memory lapses result in aimless wandering. Additionally, a subtype of PTSD was added to the DSM-5 to capture the dissociative symptoms in many PTSD patients, confirmed through latent class, confirmatory factor, and taxometric analysis [3]. The inclusion of this subtype has made it possible to tailor more effective treatments that can address dissociative symptoms when present in PTSD. DID certainly shares many features with the dissociative disorders above. One diagnostic criterion of DID, for example, specifies the presence of autobiographical amnesia as a symptom, which aligns with dissociative amnesia. Another criterion includes alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning, which has a large overlap with the altered feeling

S. Kaushal Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, FL, USA J. Calabrese (*) Department of Psychiatry, Aventura Hospital and Medical Center, Aventura, FL, USA A. Roy Windsor University School of Medicine, Santa Fe, NM, USA J. I. Reyes Saint George’s University School of Medicine, Miramar, FL, USA

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and perception that characterize depersonalization/derealization disorders. While these diagnoses have commonalities, DID is distinguished from other disorders through the criteria which specifically describe features of identity fragmentation, an aspect not included in the other dissociative conditions. Disruption of identity is a specific phenomenon in which 2 or more distinct personality states exist within an individual, with related discontinuities of experience (in some cultures, such interruptions may be attributable to experiences of possession). Despite this clear distinguishing requirement for DID, the interruptions of identity may be ambiguous to recognize, as only a small ­percentage of cases present to clinicians with observable identity alteration [1]. Because alternate personality states are not necessarily observable to clinicians, other symptoms of DID must be recognized to identify DID: both Criterion A (sudden alterations of discontinuities in sense of self and sense of agency) and Criterion B (recurrent dissociative amnesias). Thus, piecing together such characteristics within a differential diagnosis requires clinicians to be intimately familiar with the nuances of various manifestations of dissociation. Additionally, there are two categories for dissociative disorders that do not conform to the three major groupings: “other specified dissociative disorder” and “unspecified dissociative disorder.” “Other specified dissociative disorder” encompasses chronic or recurrent mixed dissociative symptoms that don’t meet Criterion A for DID or aren’t accompanied by recurrent amnesia. “Unspecified dissociative disorder” is used to describe cases of patients whose condition does not fit neatly into a known category of dissociative disorder or for whom enough evidence has not been gathered to make the diagnosis of a different dissociative disorder. The numerous diagnostic categories for dissociative disorders reflect the complexity of the symptoms encompassed by the elusive phenomenon of dissociation. Fortunately, the schema in the most recent DSM editions appears to capture the various aspects of dissociation in a clinically distinguishable manner that has been empirically validated. Indeed, the Dissociative Disorder Interview Schedule is able to discern DID from other dissociative conditions, thus supporting the idea that distinct dissociation pathologies exist [4].

 eneral Comments on Dissociation in Non-­ G dissociative Psychiatric Disorders; Etiology with Trauma From the clinician's point of view, the diagnosis of DID is one that oftentimes can be challenging to make. While dissociative symptoms are considered a key characteristic of DID, current literature suggests that a history of trauma as well as signs of dissociation, are also present in a myriad of

S. Kaushal et al.

other psychiatric conditions [5]. Trauma, in particular, has been closely linked to the incidence of dissociation. According to the Trauma Model, dissociation is considered a psychobiological condition that acts as a bulwark against overpowering or traumatic experiences [6]. Post-traumatic stress disorder (PTSD) is yet another psychiatric condition that shares a similar etiology with DID. The literature describes the idea of a dissociative subtype of PTSD, wherein patients with early onset of PTSD experience derealization and depersonalization in the setting of childhood hardships, suicidality, and significant role impairment [3]. There is also the idea of complex PTSD, which describes a condition in which the patient experiences distortions in identity and relationships, as well as emotional instability and the possibility of continued victimization [7]. Even amid dissociation, PTSD is also said to have a clinical correlation with personality conditions like borderline personality disorder (BPD) in certain patients [8]. Nevertheless, current research supports empirical evidence pointing to neurological abnormalities in areas like the temporal and frontal cortices, the insulae, and amygdalae, which account for the varied degrees of dissociation observed in several psychiatric conditions [9].

DID and Personality Disorders When it comes to axis II pathology, research has shown that dissociative disorders can carry severe personality pathology as well. Literature suggests that some of the most common personality disorders, which are comorbid with dissociative conditions, include avoidant personality disorder (AvPD), borderline personality disorder (BPD), passive-aggressive personality disorder (PAPD), and self-defeating (masochistic) personality disorder [10]. The latter two conditions have been reclassified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and fall under the subclinical diagnosis of “other specified personality disorder” [1]. Borderline personality disorder (BPD) has been markedly associated with dissociative conditions. Although there is a paucity of data that can fully elucidate the etiology of these pathologies, a history of childhood trauma, neglect, and mistreatment has been reported among patients with BPD and dissociative disorders [11]. In separate studies that compared BPD and dissociation, it was noted that 50% of BPD patients match the criteria for either dissociative amnesia (DA), depersonalization disorder, or dissociative disorder not otherwise specified (DDNOS) [12]. Furthermore, well over 20% of BPD patients match criteria for DID [12]. When compared to BPD patients without pathological dissociative experiences, BPD patients with comorbid dissociation pathologies exhibited lower working memory, executive

28  DID and Differential Diagnoses

functioning, verbal memory ability, and decreased performance across multiple cognitive domains [13]. Likewise, dissociation has been linked to increased symptom severity among BPD patients [14].

DID and Mood Disorders The incidence of axis I pathology among individuals with DID and DDNOS has been well documented in the literature. This is particularly the case for certain anxiety and mood disorders, such as major depressive episodes (MDE) and posttraumatic stress disorder (PTSD). Empirical data suggests that DID and DDNOS share similar features and phenomenological characteristics to PTSD [15]. Unipolar depression in the setting of dissociation could be difficult to study, given the complexity of certain presentations. The term “dissociative depression” was coined to describe the patient demographic that exhibited depressive symptoms, while also endorsing dissociation [16]. In trials overseeing DID patients, the diagnosis of MDE was more common in patients with DID as opposed to the controls [17]. A vast majority of DID patients also endorse suicidal ideations, suicidal attempts, and self-injury [18]. Inherent to the condition itself, individual identity states can appear to meet the criteria for depressive disorders, but this may be masked by the constant alternation of identity states in a DID patient [1]. Thus, within a DID patient, symptoms of depression could be endorsed by certain identity states. Bipolar disorder type 2 (BP-2) shares a number of characteristics that may lead a clinician to misdiagnose DID for this condition. Some of the most notable symptoms of BP-2 are the mood swings exhibited by these patients, which alter in between major depressive episodes and hypomania [19]. The DSM-V, however, points to certain clues to recognize one condition apart from the other. Whereas the mood swings in a patient with BP-2 occur steadily, and over the course of a consistent, prolonged period of time, the mood alternations can be observed rather promptly in a patient diagnosed with DID [1].

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Nevertheless, both conditions carry markedly distinct characteristics. Whereas both DID and Schizophrenia can present with depersonalizations, derealizations, and multiple types of hallucinations, passive-influence symptoms are rarely accompanied by delusional experiences in DID [21]. Furthermore, the ego-pathology observed in DID patients is described as “fluid,” while in schizophrenic individuals, it is often characterized as fragile and rigid [7]. Brief psychotic disorder and major depression with psychotic features are also common diagnoses that can be erroneously attributed to a DID patient. In such an event, it is important to make note of the extent of dissociation. Episodical amnesia and symptom depersonalization will favor a DID diagnosis as opposed to the latter two [1].

 seudoneurological Symptoms, Seizures, P and Conversion Disorder

Psychogenic movement disorders (PMD) as well as Psychogenic nonepileptic seizures (PNES) have been closely studied in the setting of dissociation. Similar to individuals diagnosed with DID, traumatic experiences usually precede symptomatology among PNES patients [22]. On the other hand, some have argued that PNES appears to be caused by dissociation processes, and that these can be treated with the correct hypnotic protocols [23]. The etiology of both conditions also seems to be related nonetheless. Dissociative seizure was term introduced to describe a state in which an individual with a dissociative condition experiences symptoms reminiscent to an epileptic seizure, but that are unaccompanied by relevant electrophysiological findings [24]. This is most notably the greatest difference amongst the two conditions. Furthermore, compared to those with complex partial seizures, patients with DID score highly on dissociation tests [1]. Conversion disorder (CD) is a neurologic, somatoform condition which can present with sensory deficits, motor symptoms, “pseudo-seizures,” or a mixed manifestation of the three [25]. As opposed to DID, CD patients do not experience an identity interruption of two or more personality states [1]. Furthermore, when CD patients experience an DID and Psychotic Disorders amnesic episode, the latter is more restricted and constrained in comparison to the amnesia that a DID patient would expeDID can manifest with a wide array of features, some of rience [1]. which are also present in select psychotic disorders. This is While there is certainly a marked distinction among the case for schizophrenia. Historically, as clinicians gained somatoform and dissociative conditions, the literature has understanding of schizophrenia, the concept of DID was reinforced the notion that the two can present in a comorbid seemingly masked [20]. Some have proposed that the ego-­ fashion. A study published by the American Journal of fragmentation observed in schizophrenic pathology is con- Psychiatry found that 47 percent of patients with CD also sidered a dissociation on its own, and that these characteristics presented with a comorbid dissociative disorder, the most could render both pathologies, schizophrenia and DID, prevalent one being dissociative disorder not otherwise specwithin the same realm [7]. ified [26]. From a neurophysiological perspective, dissocia-

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4. Ross CA, Ellason JW. Discriminating among diagnostic categories tion in the context of conversion symptoms is likely due to using the dissociative disorders interview schedule. Psychol Rep. disturbances in volition center circuitries and hypo-­ 2005;96(2):445–53. stimulation of associated structures (i.e., basal ganglia and 5. Lyssenko L, Schmahl C, Bockhacker L, Vonderlin R, Bohus thalamus) [27]. M, Kleindienst N.  Dissociation in psychiatric disorders: a meta-­

Miscellaneous/Non-physiological Presentations of DID-Like Symptoms In the setting of substance or medication use, clinicians are tasked with the responsibility of assessing whether the substance can be the sole responsible for any dissociative symptoms [1]. Early research also suggests that DID patients can also have comorbid substance use disorder [28]. As such, it is imperative to discern both conditions when presented in a single patient. Treatment plans for both substance abuse and DID can be successful if tailored accordingly. Whether a patient reports symptoms of DID for the attention of the clinician or for personal gain, patients who malinger or otherwise feign DID symptoms usually recant a narrative that is overly exaggerated and elaborate. These individuals complain of multiple symptoms of the condition, openly volunteer chronological timelines and episodes of trauma, and abnormally endorse a broad or “wide” range of affect whilst discussing specifics of their alleged condition [29]. Those who present with bona-fide DID however will underreport the well-known signs of the condition; will feel uneasy about their condition in general, and will not often endorse the subtle incursion symptoms that often accompany it [1].

Conclusion As illustrated above, the differential diagnosis of DID is broad, and complicated further by the likely presence of other comorbidities in patients with DID. Furthermore, dissociative symptoms are found in many other conditions diagnosed in the DSM-5, including PTSD and various psychotic, mood, personality, and substance use disorders.

References 1. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™, vol. 5. 5th ed. Arlington, VA: American Psychiatric Publishing, Inc; 2013. p. 5. 2. Maldonado JR, Spiegel D. Dissociative disorders. In The American Psychiatric Association publishing textbook of psychiatry, vol. 7. American Psychiatric Association Publishing; 2019. 3. Spiegel D, Lewis-Fernández R, Lanius R, Vermetten E, Simeon D, Friedman M. Dissociative disorders in DSM-5. Annu Rev Clin Psychol. 2013;9:299–326.

analysis of studies using the dissociative experiences scale. Am J Psychiatry. 2018;175(1):37–46. 6. Loewenstein RJ.  Dissociation debates: everything you know is wrong. Dialogues Clin Neurosci. 2018;20(3):229–42. 7. Moskowitz A, Dorahy MJ, Schäfer I.  Psychosis, trauma and dissociation: evolving perspectives on severe psychopathology. Hoboken, NJ: John Wiley & Sons; 2019. 8. Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J.  Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. J Psychiatr Res. 2010;44(16):1190–8. https://doi.org/10.1016/j. jpsychires.2010.04.016. 9. Lotfinia S, Soorgi Z, Mertens Y, Daniels J.  Structural and functional brain alterations in psychiatric patients with dissociative experiences: a systematic review of magnetic resonance imaging studies. J Psychiatr Res. 2020;128:5–15. https://doi.org/10.1016/j. jpsychires.2020.05.006. 10. Dell PF.  Axis II pathology in outpatients with dissociative identity disorder. J Nerv Ment Dis. 1998;186(6):352–6. https://doi. org/10.1097/00005053-­199806000-­00005. 11. Sar V, Akyuz G, Kugu N, Ozturk E, Ertem-Vehid H. Axis I dissociative disorder comorbidity in borderline personality disorder and reports of childhood trauma. J Clin Psychiatry. 2006;67(10):1583– 90. https://doi.org/10.4088/jcp.v67n1014. 12. Korzekwa MI, Dell PF, Links PS, Thabane L, Fougere P. Dissociation in borderline personality disorder: a detailed look. J Trauma Dissoc. 2009;10(3):346–67. https://doi.org/10.1080/15299730902956838. 13. Haaland VØ, Landrø NI.  Pathological dissociation and neuropsychological functioning in borderline personality disorder. Acta Psychiatr Scand. 2009;119:383–92. https://doi. org/10.1111/j.1600-­0447.2008.01323.x. 14. Al-Shamali HF, Winkler O, Talarico F, et  al. A systematic scoping review of dissociation in borderline personality disorder and implications for research and clinical practice: exploring the fog. Aust N Z J Psychiatry. 2022;56(10):1252–64. https://doi. org/10.1177/00048674221077029. 15. Rodewald F, Wilhelm-Göling C, Emrich HM, Reddemann L, Gast U. Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. J Nerv Ment Dis. 2011;199(2):122–31. https://doi.org/10.1097/ NMD.0b013e318208314e. 16. Fung HW, Chan C. A preliminary study of the clinical differences between dissociative and nondissociative depression in Hong Kong: implications for mental health practice. Soc Work Health Care. 2019;58(6):564–78. https://doi.org/10.1080/00981389.2019 .1597006. 17. Yargiç LI, Sar V, Tutkun H, Alyanak B. Comparison of dissociative identity disorder with other diagnostic groups using a structured interview in Turkey. Compr Psychiatry. 1998;39(6):345–51. https:// doi.org/10.1016/s0010-­440x(98)90046-­3. 18. Şar V.  The many faces of dissociation: opportunities for innovative research in psychiatry. Clin Psychopharmacol Neurosci. 2014;12(3):171–9. https://doi.org/10.9758/cpn.2014.12.3.171. 19. Godman B, Grobler C, Van-De-Lisle M, Wale J, Barbosa WB, Massele A, Opondo P, Petrova G, Tachkov K, Sefah I, Abdulsalim S, Alrasheedy AA, Unnikrishnan MK, Garuoliene K, Bamitale K, Kibuule D, Kalemeera F, Fadare J, Khan TA, Hussain S, et al. Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries.

28  DID and Differential Diagnoses Expert Opin Pharmacother. 2019;20(18):2237–55. https://doi.org/1 0.1080/14656566.2019.1684473. 20. Brand BL, Sar V, Stavropoulos P, Krüger C, Korzekwa M, Martínez-­ Taboas A, Middleton W. Separating fact from fiction: an empirical examination of six myths about dissociative identity disorder. Harv Rev Psychiatry. 2016;24(4):257–70. 21. Laddis A, Dell PF.  Dissociation and psychosis in dissociative identity disorder and schizophrenia. J Trauma Dissoc. 2012;13(4):397–413. 22. Fiszman A, Alves-Leon SV, Nunes RG, D’Andrea I, Figueira I.  Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav. 2004;5(6):818–25. https://doi.org/10.1016/j. yebeh.2004.09.002. 23. Erro R, Brigo F, Trinka E, Turri G, Edwards MJ, Tinazzi M. Psychogenic nonepileptic seizures and movement disorders: a comparative review. Neurol Clin Pract. 2016;6(2):138–49. 24. Fritzsche K, Baumann K, Götz-Trabert K, Schulze-Bonhage A.  Dissociative seizures: a challenge for neurologists and psy-

163 chotherapists. Dtsch Arztebl Int. 2013;110(15):263–8. https://doi. org/10.3238/arztebl.2013.0263. 25. Feinstein A. Conversion disorder: advances in our understanding. CMAJ. 2011;183(8):915–20. https://doi.org/10.1503/cmaj.110490. 26. Sar V, Akyüz G, Kundakçi T, Kiziltan E, Dogan O.  Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. Am J Psychiatry. 2004;161(12):2271–6. https://doi.org/10.1176/appi.ajp.161.12.2271. 27. Isaac M, Chand PK. Dissociative and conversion disorders: defining boundaries. Curr Opin Psychiatry. 2006;19(1):61–6. 28. McDowell DM, Levin FR, Nunes EV. Dissociative identity disorder and substance abuse: the forgotten relationship. J Psychoactive Drugs. 1999;31(1):71–83. https://doi.org/10.1080/02791072.1999. 10471728. 29. Thomas A.  Factitious and malingered dissociative identity disorder. J Trauma Dissoc. 2001;2(4):59–77. https://doi.org/10.1300/ J229v02n04_04.

Struggle of Family of DID Patients.

29

Venkatesh Sreeram, Nana Bonsu, and Faiz M. Hasan

Introduction Families comprise a subsystem in the context of society and culture. Family is a salient underpinning source in dissociative disorders, assuming a family can hold and would not disrupt by the stress of the trauma [1]. Around 90 percent of affected individuals with DID, disclosed having an abuse history in early childhood by their attachment figs [2]. Authoritative parenting style is considered a risk factor for DID. It affects certain parts within our human brain, like the forebrain, to stay dormant for years and start expressing in adulthood with confusing and unexplainable reactions. It may adversely affect the executive function of the offspring [3]. DID is a condition that may stay invisible unless, the affected consults for treatment. Having a caring and supportive family would help the individuals feel comforted, reassured, and understood, despite displaying different alters in their identities.

Attachment Theory Perspective For decades, DID was thought to be caused by physical or sexual abuse, with the extent of psychopathology depending on the duration and the severity of the abuse. However, the family history of attachment, be it secured or disorganized, may also contribute to the degree of psychopathology [4]. This attachment is usually established by 3 years of age. The severity of trauma after abuse depends on the warmth provided by the mother [5].

V. Sreeram (*) Baylor College of Medicine, Houston, TX, USA N. Bonsu Emory School of Medicine, Atlanta, GA, USA F. M. Hasan Geisel School of Medicine at Dartmouth, Lebanon, NH, USA

Lack of secure attachment results in a lack of confidence in acquiring social skills, making them less likely to interact socially. Hence, they develop avoidance. Several theories illustrated that families with disorganized attachment styles potentiate the development of DID and decrease psychological resilience when they experience trauma [6–10]. According to Liotti, the dissociation may be seen as a lack of integration between the caregiver and the individual attachment, mere a defensive reaction [11]. Family structure, dynamics, and dysfunctions could also influence the development of DID. Research studies indicate that dysfunction in the family may often lead to personality traits with psychological dysfunction [12, 13]. The transitions in DID can be surprising and striking. The family members usually notice this transition beforehand. It can lead to a myriad of emotional turmoil for the family and friends of DID suffering individuals [14]. Family may also play as a therapeutic collaborator in their recovery by helping in coping with their extreme emotional distress. [15].

 ow Affected Individuals May Perceive H the Diagnosis? Individuals suffering from DID may feel a sense of dejection, shame, or embarrassment if they reveal their condition. They tend not to show their loved ones the personality they are experiencing at that given time [16]. Often, they live confused with lapses in their memory. They may feel terrified with a lack of clarity and not have a clear idea of what could be wrong with them. It may get tough to maintain a relationship with individuals struggling with DID, as their parts of the identity may shift in seconds or minutes. It may get tougher to maintain a relationship that is real. The alters may have different beliefs, distinct habits, or mannerisms. They may also feel isolated, fearful about themselves, and lonely in their suffering. They become aware that lives can be chaotic and hard to manage. It may lead to increased self-­

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_29

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injury rates, although reexperiencing the trauma is considered a key causing factor for self-injury. They also tend to fear that their family may abandon them if they learn about their situation. If those individuals have kids in their household, they fear that their children might be taken away from them and placed in foster care. They also tend to overidentify their child as the victim and may also interchange the roles leading to shame and guilt. The child may have a similar influence on the caregiver. It ends with the reenactment cycle, which needs disruption and correction. Multiple interchangeable roles that the caregiver and the individual display after the trauma prevent the therapeutic remedy [11, 17]. In a few instances, the kids may remove from the individuals with DID care for safety [16]. These children would lose their attachment figures and may grow into developing subsequent mental health problems, if they were not placed in a supportive environment. At the same time, if the child has dissociative features, ensuring a safe and nurturing environment is crucial.

How Family May Perceive the Diagnosis? As mentioned earlier, the family may have first-hand experiences identifying the affected individuals. Often the family members may feel that the person they knew no longer exists with the continued switching between the personalities. Treatment providers may require helping the family empathize, that they may not always respond as expected, and being an accepting hand would assist them in sharing their experiences. Family members that are currently supporting and caring can also be the ones that abused them in the past and may also suffer from their own emotional difficulties. It points toward the dysfunction in the family. The caregivers having difficulty balancing their own emotions would feel burdened with the emotional requirements of affected individuals. They may become prone to abuse their dependents or expose them to get abused by others [18]. Families with authoritative or rigid parenting where everything runs in a hierarchy making the family members in the lower position have various limitations. It leads to inflexibility, unsupportiveness, inexpressible, and will suffer from considerable family dissatisfaction. A section of family members may also think that the affected individuals were behaving in this manner to seek attention or to get preferential treatment. It can get difficult to interpret whether an associated element of pretentious nature exist. It leads to the question of malingering as inevitable, as the disorder infringes the salient human quality, which is the unity of personal identity [19].

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Challenges Faced by the Family Members The reality of daily living with persons affected by dissociative identity disorder can be bewildering and tiresome. The relationship may suffer from frequent switches between different assignments and paths of careers, switches between demeanor and preferences, and irrational decisions that affect their mutual interactions. Often, the caregivers may find the person as more affectionate and intimate at one moment, while they may pretend to be unfamiliar and distant at other moments. The initial emotional expression that many families expected to show, if the family member has dissociative identity disorder would be fear. They may feel an alter which could be dangerous, and eventually start worrying [20]. Mental disorders in a family may cause emerging interactions due to their existence. The other members of the family experience feelings of burden when coping with it. It may reflect in various ways like the behavioral changes towards the affected, daily functional, and financial limitations. They altogether may affect both the affected and other members of the family [21]. The subjective burden can be seen in the attitude of caregivers towards the affected. The family members may also develop depression and anxiety with the burden they perceive in caring for the affected. The rates are higher when compared to the general population [22]. The major stressor for the family in DID was the interpersonal conflicts within the family complex, rather than disputes between an individual couple or ending a relationship. The recreation within the family may get interfered with, and they get frustrated with their leisure time frequently getting disrupted. The caregivers may also sense frequent fluctuations in emotions that may frustrate their feelings, and their relationship may be stresses with extreme fatigue and mutual caring expectations not being met. These negative feelings or frustrations by the family members may show towards the affected, which may lead to a negative conflict and trigger more dissociative symptoms or events in the affected. In a few case studies, families reported that the alters were able to express the description of abuse or assault. Also, the families get used to the postures or personalities of alters, which makes them capable of identifying with whom they are interacting [23]. In a few developing countries, where mental health is stigmatized or not that expressive in the communities, the attachment or communication within the family tends to stay below average while the conflicts were found to be more than average. Several ethical, spiritual, or cultural issues may come as hurdles to these families with DID, in terms of economic planning and responsibilities limiting the functional abilities in the community [24].

29  Struggle of Family of DID Patients.

Some of these families from developing countries who cope with spiritualism may believe their affected family member was possessed and would force them into religious rituals. There are possibilities indicating that these religious groups who practice rituals, may act as good social support groups and improve their dissociative episodes [25]. The family may identify the strategies to cope with the individual when various alters of their identity are in control by relating to each part of their identity. Understanding their triggers, which worsen their memories by creating flashbacks and leading to dissociations, would assist the family in avoiding or preventing them. The family may also need to step up in crisis situations by involving them in the right kind of help that would alleviate the situation and prevent their potential for self-destruction. The management requires planning comprehensively by not only focusing on psychological conflicts or stressful life situations but also targeting several domains of impairment is a crucial step.

 ow Support From Family Can Be Beneficial H and Impactful? Based on case studies, few family members reported that alters in affected individuals may expect a low-key response from the family with a calm demeanor and soft voice to avoid any interpersonal conflicts [15]. The affected individuals may startle even with a sudden pat that could bring back many distressing and traumatic memories. Hence the family may require education regarding avoiding any unwanted touch. The affected individual should also have the liberty of autonomy to determine and reflect when inappropriate situations arise, with the alter and the affected individual being in denial. It helps the affected to understand the alters as their system. If a child gets affected, the parents should be proficient in employing relevant child management techniques, including the appropriate rewards and applying grounding rules only for a reasonable amount of time. Having said parents cannot conclude that their child would obey their rules and expectations. Hence, communicating with attribution of all the alters may be considered beneficial [15]. The parents, however, could only be able to contribute if they become aware of the affected member of their family. Many caregivers seek support forums like blogs or groups to express their experiences, which would not make them feel isolated in this journey and also assist them with any advice others may share from their experiences [26]. Structural family therapy was helpful in dissociative identity disorders. In particular, it helps the family understand the circumstances leading the person to dissociate, and changing

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the family dynamics would help integrate the personality and defeat their dissociative barriers [27]. Reinforcing the individuals as having one identity, despite the alters, is beneficial. Family members may often feel discouraged by the limited or slow progression of improvement. The goal of therapeutic interventions is to restore the scope of affected individuals to their normalcy, be it at home or work.

Conclusion Educating the family about the crucial role of identifying dissociative experiences is required. Caution may be needed as few interactions with certain family members can be discouraging and may lead to acute decompensation of the affected individuals. It also involves educating the caregivers and support to encourage the focus on expressing the distressing thoughts or feelings of affected individuals and not reinforcing the dissociations. Treatment success depends on the therapeutic relationship between affected individuals and their families. Regularly, treatment providers involve families to conceptualize a structured plan for the affected individuals, promoting safe alternative strategies to express their negative feelings. It is crucial to notify the individual to have a set of codewords of expression and inform the family to de-escalate the situation. Little do we know about families recuperating from their family members suffering through DID. There are available support groups that families may consider attending, where they can share their experiences in a safe environment. If the families get support, it can also benefit the individuals affected by DID.  We have little to no studies available, exploring the perspectives of the caregivers and their burden on the affected. An individual recovery would heavily rely on their available support system. Having a support system that understands individuals’ triggers and the symptomatology of dissociative episodes would be critical in their recovery. As a provider, one needs to advocate for individuals with DID and their caregivers.

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168 5. Schore AN.  Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Ment Health J. 2001;22:7–66. 6. LiottiG. Disorganization of attachment as a model for understanding dissociative psychopathology. 1999 7. Silberg JL.  The treatment of dissociation in sexually abused children from a family/attachment perspective. Psychotherapy. 2004;41(4):487. 8. Barach PM. Multiple personality disorder as an attachment disorder. Dissociation. 1991;4(3):117–23. 9. Blizard RA.  Disorganized attachment, development of dissociated self states, and a relational approach to treatment. J Trauma Dissociation. 2003;4(3):27–50. 10. Byun S, Brumariu LE, Lyons-Ruth K. Disorganized attachment in young adulthood as a partial mediator of relations between severity of childhood abuse and dissociation. J Trauma Dissociation. 2016;17(4):460–79. 11. Liotti G. Trauma, dissociation, and disorganized attachment: three strands of a single braid. Psychotherapy. 2004;41(4):472–86. 12. Şar V, Dorahy MJ, Krüger C.  Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychol Res Behav Manag. 2017;10:137. 13. Cicchetti D, Cohen DJ. (Eds.). Developmental Psychopathology, Volume 2: Developmental Neuroscience. John Wiley & Sons. 2006. 14. Peterson G, Boat BW. Concerns and issues in treating children of parents diagnosed with dissociative identity disorder. J Child Sex Abus. 1998;6(3):1–14. 15. Waters FS.  Parents as partners in the treatment of dissociative children. The dissociative child: Diagnosis, treatment and management. 1998: 273–296. 16. Saakvitne KW. Some thoughts about dissociative identity disorder as a disorder of attachment. Psychoanalyt Inq. 2000;20(2):249–58. 17. Liotti G. A model of dissociation based on attachment theory and research. J Trauma Dissociation. 2006;7(4):55–73.

V. Sreeram et al. 18. Hornstein NL, Tyson S. Inpatient treatment of children with multiple personality/dissociative disorders and their families. Psychiatr Clin North Am. 1991;14(3):631–48. 19. Nissen MJ, Ross JL, Willingham DB, Mackenzie TB, Schacter DL. Memory and awareness in a patient with multiple personality disorder. Brain Cogn. 1988;8(1):117–34. 20. Emerson R.  Myriad-minded miracle: Knowing and Caring Someone with Dissociative Identity Disorder. 2019 December 10. https://overland.org.au/2019/12/myriad-­minded-­miracle-­knowing-­ and-­caring-­for-­someone-­with-­dissociative-­identity-­disorder/ 21. Kızılırmak B, Küçük L. Care burden level and mental health condition of the families of individuals with mental disorders. Arch Psychiatr Nurs. 2016;30(1):47–54. 22. Boye B, Bentsen H, Ulstein I, Notland TH, Lersbryggen A, Lingjaerde O, Malt UF. Relatives’ distress and patients’ symptoms and behaviours: a prospective study of patients with schizophrenia and their relatives. Acta Psychiatr Scand. 2001;104(1):42–50. 23. Biswas J, Chu JA, Perez DL, Gutheil TG. From the neuropsychiatric to the analytic: three perspectives on dissociative identity disorder. Harv Rev Psychiatry. 2013;21(1):41–51. 24. Verma KK, Solanki OP, Baniya GC, Goyal S. A study of the stressor, family environment and family burden in dissociative (conversion) disorder patients. Indian J Soc Psychiatry. 2017;33(3):196. 25. Delmonte R, Lucchetti G, Moreira-Almeida A, Farias M. Can the DSM-5 differentiate between nonpathological possession and dissociative identity disorder? A case study from an Afro-Brazilian religion. J Trauma Dissociation. 2016;17(3):322–37. 26. Panko C. How my Husband’s Dissociative Identity DisorderAffects my Mental Health. 2017, November 7. https://themighty.com/2017/11/ caregiver-­mental-­health-­dissociative-­identity-­disorder-­husband/ 27. Thayyil MM, Rani A.  Structural family therapy with a client diagnosed with dissociative disorder. Indian J Psychol Med. 2020;43(6):549–54.

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Krithika Krishnamurthy and Vikram Kumar

Introduction This chapter attempts to examine the role of religion and spirituality in dissociative identity disorder and disentangle what may otherwise appear as an esoteric and obscure topic into more precise associations. One cannot overemphasize the need for religion in the domain of mental health. It can often be a supportive factor by bolstering social and community support. We start by exploring religion and spirituality’s place in psychiatry. We then explore the link between dissociative identity disorder and religion from the early ages. Concepts such as Ritual and Satanic abuse are linked to severe trauma and are seen in cases with DID. Culture-bound presentations of dissociation, such as trance states, are well documented in practice. Religions worldwide have forms of prayer involving movement, dance, and music and are interpreted as a beneficial component in religious experiences. These states can include dissociation and amnesia, the central tenets of dissociative identity disorder. From the Christian Rapture to the Israeli Strambali, many versions of such experiences exist. On the flip side, there are cultural presentations, such as amok and piblokto, seen in specific populations, which are physically and mentally challenging to endure. Finally, we look at the phenomenon of possession by itself and through the lens of dissociative identity disorder. States of possession involve channeling an entity that may be spiritual, another person, or even demonic. Therefore, it can be interpreted as good or bad, depending on the situation. It is crucial to consider possession as noteworthy as it has been incorporated as a part of the diagnostic criteria for dissociative identity disorder. The possessed often undergo a complete change of personality and manifest physical traits

K. Krishnamurthy (*) Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA V. Kumar Forensic Psychiatry Fellowship, SUNY Upstate Medical University, Syracuse, NY, USA

and characteristics considered unknown to the host personality. Often ending with an exorcism, it has been studied by theologians, anthropologists, and mental health professionals, and we provide a nuanced perspective of it all. To summarize, dissociative identity disorder has always been a complex and challenging mental health disorder and is very strongly influenced by cultural and religious implications.

Discussion  eligion, Spirituality, and Their Place in Mental R Health Religion is often used as a supporting mechanism for patients and helps many of them make sense of their illness and defines their ability to cope with it. However, patients’ symptoms can also have a religious connotation, including religious preoccupations, possession states, and delusions involving religious content [1]. Although frequently used together, religion and spirituality differ in many ways. Religion indicates a set of doctrines along with specific behavioral and social characteristics. Spirituality talks about the meaning of life itself and how it relates to religion. Many clinicians fail to assess the depth of their patients’ religious beliefs, which is especially concerning in the mental health domain. Furthermore, in certain instances, the clinician’s religious beliefs come into play during treatment. In many countries, especially in those where religion is in the foreground, mental health takes the background. Mental illnesses and health-related complaints are often misconstrued as curses, black magic, and even demonic possession. Even today, in such countries, patients and families often visit their religious place of worship, for example, a temple, rather than a mental health professional. While this sheds light on the lack of awareness of mental health, it also signifies the importance of religion and spirituality in mental health. As we trace religion back to the eighteenth century and farther back, we can see mental illness or “madness”

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appear in many religious texts, including the bible. In the Old Testament, there is the story of Saul, David, and Achish, to name a few. In ancient times, shamans were both priests and physicians, often performing elaborate rituals to ward off madness and evil spirits. Around the sixteenth century, various edicts show that those who treated madness moved away from religious and supernatural causes. During the late nineteenth century, psychiatry focused entirely on biological and heritable causes of mental illness. This period saw an alarming increase in hospitalizations for those with mental illness, often termed hysteria at that point, and brought forth the emergence of both outpatient psychiatry and psychotherapy as practices. A proud, self-proclaimed atheist, Freud saw religion as a delusion shared between people and thought that although it was helpful for some, it had its hindrances. However, religion, spirituality, and mental health are indelibly intertwined and, in many cases, hard to separate. Therefore, every clinician must recognize and incorporate religion and spirituality into everyday practice.

Religion and Dissociative Identity Disorder Dissociative disorders and religion have had a longstanding and complex history. When considering possession states, it only thickens the broth further. These cases primarily depend on the culture, and their prevalence is difficult to establish. The confluence of religion and dissociative disorders were categorized mainly into three, without possession, divine possession, and demonic possession. States of possession can be considered to have a positive or negative influence on the individual involved and are complex and challenging to treat [1]. In the case of Jeanne Fry, one of her alters included that of Mary Magdalene [2]. With her exorcism taking place in Mons, France, in AD (Anno Domini) 1500, both Fry and her exorcists wrote their accounts of the event. Bourneville described it as a “doubling of personalities.” Dissociative disorders were developed in a stage-wise fashion throughout history. “Traumatic Hysteria,” a diagnosis in the nineteenth century, was considered a precursor to dissociative disorders [1]. While the DSM IV sought to change the nomenclature from multiple personality disorder to dissociative identity disorder, the DSM V further established the individual criteria of DID, with criterion A describing a disruption in the sense of self [3]. The issue of the existence of DID has given rise to varying ideas, such as the Ross-Spanos controversy. A study conducted between religious and nonreligious therapists regarding the prevalence of DID shows that both groups tended to have a low rate of diagnosing it [4]. Most cases of dissociative identity disorder stem from severe, pervasive abuse, including ritual and satanic abuse, both of which have roots in religion. Schneider

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has also described ritual cult abuse among evangelical Christian groups [4]. Therefore, anecdotal evidence and research in the domain of DID have shown a clear link between dissociative identity disorder and severe abuse. As described above, the severity extends not only to the form of abuse but also the duration. Due to the disorganized and pathological attachment patterns developed by the survivors of such abuse, many such cases often become perpetrators of such kind of trauma themselves. Most notable are ritual and satanic abuse, often involving cults and religion. However, evidence has also shown that these cases are often overreported due to the media attention garnered in such situations, and a thorough investigation is warranted.

Ritual Abuse and Satanic Abuse As we have discussed extensively in the other chapters, and what continues to be a recurring theme in genuine cases of DID, is long-term, pervasive, and severe abuse. In many cases, adopting the term “torture” is safe instead of abuse. Although widespread accounts of such forms of abuse do not exist empirically today, anecdotal evidence continues. Many mental health professionals have theorized that such forms of abuse and trauma lead to dissociation and repression, leading to the birth of alter personalities [5]. This brings us to the exciting facet of “recovered memories,” in which, in controlled therapeutic environments, patients tend to remember and recall traumatic events. The validity of such recovered memories has been questioned and is often considered an artifact of the iatrogenic inception of DID. Rather than working through the trauma, mental health professionals start ascribing degrees of meaning to the memories and labeling the patient as having DID, which worsens the burden on the patient and the health care system. When dealing with forms of abuse such as ritual and satanic abuse, most cases discovered were children and reported mainly in the eighties and nineties [6]. Due to its incredibly bizarre and violent nature, these forms of abuse negatively impact the victims. The characteristic of ritual and satanic abuse is that many victims and perpetrators are highly shrouded in secrecy. From sacrificing infants to rape and sexual assault of young victims, it also included consuming human excreta, human flesh, bestiality, and spending time in graves filled with dead animals. One of the first reported cases was that of Michelle Smith, who remembered memories of satanic abuse while in therapy and later published the book Michelle Remembers in 1980 [6]. As seen previously, such reports led to media attention and scrutiny, leading to an exodus of similar cases, such as child abuse in California’s daycare centers. However, the validity of many of these cases remains highly questionable. The US

30  DID and Religion: Possession

Department of Health and Human Services found that many cases of abuse tended to be from family members rather than ritualistic. In ritual and Satanist abuse cases, the calendar plays a significant role. The concept of satanism signifies a rebellion from Christian traditions, and the occult calendar has four periods, which are 13 weeks each [7]. This has led to “calendar abuse,” where victims undergo violent flashbacks, intrusive thoughts, and dissociative episodes on key dates, like Friday the 13th. Another number commonly associated with Satanist rituals is the number 28, which is linked to menstrual cycles. Alastair Crowley, the infamous occultist, ­associated the number with the beast Bahimiron and 28 is also considered to impart great power to the Cabbalists. These are days of significance for survivors of these abuses if a ceremony falls on them. Here, we feel it is essential to bring the concept of attachment again. We have seen the different forms of attachment in the previous chapters, with the disorganized attachment being the most destructive. In cases of such abuse, mental health professionals have theorized about the occurrence of “pair bonding,” where the victim starts to develop intense dependence on their abuser. In some cases, the victims become abusers themselves as it becomes the only way they can be vulnerable and show love. Although rare, ritual and satanic abuse cases exist, most victims repress and dissociate from the trauma. The long-­ term dissociation and repression lead to the creation of altered personalities and being diagnosed with DID. However, literature has also shown that due to the nature of the patient-­ therapist relationship, many of these cases of DID can be created iatrogenically. Torture-based mind control experiments such as MKUltra have also been cited often. Hence, the best approach continues to be a multidisciplinary one with a collection of evidence and history from various sources, including family and close friends.

 ultural Presentations of Dissociation, Trance C Experiences, and Channeling Dissociation is an alteration or disturbance in customarily integrated consciousness, memory, and identity functions. These dissociative states are also culturally dependent, with varying presentations. With the growing media attention, many diagnosed cases of DID tend to be in the Western world and are also often considered an artifact of therapy [8]. Most cultures believe in possession, malevolent spirits, and trance experiences to some degree, which often plays an essential role in presenting the cases. During the early ages, shamans were considered priests, physicians, and psychiatrists, a one-stop shop for people of all ailments to go to. These individuals could induce a trance-like state and possession states.

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Many cultures worldwide have and continue to use dance and music as agents to induce such trance-like states. The rhythmic, kinetic movements combined with a communal atmosphere cope with and relieve anxiety. Such music and dance-based trance-like states exist across many cultures, including native American tribes, the Aboriginals, to the Stambali practiced in Israel [8]. Dissociative states induced by movements, including rocking back and forth, and speaking in tongues, are also seen in significant religions such as Christianity, Jewish, and Hinduism. Cultural presentations of dissociation can also include non-possession states. Many cultures include dissociative states where individuals exhibit heightened emotions, aggressive behavior, and bizarre expressions such as piblokto, as seen in Eskimos, latah, and amok. Ataque de nervios, seen in the Latin American population, consists of episodes almost like panic attacks involving palpitations, numbness, paralysis of limbs, and amnesia. Trance experiences can include states of possession where spiritual entities or demonic spirits influence the individual. Many cultures consider states of spirit or godlike possession to signify good fortune. In Hinduism, especially in Southern parts of India, individual states of possession are colloquially termed “god dancing,” where individuals are in a state of rapture, channeling a spiritual entity and dancing vigorously with writhing movements. To this day, nearly three-fourths of patients consult spiritual and religious gurus in India rather than seeking mental health professionals. In contrast, cases of dissociative trancelike episodes involving demonic possession are often seen as a curse or punishment and involve practices like an exorcism. Channeling or trance channeling involves states where an individual act as a source or vessel through which a spiritual entity is said to communicate [9]. These experiences are worldwide and largely culturally dependent. Cases of trance-like dissociative experiences involving channeling have reported greater symptom severity in questionnaires [9]. Many cases also lack a solid amnestic component, slightly differing from DID.  Another note of note is that in cases involving channeling experiences, the extent of functional disability is not as severe as DID.  Furthermore, the channelers interpret most channeling experiences positively and, depending on culture, also comprise higher community status, respect, and power. Most channeling cases involve a singular entity, and cases have been shown to display qualities like artistic talent and the production of extraordinary music and literature. Therefore, episodes of dissociative trance and channeling differ from DID in many ways and are largely culturally dependent [9].

DID and Possession Possession is generally defined as the state in which an individual considers oneself inhabited by an entity, which could

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include a spirit, a being with supernatural connotation, or, in some cases, even deceased family members [10]. In states of possession, there are internal and external elements, where the internal element includes the entity “inhabiting” the individual’s body without consent, and the external element comprises a lack of control of one’s body. As discussed before, possession could be interpreted as good or bad depending on cultural aspects. The concept of possession has been studied and explored through the eyes of religious scholars, physicians, mental health professionals, and anthropologists as evidence has shown possession states to be cross-cultural and exist in most parts of the world in some form or other. However, a thorough investigation combined with a healthy dose of skepticism is warranted in such situations, as malingering has always been an essential threat to the diagnosis and treatment of confirmed cases of DID. Investigation with multidisciplinary teams has always been regarded as the best approach, and organic causes must always be effectively ruled out. As evidence has shown, tumors of the frontal and temporal lobes can lead to the rise of symptom presentation, which can closely mire states of possession [10]. Furthermore, these organic tumors can also cause states of dissociation and distinct personality changes, which can have the potential to manifest as a case of dissociative identity disorder. Hence, one cannot overemphasize the need for a thorough medical evaluation, including brain imaging studies. Apart from prolonged standing trauma originating early on, metabolic syndromes and causes have also been implicated in dissociative states. The behaviors and beliefs that accompany possession across cultures were extensively studied in 1976 by Bourguignon [11]. Bourguignon broadly divided possession into two forms, “possession trance” with altered consciousness and “possession” in which there is no alteration. Thence, many different classification systems for possession have been put forth by scholars, and it is no stranger to controversies. Possession states are commonly linked to the two prominent dissociative identity disorder symptoms, amnesia, and dissociation. With the possessed expressing different body mannerisms, speaking unknown languages, and a sense of loss of agency, possession states were included as a part of the DID diagnostic criteria. Just as we have seen with DID, due to the growing media attention and awareness, the sixties and seventies saw a sharp rise in reported possession cases, with theologist Malachi Martin describing a 750 percent rise in exorcisms [12]. In early England, people believed these possession states were due to Maleficum or dark magic [13]. Gunter, in 1604 began a detailed study of possession and medical involvement in the phenomenon. The “possessed” have been known to display symptoms such as uncontrolled convulsions, changes in weight and even height, vomiting and foaming around the mouth, and production of foreign bodies, such as a case in 1605, who was able to void pins through her nose and urine.

K. Krishnamurthy and V. Kumar

Discussion Although Demonic possession is considered a form of these possession states, religious scholars and mental health professionals often view it as a separate entity. Perhaps this distinction is due to the destructive nature of demonic possession and the cross-cultural opinion that the possessed are experiencing a form of “punishment.” Considering some of the major religions in the world, Christianity, Hinduism, Judaism, and Islam, Demonic possession is addressed in varying ways yet with similar themes. Demons are considered to be highly malevolent and the absolute opposite of anything godly. In Islam, various entities are described, including satanic beings (Shaytaan), angels (Farista), spirits (Jinn/Djinn), demons (Marrid), and evil spirits (bhut) [14]. Similar nomenclature is used in Hinduism, such as Bhoot (ghost) and Shaitaan (Demon). In Christianity, especially Catholicism, Demons are viewed as foot soldiers doing the bidding of the Devil or Satan. They have many names, such as Baal or Beelzebub, and an essential part of the Catholic exorcism process involves discerning their name to case the demonic entity out. As the final step in the multidisciplinary approach to cases of supposed possession, following examination by a physician, psychiatrist, and psychologist, a priest is involved [10]. A religious analysis of the patient and their family members is conducted. A noteworthy finding in many cases is that of those close to the supposedly possessed individuals; some often hold solid convictions that the possession is somehow the fault of the afflicted due to a religious offense or a failure to adhere to traditional family conventions [10]. This approach further demonstrates the importance of religion and spirituality in mental health care. For example, in India, Babas or religious gurus perform hundreds of exorcisms, where the demonic entity is driven out with chanting, dancing, and even throwing profanities. In Christianity, separate cohorts of priests are trained explicitly in exorcism, and only such ordained priests can conduct it upon the Church’s approval. The priest collects audio and video evidence, interviews of the possessed and family members, and assessments from medical and mental health professionals, and once confirmed by the Church, an exorcism is performed. Therefore, possession states have been included as a part of the diagnostic criteria for dissociative identity disorder as they commonly involve symptoms such as dissociation, amnesia, and a loss of sense of agency along with a distinct change in personality. As we have sought to explain through this section, possession states are cross-cultural and exist throughout the world and can include possession of a spirit, godly entity, or a demonic entity. They are viewed as good or bad depending on the perspective and state of possession— similarly, almost all forms of possession end in some exorcism rituals performed by priests worldwide.

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Conclusion

References

In conclusion, in this chapter on dissociative identity disorder and religion, we emphasize the diverse presentation of this disorder in the context of spirituality. Often considered a controversial diagnosis, dissociative identity disorder has enjoyed attention and infamy in selective pockets in time due to the attention of the media. Many mental health professionals continue to struggle with the validity of this disorder and its existence. In the mental health domain, religion and spirituality have often been seen as positive concerning the prognosis of patients. They can provide support and a sense of cohesiveness where it is lacking. However, the same concepts also influence the different presentations of the disorder. From culture-bound presentations to trance states, most religions in the world have practices and rituals which involve dissociation. From the age of the shamans to the modern-day priests, these experiences have been interpreted as good or bad depending on their course. Therefore, in this chapter, we bring such experiences to light and explore how they play out in the context of dissociative identity disorder. We also place a particular emphasis on the phenomenon of possession as not only is it a part of the diagnostic criteria but also experienced and interpreted throughout the world in myriad ways. From the time of Jeanne fry to that of Sybil, possession states have been well documented and mired in controversy as they are debilitating and, in many cases, life-consuming. By bringing these aspects to the reader’s attention, we conclude that religion and spirituality have a critical role in the presentation and course of dissociative identity disorder, and a complete and thorough investigation and analysis is warranted.

1. Huguelet P, Koenig HG.  Religion and spirituality in psychiatry. Cambridge: Cambridge University Press; 2009. https://doi. org/10.1017/cbo9780511576843. 2. Hart O, Goodwin J. Jeanne Fery: a sixteenth-century case of dissociative identity disorder. J Psychohist. 1996;24:18–35. 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (dsm-5(r)). 5th ed. American Psychiatric Publishing; 2013. 4. McMinn MR, Wade NG. Beliefs about the prevalence of dissociative identity disorder, sexual abuse, and ritual abuse among religious and nonreligious therapists. Prof Psychol Res Pr. 1995;26(3):257– 61. https://doi.org/10.1037/0735-­7028.26.3.257. 5. Ost J, Wright DB, Easton S, Hope L, French CC. Recovered memories, satanic abuse, dissociative identity disorder and false memories in the UK: a survey of clinical psychologists and hypnotherapists. Psychol Crime Law. 2013;19(1):1–19. https://doi.org/10.1080/106 8316x.2011.598157. 6. Bottoms BL, Davis SL.  The creation of satanic ritual abuse. J Soc Clin Psychol. 1997;16(2):112–32. https://doi.org/10.1521/ jscp.1997.16.2.112. 7. Badouk EO.  In: Epstein OB, Schwartz J, Schwartz RW, editors. Ritual abuse and mind control: the manipulation of attachment needs. Routledge; 2018. 8. Somer E.  Culture-bound dissociation: a comparative analysis. Psychiatr Clin North Am. 2006;29(1):213–26. https://doi. org/10.1016/j.psc.2005.10.009. 9. Pederzoli L, Tressoldi P, Wahbeh H. Channeling: a non-pathological possession and dissociative identity experience or something else? Cult Med Psychiatry. 2022;46(2):161–9. https://doi.org/10.1007/ s11013-­021-­09730-­9. 10. Perrotta G.  The phenomenon of demonic possession: definition, contexts and multidisciplinary approaches. Psychol Ment Health Care. 2019;3(2):01–13. https://doi.org/10.31579/2637-­8892/019. 11. Cohen E.  What is spirit possession? Defining, comparing, and explaining two possession forms. Ethnos. 2008;73(1):101–26. https://doi.org/10.1080/00141840801927558. 12. Betty S.  The growing evidence for demonic possession: what should psychiatry?S response be? J Relig Health. 2005;44(1):13– 30. https://doi.org/10.1007/s10943-­004-­1142-­9. 13. Bonzol J. The medical diagnosis of demonic possession in an early modern English community. Parergon. 2009;26(1):115–40. https:// doi.org/10.1353/pgn.0.0132. 14. Dein S, Illaiee AS. Jinn and mental health: looking at jinn possession in modern psychiatric practice. The psychiatrist. Cambridge University Press; 2013;37(9):290–293.

Dissociative Identity Disorder and Clinical Trials

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Safeera Khan

Modern medical advances have helped millions of people live longer, healthier lives. We owe these improvements to decades of investment in medical research Ike Skelton

Dissociative Identity Disorder (DID) is one of the most misunderstood Psychiatric/medical and clinical conditions because of the complexity of the symptoms and scarcity of available evidence-based research. The course of dissociative identity disorder (DID) is also complex and uncertain, especially if the causative circumstances are not addressed, and the abusive environment persists. Several studies show that an estimated prevalence of DID was around 1–5% in the general American population [1]. DID and other dissociative disorders are more common in the clinical population, affecting around 6–10% of the inpatient population and 6% of the outpatient population (DID and dissociative disorders as a whole are more common in clinical settings. DID has been determined to affect 6–10% of inpatients [1], and 6% of the outpatient population [2]. Despite its prevalence, it was still a mystery to healthcare professionals for a long time and was considered another disorder like Schizophrenia. As Zora Neale Hurston said, “Research is a formal curiosity. It is poking and prying with a purpose”. Recent research has given clarity in understanding the situation and clearing out several myths about the condition. However, there is still less available research that can provide further insight into the condition.

S. Khan (*) California Institute of Behavioral Neurosciences and Clinical Psychology, Fairfield, CA, USA

Clinical Trials Related to Symptoms DID usually occurs as a defense mechanism in people with childhood trauma by developing dissociation from those situations. According to researchers, it’s twice as likely to develop DID in later life if the child’s mother experiences trauma within 2 years of that child’s birth [3]. The authors conducted a multi-center case-control study involving 52 cases and 146 controls. They found that any serious traumatic events like a mother’s loss within the first 2 years or abuse at that time are frequently linked to the development of DID [3]. However, not everyone with abuse develops DID, indicating the role of other factors like a disoriented, detached lifestyle and lack of family support or social support. The presence of these factors, along with the history of abuse, increases the chances of developing DID.  Hence, these patients can be screened earlier and identified to provide them with a better support system. Around 95% to 98% of patients with dissociative identity disorder have a history of childhood abuse [4]. Some studies have evaluated various etiological factors and the symptoms of DID; however, very few clinical trials help understand the complex nature of the switching of alters or the physiological and clinical aspects during the switching or for the different distinct autobiographical personalities. A study was conducted in 2012 by Pales et al. to assess the role and the prevalence of a history of sexual abuse in previously opiate addict patients who were on methadone maintenance treatment (MMT). They involved 125 patients on methadone maintenance treatment, of which 76 were females and 49 were males [5]. Eighteen out of these were patients with DID.  History of sexual abuse was explored, and the patients who were sexually abused showed a higher

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dissociative Experiences Scale Score and DID [5]. Most of the abused patients were females and were diagnosed with OCD, PTSD, and DID. Although DID and PTSD were less common than OCD, the patients with DID and PTSD showed more dissociation scores and had more negative life events and assaults [5]. Some clinical trials and other research focus on the physiological and clinical events occurring for different alters, how they change during switching, or how they differ for different personalities. A study by Van der Hart, Bolt, and Van der Kolk involved 35 female participants from DID who met the DSM-IV criteria in 17 treatment centers and 18 therapists published in 2008 [6]. They aimed to explore how DID patients remember their traumatic vs. non-traumatic experiences. They used questionnaires like the Childhood Experience Questionnaire (CEQ), Dissociative Experience Scale (DES), and Traumatic Memory Inventory (TMI) to assess them. All 30 participants reported childhood abuse, 28 reported sexual abuse, and 28 reported physical abuse in their childhood, whereas 26 reported both types of abuse [6]. Only two participants did not recall any childhood abuse but remembered the abuse in their early adulthood. Twenty-­ seven of these participants could not recall a section of their lives and had amnesia about a certain section of their life. Some reported that an image or a similar incident re-­activated the previously not remembered memories. Most participants could not recall the non-traumatic events or experiences of their childhood. The authors reported a fragmented initial recall of emotionally significant but non-traumatic events among DID patients [6]. This study concluded that the memories related to past traumatic experiences in patients with DID, which are of the sensorimotor type, gradually develop more sensory dimensions. Over time, they can gradually narrate their experiences. This narrative component may not necessarily be personalized. [6].” In another clinical trial conducted in 2003 by Elzinga et al., 12 patients, out of which one was male and 11 were female, were recruited from two clinics [7]. Nine of these participants had PTSD as well, and two had a borderline personality disorder. Several memory tasks were performed by switching the patients to different memory and amnesic states to investigate amnesia between different personality states [7]. Patients in this amnestic state demonstrated an overall decrease in explicit memory. In contrast, implicit memory was fully preserved in all states. According to the authors, these results may point to the role of retrieval inhibition in DID. They may help further conceptualize memorization in patients with DID [7]. They concluded that more research is needed to assess the role of past trauma and dissociation as the most common causative factor in different personality states and related memory processes [7]. Similarly, earlier in 1998, Peters et al. conducted experimental research on memory function in DID and focused on

S. Khan

the between-identity transfer of newly learned neutral material [8]. They tried to find if self-reported asymmetries by patients of DID, in between identity transfers, can be replicated while conducting memory tests. If there is no direct transfer, will there be an implicit transfer? The results of this study demonstrated the amnestic asymmetry for explicit transfer, although between the amnestic identities, there was some leakage [8]. It was found that among various personality traits, one is dominant. One can be a neutral state, whereas the other may be a traumatic personality. Researchers were intrigued to understand the differences between these two different personalities. A clinical trial conducted in 2003 involved 11 females diagnosed with DID. They investigated the traumatic and neutral personality states [9]. Brain mechanisms related to consciousness and the anatomical localization of selfawareness in patients with DID were investigated by functional neuroimaging of core consciousness’s different emotional and mental states. This research demonstrated that at least two distinct mental states of self-awareness or alters were generated due to consistent changes in localized brain activity. Each mental state had access to its version of traumarelated memory [9]. Because these DID patients may have different access to their two autobiographical affective memories, the researchers evaluated them while listening to their trauma-related script. The rCBF patterns in neutral and traumatic personality states were assessed to find the neural correlates in their different autobiographical selves. The neutral personality state alters did not find the script self-­referential, whereas the traumatic personality state alters awareness of the self-referential nature of the script. This showed the difference in the activation pattern. The research showed different regional cerebral blood flow patterns for different alters and senses of self. This demonstrated that the medial prefrontal cortex (MPFC) and the posterior associative cortices have an integral role in the conscious experience of a person with DID [9]. According to Damasio’s research in 2020 and 2021, DID patients must have one core self since they use the same biological resources. They can have different autobiographical selves because of their distorting environmental influences. The research findings by Reinders and co-authors were consistent with this theory of Damasio and co-workers [10]. Research involving pediatric patients with DID has demonstrated that the alters have fewer amnestic barriers between them. However, they gradually become more individualized and strengthened after alters are used and exposed to varying situations.

Upcoming or Ongoing Clinical Trials A clinical trial registered with clinical trials.gov is currently enrolling adult participants with DID and PTSD to evaluate the neurobiological basis of traumatic dissociation in a cross-­

31  Dissociative Identity Disorder and Clinical Trials

diagnostic sample of women with childhood abuse and neglect histories. Since it is presumed that there is a region-­ to-­ region interplay involved in etiology and dissociative symptom development, the authors of this study consider the use of intrinsic functional connectivity MRI (fcMRI) to represent a valuable next line of investigation into the ­neurobiology of traumatic dissociation and intend to explore this in this study [11].

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Collin A Ross proposed a clinical trial in 2003 involving psychotherapy treatment with three groups of patients and two treatment conditions after reviewing the literature on managing DID. The subject groups are borderline personality disorder without dissociative identity disorder, dissociative identity disorder without a borderline personality disorder, and both conditions present concurrently. The participants can be randomly given either Dialectical behavioral therapy or Trauma Model therapy to find a better treatment approach for DID. The evidence showed a cost reduction in Clinical Trials Related to Treatment Options health care and inpatient treatment [14]. A clinical trial published in 2022 by Schlumpf et  al. Dissociative disorders or dissociative trauma survivors have investigated 21 patients with post-traumatic stress disorder several treatment options available. Commonly used trauma-­ and 23 with complex dissociative disorder, including focused therapies are the exposure therapies such as eye DID. EEG was done before and after 8 weeks of treatment. movement desensitization and reprocessing (EMDR) and They aimed to evaluate if there is a strengthening in funcprolonged exposure (P.E.) therapy, where specific traumatic tional network connectivity on EEG while performing an memories, themes, and emotions are addressed, and cogni- emotional regulation assigned task in hospital settings and if tive behavior therapy (CBT). In EMDR, the specific trau- these neural changes reduced their symptoms and improved matic material while making bilateral movements is either emotional regulation. They found that the patients with these recalled or talked about while watching bilateral blinking conditions had significantly lower functional connectivity lights or similar. In P.E. therapy, the traumatic memory is than the control group during the cognitive reappraisal. This talked about extensively as if it is happening at that time. functional connectivity was significantly increased after There are no evidence-based guidelines available for the treatment, the patient’s symptoms were reduced in intensity, treatment of DID at present, an there are very few clinical and they could have better emotional regulation. They constudies available about DID as well. The International cluded that phase-oriented treatment strengthens the inter-­ Society for the Study of Trauma & Distortion (ISSTD) rec- regional connections in the brain that usually activate when ommends a phase-based management approach. The first the patients do an autobiographic recall [15]. Similarly, stage is stabilization, where psychosocial functioning and a Brand and the co-authors, 2009 in their cross-sectional study gradual increase in symptom control are focused. After stabi- involving 280 patients, showed the effectiveness of a five-­ lizing the patient, the traumatic memories are confronted in phase model. The model helped reduce dissociation sympthe second stage as exposure therapies. The third phase then toms [16]. focuses on the stabilization and reintegration of the altered or personality states of the patient [12]. Keeping this in view, a recent randomized controlled trial evaluated a structured Research Related to Medical Management protocolled group treatment delivered in a naturalistic clinical setting to patients with Complex Dissociative Disorders Most of the management options used in management are (CDD) as an add-on to individual treatment. The researchers behavioral therapies. No clinical trials have compared the enrolled 59 patients randomized to either stabilizing group use and effectiveness of medications and drugs with other treatment combined with individual therapy or individual therapies in treating DID. Most of the medications that are therapy alone in a delayed-treatment design in 20 sessions used or favored by psychiatrists are anxiolytics and anti-­ [13]. The treatment was in accordance with the manual depressants. Although there have been no clinical trials Coping with Trauma-Related Dissociation with the primary evaluating the efficacy of drugs, a few case reports have outcome of Global Assessment of Functioning (GAF). The been published to assess the role of some medications in secondary outcomes were PTSD and dissociative symptoms, treating DID.  Kitashiro and Kinoshita 2005 evaluated the general psychopathology, and interpersonal difficulties. All effects of perospirone, a drug usually used in treating mixed model treatment options showed similar results of Schizophrenia, in a patient with DID.  The patient was a having no interaction in the primary or secondary outcomes 30 years old woman with two alters, one male of 23 years during the delayed treatment period, and participation in sta- and the other female of 17 years. She was a known patient bilizing group treatment does not have any better outcome in of DID for 13 years. The female alter could hear the male patients with deliver complex dissociative disorders. alter, the main presenting symptom. She also had anxiety However, psychosocial function, PTSD symptoms, and gen- and dissociation. She was given the drug for 5 months, and eral psychopathology showed significant improvements over her symptoms were reduced. The drug was then tapered off a 6 months follow-up period [13]. gradually over 9 months.

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Similarly, in another case study conducted by Ballew, Morgan, and Lippmann in 2003 [17], IV Diazepam was used to assist in successfully retrieving memory, including traumatic memories, in an amnestic patient with DID.  The ­management option, however, still lacks sufficient evidence to be used for this purpose, specifically for DID.

Future Direction of DID-Related Research Although clinicians and therapists have a better understanding of the condition than before, DID still needs to be explored further to be fully understood in several areas and to clarify the myths that still revolve around the condition. Current research still leaves many unanswered questions, including the effects of genetic and environmental factors that predispose certain individuals more than others to develop DID and an in-depth understanding of how different brain areas are involved in switching and in the personalities of these alters. Exploring the physiological and psychological differences in different alters is also necessary. There is also a dire need to explore more treatment options. More clinical trials are needed to explore other medication groups that may help reduce the symptoms and improve the quality of life in people with DID. There is also a need to develop evidence-based guidelines to manage and treat DID.

References 1. Colin AR, Duffy CMM, Ellason JW.  Prevalence, reliability, and validity of dissociative disorders in an inpatient setting. J Trauma Dissociation. 2002;3(1):7–17. https://doi.org/10.1300/ J229v03n01_02. 2. Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D. Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry. 2006;163(4):623–9. https://doi.org/10.1176/ajp.2006.163.4.623. 3. Pasquini P, Liotti G, Mazzotti E, Fassone G, Picardi A, Italian Group for the Study of Dissociation. Risk factors in the early family life of patients suffering from dissociative disorders. Acta Psychiatr Scand. 2002;105(2):110–6. https://doi. org/10.1034/j.1600-­0447.2002.01062.x. 4. Korol S. Familial and social support as protective factors against the development of dissociative identity disorder. J Trauma Dissociation. 2008;9(2):249–67. https://doi.org/10.1080/15299730802048744.

S. Khan 5. Peles E, Potik D, Schreiber S, Bloch M, Adelson M.  Psychiatric comorbidity of patients on methadone maintenance treatment with a history of sexual abuse. Eur Neuropsychopharmacol. 2012;22(12):883–91. https://doi.org/10.1016/j.euroneuro.2012.04.002. https://pubmed.ncbi.nlm.nih.gov/22564825/. 6. Van der Hart O, Bolt H, Van der Kolk BA.  Memory fragmentation in dissociative identity disorder. J Trauma Dissociation. 2005;6(1):55–70. https://doi.org/10.1300/J229v06n01_04. https:// pubmed.ncbi.nlm.nih.gov/16150685/. 7. Elzinga BM, Phaf RH, Ardon AM, van Dyck R. Directed forgetting between, but not within, dissociative personality states. J Abnorm Psychol. 2003;112(2):237–43. https://doi.org/10.1037/0021-­ 843x.112.2.237. https://pubmed.ncbi.nlm.nih.gov/12784833/. 8. Peters ML, Uyterlinde SA, Consemulder J, van der Hart O. Apparent amnesia on experimental memory tests in dissociative identity disorder: an exploratory study. Conscious Cogn. 1998;7(1):27–41. https://doi.org/10.1006/ccog.1997.0323. https://pubmed.ncbi.nlm. nih.gov/9521830/. 9. Reinders AA, Nijenhuis ER, Paans AM, Korf J, Willemsen AT, den Boer JA. One brain, two selves. NeuroImage. 2003;20(4):2119–25. https://doi.org/10.1016/j.neuroimage.2003.08.021. https://pubmed. ncbi.nlm.nih.gov/14683715/. 10. Damasio AR. The feeling of what happens: body. Vintage, London: Emotions and the Making of Consciousness; 2000. 11. Kauffman M.  McClean hospital. Evaluating the neurobiological basis of traumatic dissociation in women with histories of abuse and neglect. 2023. https://clinicaltrials.gov/ct2/show/NCT0275733 9?cond=Dissociative+Identity+Disorder&draw=2&rank=1. 12. International Society for the Study. Guidelines for treating dissociative identity disorder in adults, Third Revision. J Trauma Dissoc. 2011;12(2):115–87. https://doi.org/10.1080/15299732.2011.53724 7. 13. Baekkelund H, Ulvenes P, Boon-Langelaan S, Arnevik EA. Group treatment for complex dissociative disorders: a randomized clinical trial. BMC Psychiatry. 2022;22(1):338. https://doi.org/10.1186/ s12888-­022-­03970-­8. 14. Ross CA.  A proposed trial of dialectical behavior therapy and trauma model therapy. Psychol Rep. 2005;96(3 Pt 2):901–11. https://doi.org/10.2466/pr0.96.3c.901-­911. https://pubmed.ncbi. nlm.nih.gov/16173357/. 15. Schlumpf YR, Nijenhuis ERS, Klein C, Jäncke L, Bachmann S. Functional connectivity changes in the delta frequency band following trauma treatment in complex trauma and dissociative disorder patients. Front Psych. 2022;13:889560. https://doi.org/10.3389/ fpsyt.2022.889560. 16. Brand R, Classen C, Lanius R, Loewenstein R, McNary S, Pain C, Putnam F. A naturalistic study of dissociative identity disorder and dissociative disorder NotOtherwise specified patients treated by community clinicians. Psychol Trauma Theory Res Pract Policy. 2009;1(2):153–71. 17. Ballew L, Morgan Y, Lippmann S. Intravenous diazepam for dissociative disorder: memory lost and found. Psychosomatics. 2003;44:346–7.

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Vedat Sar

Introduction

Clinicians should operate like archeologists, i.e., sensitively approaching the layers of structures and following the Dissociative identity disorder (DID) can be healed by good sequence as they are organized in the patient’s mind. generic psychotherapy. This can be conducted only by a ther- Symptoms are disturbing; thus, their removal relieves the apist who is capable of orchestrating the communication patient. However, this is not the most vital and urgent task. between therapist and patient in a sincere and genuine man- Namely, one should not forget that symptoms usually create ner without falling into the trap of attempting to apply one or a new hierarchy of mental content and may serve as keyseveral of the brandmarked therapy methods that may appear stones preventing further collapse. Their sudden and unpreas evidence-based. Such generic psychotherapy requires the pared removal may undermine this balance in such an skill of looking at the bigger picture and 360-degree cover- inappropriate manner that life becomes difficult to bear after age of the dynamics involved in a particular condition. That such a reorganization. As a rule of thumb, saving the sufferer said, any trauma treatment today covers certain clinical is superior to the successful treatment of a disorder when domains anyway: post-traumatic symptoms, attachment practicing attempts at healing [3]. problems, dissociative symptoms, affect dysregulation, self-­ On the other hand, leaving a patient untreated despite an problems and cognitive distortions, and comorbidities. The accurate diagnosis of DID, or just pursuing a partial improvepreferred treatment is a phase-oriented and titrated psycho- ment beforehand (notwithstanding its life-saving importherapy which is conducted in a multimodal framework. On tance) is not ethical. This is due to the always-existing option the other hand, this multi-dimensionality does not mean that of recovery and even healing, whether it can be achieved or the psychotherapy of DID should pursue parallel tracks of not. The patient should be at least informed about this posdifferent methods. On the contrary, good generic psycho- sibility and the willingness of the therapist to strive for it. On therapy is to be conducted in a unitary fashion. the other hand, the clinician should also declare that, to Not to enter into conflict between diverse perspectives, standby, she is ready to accept any level of recovery or even the definition of a generic psychotherapy style should be solely carrying the patient until she is ready to make steps made in five dimensions: discourse, theory, model, tech- forward or real conditions allow this [4]. Nevertheless, one nique, and application [1–3]. None of these can replace any should also know that such a minimum condition of treatof the others. To protect sincerity and genuineness, the iden- ment should not become a circulus vitiosus or a lack of contity of each dimension in itself is crucial in any particular cern. Both parties in the therapeutic situation should keep situation of therapeutic intervention. That is, without unin- alive the potential and hope for more effective movements tentionally falling into self-deception, the therapist should be toward recovery in a watchful manner which is different aware that the principle of “what you see is what you get from a passive “wait and see” attitude. (WYSWYG)” is met in their own work [3]. Patients with DID is a childhood-onset disorder as the chronic traumaDID are extremely sensitive to genuineness and inconsisten- tization itself. A person with DID may remain without manicies may easily undermine the feeling of trust in a therapeu- fest symptoms for years while the subject continues to tic setting. experience dissociative symptoms. The latter do not prevent the patient from remaining functional in everyday life. Symptoms may be subjectively disturbing (e.g., anxiety due to threatening voices inside of the head) or may catch the V. Sar (*) Department of Psychiatry, Koç University School of Medicine, attention of others due to apparent deviations from the norIstanbul, Turkey mative (e.g., being destructive to oneself or others) or both. e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_32

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One other pathway is the manifestations of medical (e.g., functional neurological symptoms such as psychogenic seizures and dissociative amnesias) phenomena, which necessitates seeking professional assistance. Empirical reports and clinicians’ observations usually claim long durations covering years to achieve integration. While this may be valid to a certain extent, observations about shorter treatment durations with positive outcomes are also being made in particular among children, adolescents, and young adults in their early twenties. Thus, the treatment duration of DID is as heterogeneous as its clinical surface. Early diagnosis may shorten the treatment duration.

General Principles Treatment of DID is shaped according to the diagnosis as well as personal needs. The basic treatment modality is outpatient intensive individual psychotherapy. Because of its intensity and the therapist’s ongoing active attitude, some authors have dubbed this long-term, short-term psychotherapy. In the treatment of DID, control of emotional turmoil and related enactments should be established from “inside.” For some patients, hospitalization may be indicated for crisis episodes and comorbidities or to be distanced from an abusive environment. Fusions of different alter personalities should be performed whenever it appears to be appropriate. This may be through the wish of the patient, or due to the loss of function of an alter personality. Integration is a broader reorganization. Integration starts from the beginning of the treatment and continues with fusions. Fusions can occur spontaneously or be induced by the therapist. The preparedness of the alternate personalities should be assessed by the general status of the patient and the explicit ratification by the host and in particular of the alternate personalities. Spontaneous fusions occur after the gradual dissolving of dissociative barriers and the emergence of coconsciousness between alters. Fusion can be carried out through a ritual or ceremony using visual imagination.

Dealing with Crises (“Nervous Breakdown”) Crisis is an important concept in DID. The resolution of each crisis contributes to the progress of treatment. However, the clinician should keep in mind that boundaries are tested during crises. Self-mutilation, suicide attempts, functional neurological symptoms, and an acute dissociative reaction to a stressful event may constitute daily crises. Persecutory alter personalities (i.e., those who are critical to the host personality) frequently play a role in transient conditions. Suicidality and self-mutilation may occur due to panic and chaos, fear of abandonment by the therapist or others, or anger that has not been expressed. In a college population study [5,

6], alongside bodily self-detachment, detachment from external reality had the highest correlations with self-­mutilative behavior. Most of the DID patients think on suicide. However, the majority of suicide attempts are thwarted by anti-suicide hosts or alter personalities. “Internal homicide” due to a conflict between two alter personalities is also a version of suicide [7]. Assessment of suicidality should consider relational aspects as well. Safety agreement may be helpful unless the overall condition points to an absolute potential for a suicide attempt. The latter may be due to the overall severity of the condition, suicidality claimed by the majority of host and alter personalities, severe major depression generalized to the whole personality system, or living in a highly abusive environment. Frequent switchings propel personality states forward, bringing with them memories of childhood trauma. They may be disoriented to believe that they were in the place and time when the trauma was occurring. Sometimes, it is difficult to distinguish them from flashbacks [7]. On the other hand, rare switching leads to epochal DID [8], which can be recognized by large amnestic periods of life rather than daily crises. The frequency and timing of switchings between distinct personality states seem to be a function of the “internal moderator”; i.e., a central regulation activity of mind as hypothesized in the “functional dissociation of self” model shortly presented below [9]. Dissociation is a constant feature of post-traumatic conditions, regardless of the primary psychiatric diagnosis [10, 11]. DID and PTSD may precede each other chronologically or may be copresent depending on the status of the patient on the spectrum between avoidance or intrusions of traumatic mental content [12]. Treatment seeking in a state of crisis in the context of DID can also be explained by anxiety-­laden PTSD. For example, in a case of “vampirism” with coexisting PTSD and DID, the host personality was suffering from flashbacks due to PTSD while a disillusioned-­traumatized “child” alter personality triggered violent attacks to be carried out by an aggressive part [13]. Being unaware of the inner cycle, the patient was suffering from a temporary loss of control following an increased “appetite” for blood and subsequent acts of assault to collect it. Diminished dissociative barriers may also lead to the emergence of PTSD symptoms during treatment of DID which were lacking initially.

Coping After Resolution Treatment should not be ceased after final fusion or even integration. Living a non-dissociative life is challenging for the patient. Readjustment to significant relationships is required. A new sense of self-identity is to be established. The patient may have been oppressed to behave in a submissive style, as observed in cases of “complaisant overadjustment” [14, 15]. Integration may not be sufficient to correct this situation, and the therapist should make the patient aware of the pattern. The patient cannot use dissociative mechanisms to solve the prob-

32  Recovery from Dissociative Identity Disorder

lems anymore. She can recognize her past as a whole after integration. Depression may follow the euphoria of this achievement. The patient’s feelings toward the abuser are now integrated. The blame for her and others’ behavior in relation to this condition has now been appropriately assigned. She should know that she was sick while experiencing this tragic process. She will denounce her idealization of the abuser. The patient is alone now, and she can experience mourning about lost alters. Disillusionment with integration may also cause mourning, as it did not prove to be the ideal condition that they had envisioned. She should also understand that the world is full of pain and far from being perfect. Perceiving the emotions should be learned now because the patient has learned to dissociate the vehement emotions previously [7]. The patient should come to follow-­ up interviews after treatment, too. Kluft [8] reported that the possibility of relapsing diminishes after 27 months. In my experience, this is related to the features of the particular patient rather than the duration per se.

Fig. 32.1  The layers of treatment of DID

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Layers of Treatment “Tiefenpsychologie” (depth-psychology) was a term devoted to the theory, practice, and research on the patterns and dynamics of motivation and the mind including those operating beyond one’s awareness. Once having been the domain of psychoanalysis, a renewed and more general understanding of “depth-psychology” is indicated more than four decades after the emergence of the DSM-III which presented an official psychiatric nosology and classification based on the “surface”; i.e. clinical phenomenology. Treatment of DID resembles the work of an archeologist or restaurateur who has to respectfully consider the layers of the material to be brought to daylight. The treatment of DID requires different approaches to handling the clinical surface, core dissociative dimensions, and the basic dissociation in the tripartite self-system, which is the fertile ground of the clinical phenomena (Fig. 32.1).

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Clinical Surface The description of DID is subsumed under two diagnostic criteria in DSM-5: identity disruption and amnesia. In reality, patients with DID present the entire spectrum of dissociative phenomena. Beyond this, the clinical surface of DID is so polysymptomatic and even poly-syndromatic that the diagnostic criteria of several psychiatric disorders may be met at the same time whether this means comorbidity or mere phenocopy. To make it simple, DID is a clinical condition with at least two layers: the clinical surface and the main dissociative features which are required to be determined for an accurate diagnosis. Nevertheless, there are pathways, cross-roads, and junctions of coping with traumatic memories that go across these two layers. Clinical surface of DID may require general psychiatric treatment including pharmacotherapy, depending on the prevailing conditions. However, the surface treatment never stops DID, necessitating an in-depth evaluation and intervention. Alongside several psychiatric syndromes that prevail on the surface, one of the main junctions of the post-traumatic spectrum is the so-called diagnostic criteria of borderline personality disorder (BPD) which, in fact, are heavily correlated in number with the severity of dissociation and developmental traumatization. This is meant in a transdiagnostic fashion, i.e., without necessarily referring to a disorder of personality. Furthermore, patients with DID may present with functional neurological symptoms, dissociative depression, experiences of possession, dissociative psychosis, and many other phenomena that are shared with other diagnostic categories.

Core Dissociative Dimensions Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alteration are core clinical dissociative dimensions [16]. These phenomena may also appear in various general psychiatric symptoms such as hallucinations, trance states, behavioral signs of switching between personality states, experiences of possession, flashbacks etc. Indirect results of the core dimensions such as fugue states or experiencing someone else inside should be taken into consideration in evaluation of the core dimensions. Core dimensions do not respond to pharmacotherapy, however, they are clues for in depth psychotherapy and allow monitorization of the course of the treatment.

Functional Dissociation of the Self Adapting to and accepting reality is a process that does not always take place optimally. Nevertheless, the developing

V. Sar

individual has the armamentaria to maintain such adjustments, which can be described at various function levels of the organism including biological mechanisms. One such theory considers a type of psychological dividedness as an adaptive response to frustrations: functional dissociation of the self [9]. According to this theory, the sociological self is the aspect of the individual that has been developmentally established to protect the psychological self. While the sociological self-­ constitutes an interface with the “external” world, the psychological self represents the authentic qualities of the person. A harmonical relationship between the two selves is healthy, whereas their detachment results in deficient inner nurturance of the sociological self and in a frozen and restricted psychological self. Being more and more a “slave“ of the “external” world, the sociological self becomes fragmented to carry this heavy work. A dissociated individual’s distinct personality states operate to a large extent in the domain of the sociological self, which, if detached from and in contrast to the psychological self, tends toward mot-a-mot thinking, competition, rigidity, and power-based conflict resolution. Such a detached sociological self may become malignant in interpersonal relationships and may harm even to the institutions and the society as a whole. Alternatively, it may be unable to adjust to the external world.

Traumatic (Symptomatic) Self Basic dissociation is caused by the individual’s developmental detachment from his or her sociological and psychological selves. This is the main level of in-depth psychotherapy of DID and, in fact, the fertile ground where the core dissociative dimensions and clinical surface successively emerge. According to the theory of functional dissociation of the self, distinct personality states (identity alteration) are manifestations of the fragmented sociological self. Being itself a component of normal psychological development, the sociological self cannot be perceived at the level of clinical symptoms. The latter is carried out by the traumatic (symptomatic) self, which seeks help through polymorphous clinical phenomena. The traumatic self also prevents the sociological self from paradoxically harming the psychological self. In fact, it departs from the psychological self to keep it unitary while covering traumatic experiences. However, the traumatic self is adopted by the sociological self subsequently. An enlarged traumatic self may even occupy the sociological self, which may have destructive consequences. This shift makes the traumatic self unable to process its resistances, which is possible only in the domain of the unitary psychological self,* which remains a unitary source of inner strength. The most malig-

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nant and non-adaptive behavioral outcome might be an unusually enlarged traumatic self which “possesses” the sociological self.

Internal Moderator This tripartite self-system is hypothetically inspected by an “internal moderator” which operates as an “on and off switch” allowing or restricting the expression of a mental content (e.g., emotion, behavior, memory, or sensorimotor function) and the time interval in which they are to be conducted including the frequency and timing of switching between distinct personality states. In DID, the internal moderator is functionally overwhelmed due to the imbalance of the tripartite self-system. Returning to daily functions requires the relief of the “overwhelmed” internal moderator. Thus, recovery of the moderator is possible, and its loss of function is reversible in DID and other post-traumatic conditions. However, in schizophrenia and bipolar disorder, the internal moderator is impaired, which cannot be recovered solely through (but may benefit from) psychotherapeutic interventions.

Natural Self and Emotions The natural self maintains the system with life energy. In the theory of functional dissociation of self, emotions are originally independent of and available to any entity in this model of mind. However, they can be temporarily adopted by selves (including distinct personality states, which are fragments of the sociological self). However, the internal moderator is the basic “carrier” of emotions and delivers them to the service of the adopting entities like a “forklift.” The functional impairment of the internal moderator leads to affect dysregulation, which can respond to psychotherapy better than drug treatment. On the other hand, primary disturbances of the internal moderator as carrier of the emotions may lead to mood disorders, which hardly respond to psychological interventions only (Fig. 32.2).

Fig. 32.2  Self-system, emotions, and the internal moderator

Dissociated Self-System in Treatment Dialectical Dynamic Therapy (DDT) is aimed at reestablishing the balance between a “detached and enlarged” sociological self and a “restricted and frozen” psychological self. Such repair is possible through a reduction in the sociological self and an “awakening” of the psychological self. Resistances of the traumatic self should also be resolved to start the clinical improvement process. The latter can be achieved by working in the modalities of the psychological self but not in those of the sociological self. Thus, the psychological self serves as an infinitary inner resource that is never fragmented. Nonetheless, the interaction proceeds as a result of a positive “domino effect” between these entities. The therapist operates by pursuing the layers from surface to depth and weaving contacts in an inner system that goes beyond integrating alternate personalities (Fig. 32.3).

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Fig. 32.3 Functional dissociation of the self in treatment

Touching the Internally Detached Individual Management of the clinical surface requires general psychiatric skills, as comorbidities are abundant in DID. As this is the first step in approaching the internal world and further psychological layers of the patient, the therapist should be aware of the coping mechanisms that bridge the clinical surface with the in-depth psychopathology. In fact, the polymorphous clinical surface of general psychiatric symptoms represents resistances of the traumatic (symptomatic) self: depressive manifestations, traumatic obsessions, and loss of psychosocial mutuality (traumatic narcissism) [17]. Their presentations are flavored by the actions of the internal moderator as well as contextualization of their sociological and psychological selves alongside passive influences or direct enactments of alternate personalities. DID treatment is a type of psychotherapy that recognizes personality states and works on the traumatized person to reverse the processes that led to their emergence of them. Transformation of the patient’s subjective reality is the prerequisite of integration, i.e., accepting one’s biography and the truth as they are. The disintegration rooted in the effort to minimize the traumatic impact of the event by establishing other inner perspectives should end in unification. The reversal of the disintegration can be achieved through the patient’s acceptance that this “hand-made” inner world does not reflect external reality.

Experiencing Inside or Outside Although mental intrusions from within (e.g., interference of alternate personality states) may have unlimited capacities to

escape reality as an activity of the inner world, they are limited in agency. This is due to the partial control still maintained by the host and other personality states of the internal system. The opposite is valid for externally experienced mental content unless a culture or subculture enables liberty to some of these deviations from normative. An example of this might be an experience of possession by shared external entities that operate like “currencies,” making exchange possible; i.e., in contrast to private alternate personality states, they can move from one person to another. They are aberrations that the community has come to accept as shared, agreed-upon realities. Unfortunately, the extension of inner experiences to the external world (unless approached and engaged specifically and accurately), may elicit resistance and thereby impede therapeutic interventions. This is the reason why working individually and “inside” the patient provides more fertile opportunities for therapeutic change. A concurrent diagnosis of borderline personality disorder (BPD) and dissociative disorder (DD) led to more identity confusion, derealization, and overall severity of dissociation in a college population study [5, 6, 11, 18]. The latter was also correlated with the total number of DSM-5 BPD criteria met. Thus, rather than remaining limited to the categories of DSM-5 DDs, this spectrum appeared to provide a condition suitable for analyzing trauma-related dissociative phenomena from a broader perspective. In this series of studies, as an internally experienced type of identity disturbance and predictor of both BPD and DD, mental intrusions from within were predicted by denial or minimization of trauma history (i.e., idealization of the perpetrator-­caretaker). An alternative to this type of experience in the internal world was an externally experienced identity disturbance such as being perceived as a different

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person, expressing anger, having imaginary friends, and detaching from external reality (a component of derealization). Expectedly, as an undermodulated condition, the latter pattern led to a diagnosis of BPD rather than DD. This difference between the diagnoses of BPD and DD seems to represent the utilization of the on-and-off switch of the internal moderator in either direction. Compared to those with DD, BPD patients were more aware of their amnestic gaps [18]; i.e., they did not tend to have “amnesia to amnesia” [19]. This may be due to the tendency to have the copresence/co-consciousness of [1, 2] rather than the complete replacement of distinct personality states with each other in BPD. Patients with DD may try to terminate contact (i.e., avoid) with their inner disturbance. The person with BPD, however, strives to catch and express the origins of this. The phenomenon of BPD is predominantly about distancing from external “reality” while claiming to participate in it “extensively.” The opposite seems to be valid for DD: Distancing from (and surprisingly finding an “enemy” in) oneself while claiming to take contact with the internal “world,” i.e., the town of “expectedly limitless possibilities.”

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The Body as a Container of Negative Emotions

In the above-mentioned college population study, bodily self-detachment was predicted by physical and emotional neglect but not by any type of abuse, albeit the latter might have been underreported due to denial or amnesia [5]. Indeed, bodily self-detachment was associated with dissociative amnesia but not with other dissociation measures. Similarly, among a group of patients with fibromyalgia or rheumatoid arthritis (two chronic psychosomatic disorders that cause bodily pain), all types of childhood abuse (intrusion type of trauma) predicted cognitive-emotional dissociation while emotional neglect predicted somatoform dissociation [21]. Childhood neglect (omission type of trauma) and somatoform dissociation seem to be “off-­ makers” (in terms of the internal moderator) of the switching between “inside” and “outside.” In the above-mentioned study [21], somatoform dissociation was associated with a lifetime diagnosis of depressive disorder, i.e., representing a trait. Cognitive-emotional dissociation, however, was associated with the current severity of depressive disorder. The latter predicted expressed anger which was associated with loss of control, Undulant Course Versus Intermittent Crises a number of BPD criteria, and dissociative amnesia. Loss of control was predicted by all types of abuse, identity fragIn the above-mentioned college study, the presence of mem- mentation, and dissociative absorption (narrowing of conory gaps and identity alterations did not interfere with the sciousness). This pattern indicates a crisis state (nervous reporting of childhood sexual abuse [20]. Interestingly, those breakdown), which seems to be associated with an outburst participants without a report of childhood sexual abuse of overmodulated anger, possibly related to “reminisreported more intrusive memories, dissociated behavior, and cences” of trauma. Thus, such dissociative depression may generalized amnesia which resembled an individual close to represent the emergence of a closed system through a winembarking on a trauma-related enactment (return of the dis- dow that has to be both diagnostic and therapeutic. Thus, sociated). The latter group tended also to report bodily self-­ childhood abuse (intrusion type of trauma) and cognitivedetachment, detachment from external reality, and emotional dissociation seem to be “on-makers” (in terms of experiencing identity disturbance in the outside world; i.e., a the internal moderator) of the switch between “inside” and pattern of distancing from both oneself and the environment “outside.” including the body. Might identity alteration be a way of copIn an epidemiological study among women, childhood ing with the awareness of sexual abuse? And could bodily physical abuse and lifetime diagnosis of major depression self-detachment indicate a burden of amnesia to sexual abuse? and/or dissociative disorder predicted functional neurologiIn the same study, reported childhood sexual abuse was asso- cal (conversion) symptoms (a type of sensorimotor dissociaciated with cognitive-emotional self-detachment and percep- tion) [22]. While dissociative depression was linked to a tual detachment but not with bodily self-detachment. combination of omission and sexual bodily intrusion, physiApparently, identity alteration and amnesia (the two main cal abuse (non-sexual bodily intrusion) added sensorimotor diagnostic criteria of DID in the DSM-5) are common in dissociation to this condition, possibly due to unassimilated both BPD and DID (pathway 1) while bodily self-­detachment sensorimotor reactions, i.e., somatic memory. is more associated with other specified dissociative disor- Depersonalization and amnesia are the most frequent dissoders, i.e., OSDD (pathway 2). Thus, the poles of DID and ciative symptoms in patients with conversion disorder [23]. BPD are characterized by an undulant course in daily life. Functional neurological (conversion) symptoms seem to repThe alternative to this undulant course of identity distur- resent both “on” and “off” switching as they may have both bance is an apparent stability interrupted by transient crises positive (e.g., dissociative seizures) and negative (e.g., musand reenactments. The latter is a further version of on-and-­ cle paralysis) qualities. Unfortunately, there is no empirical off switching of the internal moderator directing the “rail- research on the differences between DID with and without way” keeping experiences inside or expressing them outside sensorimotor seizures while the opposite has been better with less frequency of utilization. studied up to now.

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Dissociative Depression

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there are cases of dissociative psychosis with a longer duration that resemble schizophrenic disorder. Şar [24] has proposed the term “dissociative depression” for Nevertheless, patients with DID or related types of OSDD a complex posttraumatic condition that may involve features usually have cognitive insight overall and into their illness of BPD and transient loss of control in addition to the symp- except during an episode of dissociative psychosis [29] toms of unipolar depression and dissociation. In a study on which can be prolonged. For example, one such breach women in the general population of a town in central Turkey between internal world and external reality in DDs is known two decades ago, dissociative depression (current major as “internal homicide” [7]. This is an annihilating act driven depression comorbid with a lifetime diagnosis of dissocia- by an alternate personality state when a patient succeeds in tive disorder) was predicted by educational deprivation (as a completing such self-destruction by targeting her own body. type of culturally legitimated neglect or restriction/oppres- Given such inner turmoil, vital decisions about one’s life sion relatively prevalent in this geography at the time of the should be postponed until the patient is able to do them. study) and childhood sexual abuse [25]. In fact, the limits of Nonetheless, decisions about preventing further harm to the the lifelong psychosocial growth of an individual are partly patient should be made as much as possible by the therapist, predetermined by the parenting style to which she has been who is the patient’s truster by definition. exposed. The latter factor is sensitive to intergenerational There may be personality states which are isomorphic trauma transmission, as well as the cultural evolution of chil- with real people around the patient including friends and famdrearing modes over time. ily members. In this case, the host personality may mix up the This is almost suggestive of a novel definition of dissocia- real person with the isomorphic alter. If these personality tion in that the Dissociative Experiences Scale (DES) was states are of persecutory nature, the general condition may positively correlated both with grandiose narcissism and look like a paranoid psychosis. The solution is for the host to depression scores despite negative correlations between the recognize the altered personality state as such and, if possible, latter two. Indeed, grandiose narcissism and depression can fuse them. Another possibility is the existence of an alter percoexist only in a dissociated inner world, which becomes sonality that has psychotic (paranoid) features and takes full manifest in the vicious cycle between “traumatic narcissism” control from time to time or becomes co-conscious. Such and “dissociative depression” [26]. altered personalities seem to be related to relatively early In a study among young adults, overprotection-­ (first few years of life) and severe traumatization [30, 31]. overcontrol, together with emotional neglect, predicted dissociative depression among young adults [26]. This is a covered type of childhood trauma combined with intrusion Mot-a-Mot Thinking (Traumatic Obsessions) and hidden omission presented as normative “careful” caretaking. In fact, such a combination represents a double bind Linear thinking (cause  =  effect) hinders effective psycho[27]. The preoccupied and fearful attachment styles as pre- therapy. This should be challenged whenever appropriate. dictors of dissociative depression [26] mirror the betrayal With its power-driven structure, the domain of the sociologi[28] aspect of this perplexing caretaking style. Such a com- cal self is prone to polarization in the cognitive-emotional bination represents an ambivalent relationship, which his- sphere. Rigidity of thinking also leads to diminished cognitorically is a well-known psychodynamic cause of tive insight. Namely, cognitive insight is empirically defined depression. as the difference between self-reflection and self-certainty. If combined with diminished self-reflection, elevated self-­ certainty would lead to delusional thinking. Interestingly, Dissociative Psychosis individuals with a DD have elevated self-certainty to a scope unusual for non-psychotic disorders. But, self-reflection is One type of severe decompensation of DID is called as not disturbed in DD, such that the increased self-certainty “revolving door crisis” [7] when the alternate personality does not undermine the cognitive insight in the final states enter in a loop of rapid switching. An alternative to this analysis. situation is the collapse of dissociative barriers: “co-­ In fact, regulating reality perception necessitates taking consciousness crisis (Kluft, personal communication 1995). into account the mutuality of the internal and external worlds. Both conditions may evolve to a “dissociative psychosis,” a Adversities in childhood disrupt the psychosocial mutuality. condition formerly known as hysterical psychosis [20]. The balance between internal and external worlds is to be Amnesias, hallucinations, somatic experiences, and disconti- optimally established via the caregiver’s adequate mirroring. nuities in associations may appear like manic, schizophrenic, In earlier periods of the life, internal and external world are or delirious conditions. Such brief psychotic attacks may equated: “psychic equivalence” [32]. Alternative perspeccease in a few hours or a few weeks latest. Nevertheless, tives of reality are scarcely considered in this condition. In

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“pretend mode,” however, thoughts and feelings can be expressed in the absence of objectively real presentation. The opposite of the pretend mode is known as the “teleological mode” which is characterized by a black and white perception of reality which focuses on what is physically apparent. In DDs, internal reality is experienced both in psychic equivalent and pretend modes. This is in a dialectical fashion described as the “dissociation paradox” [29]. A helpful construct for understanding the developmental and interpersonal origins of perception of reality is mentalization. Mentalization is the ability to understand the mental state of oneself and others. The development of mentalization capacity and mirroring experiences with primary caregivers are linked. The caregivers should be able to express an affect while indicating that they are not expressing their own feelings. This is the so called marked (as opposed to the unmarked) mirroring which helps the child to differentiate their (the child’s) mirrored emotions from those which are not theirs. Otherwise, the caregiver’s expression may seem to mirror the child’s own emotion and, consequently externalize (as a first example of extratensive processing) the infant’s experience and may overwhelm the infant due to the mismatch with the origin. Additionally, a predisposition to experience emotions through other people might be established by this early interpersonal template. This is the first step leading to emotional dysregulation which further shapes perception of reality [32] which results in more features of BPD in clinical phenomenology.

Trauma Types and Interpersonal Boundaries Childhood trauma may be divided into omission (neglect) and intrusion (abuse) types. Another division may be between bodily (sexual and/or physical abuse and neglect) and cognitive-­emotional (emotional abuse and neglect) types of adversities, which may initiate different coping mechanisms. While omission and intrusion both refer to a threat to personal and interpersonal boundaries in different ways, bodily and cognitive-emotional maltreatment refers to a threat to selfcontrol of (or self-regulation of) one’s internal (i.e., mind and emotions) and external (i.e., body and behavior) presence; both being the most important and stressful consequences of cumulative traumatization that must be monitored and dealt with throughout every treatment until recovery. Intrusion type of childhood traumas leads to a polymorphous clinical phenotype [33]. However, omission types of childhood trauma result in bodily self-detachment and detachment from external reality, both of which have been shown to be significant predictors of self-mutilation [5, 6]. In the above-mentioned college study, bodily self-­detachment was predicted by physical and emotional neglect but not by any type of abuse, albeit the latter was underreported due to

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denial or amnesia [5]. Indeed, this pattern of disowning the body [34] was associated with dissociative amnesia but not with other dissociation measures. The combination of overprotection-overcontrol (intrusion presented as love and care) and emotional neglect, on the other hand, represents a double-bind in the relationship with a caretaker. This is a kind of “betrayal” [28], a phenomenon that leads experiences to be traumatic by disrupting the subject’s perception of reality [27]. Overprotection-overcontrol is, in fact, a type of intrusion presented as normative careful caretaking. Typically, these parents are oppressive-restrictive and prone to boundary violations. Different than the verbal emotional abuse, the relatively invisible quality of this type of emotional abuse creates both anger and guilt. Such interpersonal interference may have started “very early” [35] in life, affecting the developmental period of mirroring by the primary caretaker [32]. Coping with abuse and neglect seems to lead to different types of “identification with the aggressor.” While abuse would more readily lead to projective identification (close to BPD phenomenology), emotional neglect boosts introjective identification (close to DID phenomenology). Aggressive-­ rejecting-­conflictual and narcissistic-identificatory-­fusionary types of object relationships have different consequences in terms of the experience of belonging to a larger context or greater whole, whether this is family, community, or any conception of what that wider context might look like or comprise. Interestingly, in a college population study, childhood sexual abuse and physical neglect, both being severe types of intrusive trauma targeting the body, were predictors of grandiose narcissism [26]. It was not surprising that the latter was related to the severity of dissociation, which was presented as a mask of strength concealing depression. This most concrete type of traumatization in childhood seems to initiate an attitude of pseudo-autonomy and readiness to fight any threat of dominance. An “as if” personality emerges which is “reversible” on encountering and is easily directed by an external power. This is due to the dominance of one’s “sociological self” detached from her more unitary, authentic, and compassionate “psychological self” [9]. Such narcissism is susceptible to manipulation of individuals and masses by abusive powers even against their own interest. “Quasi-­ leaders” who themselves are nothing more than puppeteered sociological figures or “pseudo-masters.” Unfortunately, one method of coping with pain is utilization of others (individuals, groups, or communities) as proxies; i.e., as extended victims. Hence, the need to develop awareness about and obtain courage and strength to recognize and accept the truth and one’s vulnerabilities in this regard; i.e., difficult tasks which effective psychotherapy can facilitate (unfortunately, only on an individual basis and limited to those heroic individuals who see a merit in it).

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Working with Alternate Personality States

ation in which being takes place. Through this maintenance of fidelity, truth has the potential to emerge. Thus, the emerNeutrality toward different alter personalities (e.g., avoiding gence of an event, subject, and truth constitutes a cycle. any preference between “good or bad”) should not be under- Dialectical thinking is crucial in processing an “event” stood as handling all of them in the same manner for all through accommodation and assimilation. This process is aspects of treatment. Not only the balance of the alter per- interrupted in the aftermath of a noxious event, which turns sonality system but also the process of the interactions of out to be a traumatic injury. alter personalities with the therapist is also a significant facAs the crucial structure of DDT, the “comradeship” of tor, i.e., working with whom, when, why, and how? The host “master and slave” is a declaration of respect to the mere personality is the one that must and should be safeguarded. existence and life. This takes into account that, to secure the Indeed, working with alternate personality states overall supportive effect of a relationship, both participants have to saves the host. Some alter personalities with borderline-­ respect the limits and boundaries of this encounter while dependent characteristics may refuse to return to the host authentically sharing the pain. “Transmuting internalization” after being directly contacted. This can be identified and [37] has been proposed as the identificatory mechanism of expected prior to the contact with this personality state by leaving the “self-objects” in psychotherapy, which is collecting information about the inner world from the host expected to occur in response to “optimal frustrations” in the personality. Contacting those alter personalities may be post- context of an empathy-based relationship. I would propose a poned while some others need to be dealt with soon. The therapist–patient relationship based on “feeling with” therapist may prefer to contact an altered personality through (“Mitleid/Mitgefühl”) rather than empathy or “feeling into” imagination or by direct conjugation, depending on the (“Einfühlung”). Namely, the urge of empathy (in fact, a accessibility and potential hazard to clinical stability. Fusions “mission impossible”) forces the therapist to match his/her without direct contact with altered personality states may own memories with those of the patient while “feeling with” also preferred for the same reason. The therapist utilizes the invites the therapist to recognize the patient’s suffering as information collected by the host, like a “medical report” “real” however painful or frightening the “truth” is. about the past and present of the condition, which is taken as the basis for organizing the precise or personalized approach about how to manage altered personalities in an index patient. Prerequisites of Change

Intervening in an Emancipatory Way The narcissistically created inner world is a way of coping with the imagined (ideal) individual psychosocial maturation which can only be achieved to a limited extent, i.e., the wish to overcome the discrepancy between one’s ideal and actual selves. To bridge the discontinuities about reality, compensatory grandiose narcissism requires a “folie à deux” with “self-objects.” Indeed, in a college population study, vulnerable narcissism was predicted by preoccupied attachment but not any other type of childhood trauma and neither dissociation scores [26]. This position seems to reflect a situation of dependency on self-objects in order to confirm the fantasies of excellence and completeness. Namely, the only other predictor of vulnerable narcissism was the disappointment in an allegedly secure relationship, resulting in depression and defensively recursive grandiose narcissism subsequently maintained by dissociation. Alain Badiou [36], a French philosopher, proposed the concept of “event,” defined as an unexpected occurrence that challenges the status quo. The event puts the witnessing individual in the position of making a decision. One becomes a subject by enacting fidelity to the event. In this way, one performs a generical procedure and potentially recasts the situ-

As the basic carrier of the treatment, mutual trust requires maintenance. This is based on a synchronous combination of warmth and distance as carried by a professional relationship and is different from neutrality, which may weaken the presence of the therapist. Nevertheless, one should be aware of the internal and external threats to the therapeutic setting and be able to manage them appropriately.

Establishing Safety and Security Briere [38] defines trauma-related dysfunctions as “attempted solutions to dilemmas that are more focused on survival than recovery.” Fear of chaos in one’s internal (loss of control of emotions) and external world hinders productive work. This is the way people are controlled in an abusive environment by undermining the courage of an uprising leading to change. Addressing rigidity in thinking and opening up the individual’s closed internal system can help boost the mastery required to overcome such fears. In fact, both limitations have a developmentally traumatic origin. The inner world of the disintegrated individual is organized to cope with emotional pain and fear. However, mental content, when conveyed to someone else, effectively transmutes to the status of external reality. This can endanger the

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subject’s fragmented internal world and jeopardize the intervening therapist’s productive work. On the other hand, sharing the inner experience in a safe environment is itself transforming. The paradox experienced in the therapeutic setting, which is a source of both emotional threat and healing, should be considered when evaluating traumatized people. Internal or psychological “realities” constitute a virtual presence compared to the actual external world. Rather than a cause of psychological detachment, “alternate” personality states may emerge as a response to it. This is described as confusion and alterations of identity in clinical psychopathology. A premature merger of the two worlds is not adaptive. A fantasy turning to reality may be a frightening rather than pleasurable experience. This is why DDs are often hidden, not only because of conscious shame or voices that forbid sharing their presence. Nevertheless, confiding a secret in a safe environment may strengthen the bond with the therapist. Indeed, in a college population study on the spectrum of BPD and DD [5, 6, 18], there were discrepancies between scores obtained by self-report and clinician-administered standardized assessments. These differences between the data collected in personal and interpersonal settings were too consistent to be considered as merely a sign of the psychometric weakness of the instruments. In fact, they reflected the real condition, i.e., perceptual differences and alterations, which are aspects of dissociation. For example, although both BPD and DD diagnoses were associated with dissociative amnesia in clinical interview, DD patients underreported this in self-assessment [18].

Dealing with Ongoing Abuse Ongoing abuse interferes with treatment. However, this is the default condition for most of the families that rather than the intervention itself, its timing becomes more important strategically. The strengthening of the index patient is the priority unless there is an urgency for direct intervention in the system. Without the alliance with the patient, the therapist cannot deal with the system effectively. Abuse and neglect may be overt or covered. The “deliberately” submissive attitude common in rather traditional circles of the Turkish society was described as “complaisant overadjustment” [14, 15]. This is a role given to individuals in their families which is commonly seen among patients who develop symptoms of “hysteria.” In fact, this is an example of “enslaving” with the ratification and even willingness of the affected individual. Targeting mostly young women and girls, such oppressive practices may also destroy men’s life. Nevertheless, this attitude mostly superposed on developmental adversities of earlier life periods. Such over

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adjustment may end up in psychological decompensation following a major life event. Not infrequently, such “uprisings” may arise from a victim’s dissociated internal world, such as acute dissociative psychosis, which may be superimposed on a DID or OSDD that has been dormant or undiagnosed for years [39].

Appropriate Timing of Trauma Exploration Trauma therapy is not solely a matter of listening to a tragical story. The therapist works like an archeologist or restaurateur who respects the “original” of the patient through pursuing the psychological layers. The path, continuity, and even discontinuities of the chain of transitions between mental contents are all healing tools. Untimely efforts to complete the whole “reality” (i.e., taking history as if a testimony) may even be antitherapeutic unless there is an urgent necessity. Awareness of the experience of trauma may impede integration unless paced therapeutically, i.e., in a phase-oriented fashion. Untamed awareness may lead to post-traumatic stress disorder (PTSD); that is, individual dissociative barriers are both dissolved and subsequently re-created. This describes and comprises the basic dynamics of any posttraumatic condition: avoidance and intrusion of mental content and overmodulation and under modulation of emotions [12].

The Dialectical Dynamic Therapy (DDT) Theoretical Foundations The core of trauma treatment is the restoration of one’s self-­ identity. According to German philosopher Hegel [40], the ability to be self-conscious is the purest form of knowing oneself. When you know yourself, you can bestow qualities on yourself. As you find out about the world around you, the objects in the environment can also contain qualities that you first learned by knowing yourself. Recognition of oneself requires ownership of the experience which should occur not only in a cognitive but also on an emotional level. Nevertheless, by definition, such integration is not fully available to the dissociative patient due to the mental avoidance of the traumatic material including but not limited to memories. Such struggle about knowing and not knowing interferes with the experience of identity including the relationship with one’s body. In his first book, German philosopher Hegel [40] stated that self-consciousness is the awareness of another’s awareness of oneself. Thus, introspection is not sufficient to achieve this purpose. Nevertheless, the encounter of two independent self-consciousnesses leads to a power struggle between them. This conflict is typically inquired and solved in a rela-

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tionship characterized by the dynamics between a “master” and “slave.” Mutual “recognition” of two unequal each other leads to the emergence of self-consciousness. The outcome is an abolition of both stances. In Dialectical Dynamic Therapy (DDT), this relationship of “unequal” is utilized as a tool of change, source of creativity, and the dynamics of progress. Dialectical thinking is about dealing with thesis and antithesis (accepting the coexistence of the opposite) to achieve a creative-integrative synthesis. This is the highest step of the individual cognitive development [41]. Dialectical thinking is the core principle of understanding psychotraumatology [42]. DDT is well shaped for the treatment of trauma-related and dissociative disorders because the internal world (the focus of dynamic psychotherapy) of a traumatized patient is a power-driven sphere. Besides mirroring the external reality characterized by power relationships, such an internal world may also emerge as a consequence of compensatory mental operations. For example, the lack of reliable support by a caregiver during developmental years leads to the emergence of omnipotent self-aspects. In fact, such traumatic narcissism originates from the need for self-­ sufficiency. These inner objects buffer against vulnerability in interpersonal relationships. They are not imported from outside world but are created by the modification of the self by oneself [43]. The psychodynamic tradition of psychiatry did not show an interest in dealing with the ancient concept of dialectics and, in particular, the Hegelian version. The waxing and waning stream of psychotraumatology and the psychodynamic tradition remained as separate tracks either. This impossibility of putting together the concept of DDT throughout the twentieth century seems to be an omission too systematic to be considered as mere coincidence. Rather, it seems to be a “cul de sac” of epistemological avoidances of “brandmarked” therapies which, per definition, do not allow the “client” to become a master. Still in accordance with the Zeitgeist, this situation continues to constitute a fragmented scenery of “psychotherapies” [44] as valid also for the nosological status of the trauma-related disturbances in the current era of Occams razor [20]. Thus, developmentally traumatized “second opinion” patients who did not benefit from past therapies abundantly prevail in the “market” of psychotherapies, as happened once to Mr. Z who was, in fact, a victim of childhood sexual abuse, nevertheless.

The Dialectical Discourse Power struggles threaten knowledge production. According to the French psychiatrist Jacques Lacan [45], in a world of power bound by the “master’s discourse,” the sole scientific

V. Sar

attitude was, for him, asking questions (“hysterical” discourse) but not replacing the truth, directly or indirectly, with “master’s” reality as performed by the “academic discourse” [46]. Thus, science would only be possible in “hysterical (dissociative in today’s terminology) discourse,” in which the subject is divided to challenge reality by asking themselves questions. Indeed, “hysteria” has challenged clinical and scientific knowledge in medicine throughout centuries, beginning with Hippocrates. Given the psychological setup and traumatic antecedents of people with dissociative disorders, this is not a surprise. First of all, they are the voice of uprising. This can be possible as they are capable of looking at reality from contradictory perspectives, albeit they need the help of a healer to turn this potential into a synthesis while preventing self-harm and, hopefully, triggering some progressive change in their environment and in the world. In my view, neither asking questions nor challenging (hysterisizing) the master signifiers of a patient in the “analytic discourse” (ironically, the chosen word analysis itself refers to an antithesis of synthesis) is sufficient for the effective treatment of post-traumatic phenomena. Instead, dialectical discourse, as represented by DDT, should be the primary guide for effective general psychotherapy. Following the line of the above descriptions, the dialectical discourse, as proposed in this paper, is based on a combination of the “master’s” and “hysterical” discourse. In master’s discourse, it is the “slave” who collects and produces knowledge that the “master” orders and appropriates. In hysterical discourse, again, the slave is divided to question the reality which is a bit problematic in master’s discourse. Unlike in the analytical discourse either, in dialectical discourse, the master tolerates being divided himself and lets his “master signifiers” (mindset, previously learned information) be challenged by the slave’s knowledge. Thus, to address the power paradox involved in a post-­ traumatic constellation, the therapist should dialectically reverse the roles in the master’s discourse and challenge (i.e., “hystericize”) the “master signifiers” of the therapist. In fact, the relationship between the patient and the clinician is necessarily asymmetrical due to the latter’s official training and approval for this purpose (the master) in this dyad. Therefore, while conducting this procedure of re-creation of knowledge, the therapist does not renounce being the responsible leader; i.e., one should not mix up the position on the chess board with the figure itself.

Four Steps of DDT Technically, DDT is composed of four steps: Paradigm shift, identificatory operations carried out in the master-slave dynamics, overcoming fear of loneliness following the emergence of selfhood, and ratification of the acquisitions

32  Recovery from Dissociative Identity Disorder

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Fig. 32.4  The four phases of Dialectical Dynamic Therapy (DDT)

(Fig. 32.4). The first step introduces the patient to the core of the work that will be done in the second step. The master-­ slave dynamics takes full effect in the second step. During this stage, communications are conducted in the “pretend” mode, which means that “real-time” meta-awareness of therapeutic movements is not expected on either side of the interaction. Rather, the change in mental status of the patient serves as a clue of the shift in a positive direction. The third step is to gather the results of what has already been done. Following recovery, a period of follow-up is indicated. The clinician checks the stability of the therapeutic achievements by exposing the patient to challenges in a controlled fashion.

The Paradigm Shift Trauma is more than just a stressful situation. In fact, it is the response to a threat that becomes a long-term inner process if interrupted. Even acute traumatic experiences may be embedded in an ongoing chronic process. Nevertheless, such events are embedded in the biography of the affected individual as the broader context. Traumatized patients, those who suffer from consequences of adversities in early life, cannot make a differentiation between their “original (authentic)” qualities and those that represent the “acquired” post-traumatic process [47]. The distinction between them

leads to a paradigm shift about understanding themselves. For example, identifying a dissociative disorder that remained unrecognized for years is a solid example of such a distinction. However, achieving clarity of vision about the blurred boundaries between one’s “constitution” and the acquired deviations may raise challenges for these patients; i.e., the ability to initiate meta-awareness of their trauma-related functioning is impeded. Such patients need to look at their own detachment from a distance, which frequently triggers a joyful Aha-Erlebnis if obtained in a safe environment. This empowering insight (on condition that the clinician does not turn it into a fearful one), which is also experienced emotionally functions like a deconstructive encouragement. Thus, recognition of the distinctness of the prolonged inner process of trauma by both the clinician and the affected person is the first step of healing.

Identificatory Processes Taken the theoretical assumptions the DDT is based upon, this is the place where operations are conducted in the context of a master and slave relationship. The positions of the therapist and the patient are, by definition, asymmetrical; i.e., the therapist is perceived as the master. The identificatory process develops through questions of the therapist. The

192

patient takes the role of the narrator master. Nonetheless, at the level of knowledge production, the roles become interchangeable, as proposed by dialectical discourse. German dramaturge Bertolt Brecht’s “epic theatre” is a progressive example of being both on the stage and in the audience. Specifically, estrangement effects are used to prevent the audience from becoming permanently identified with the actors. Paradoxically, the attitude viewer’s the boundary between the stage and the hall that the audience participates in the play, which “transforms” them. This is different than identification with either pole of the “trauma triangle” (victim, perpetrator, and rescuer) in a scenario that interferes with an emancipatory transformation of the audience as opposed to rating-seeking soup operas. One dimension of the identificatory processes is the incorporation of the codes obtained from the therapist which is aimed at fixing the damaged (divided) master identity of the patient. Analogous to biology, this process resembles the repair of a broken DNA chain. The “cell membrane” opening is to be performed by the paradigm shift stage of DDT already, which is required to make the patient ready to take what is given. The therapist repairs Dividedness of the master identity of the patient through delivery of his artificial (copied) self. This transfer occurs through the therapist’s recognition of oneself in the patient in the condition that the latter becomes aware of this experience. Reciprocally, the therapist ratifies the patient’s recognition of himself in the therapist’s pure master identity. The second dimension of the identificatory processes is the re-creation of knowledge by collaboration of the master and slave. This is the place where the dialectical discourse prevails as the core of the intervention in the dyad of therapy relationship. The therapist lets his/her “master signifiers” (mindset, previously learned knowledge) be challenged by the slave. The patient learns how to “catch a fish” rather than just being a “consumer”; that is, the patient turns back to his/ her master identity. As a source of inspiration, the therapist (master) delivers several formulae to the patient, who chooses which to utilize in achieving solutions for individual impasses and those arising in therapy. This is a process of proposing and ratification, which can also follow inspirations delivered by the patient. In fact, there is (almost) no (such thing as) as (a) master or slave, but the process of ratification does! (Fig. 32.5). Nevertheless, the invitation to initiate assists in the acquisition or regaining of a sense of agency and, subsequently, a sense of self. This empowerment increases the patient’s desire for recovery, reduces fear and pain, initiates creative learning alongside modeling, and fosters hope, conviction, and belief. Technically, the “slave” is expected to achieve a status where he/she does not need a “master” anymore because he/ she becomes the master themself. This is a four-hit proce-

V. Sar

dure: First, transition from having really been enslaved by his/her environment into a symbolic status of slave-in-­ therapy is indicated. In the second hit, the therapist delivers his/her artificial self to the patient to make him/her a “pseudo-­ master” in the dyadic therapy relationship by repairing his/ her broken master identity. The third hit is freeing the master-­ identity of the patient paradoxically (ironically) by “un-­ shackling the slave.” The final step is the integration of all that is acquired into the “core.” To be accepted by the patient’s internal world, these interventions must be launched in such a “natural” and subtle way that the patient’s perception of the entire experience remains as: “I did it myself.” Obviously, such “apoptosis” of the (artificial self of the) therapist (as a true master) to achieve the supreme goal of healing goes beyond the psychoanalytic principle of “absence.” This is nothing else than the breaking free of a reciprocally “un-shackled” master. As the third dimension, validation of the impacts of traumatic memories by the therapist is necessary to alleviate some posttraumatic structures. In fact, they are tests conducted by the patient to secure the emancipatory attitude of the therapist who will serve in further stages of the therapeutic process. Contacting alternate personality states should not interfere with the transition of the patient to his “master-­ identity” as the latter is the supreme task for healing.

Overcoming the Fear of Loneliness The dissociation phenomenon and coping strategy confirms that the human individual is a social creature in that detachment from the environment disturbs the coherence of one’s internal world. Kierkegaard [48], in his book on “Sickness Unto Death.” assumed that human existence was based on relation (although not necessarily interpersonal: “A human being is a spirit. But what is spirit? Spirit is the self. But what is the self? The self is a relation that relates itself to itself or is the relation relating itself to itself in the relation.” In my view, it is the relation between the two selves that constitutes the integrated self of the individual. The latter turns to a source of reassurance in the face of being alone and “standing in the spaces” [49] without losing the truth amid different realities. Becoming oneself requires symbolically distancing from one’s “self-objects” [37] as well as from the Lacan’s “Big Other” [50]. Completion on this process alleviates fears of abandonment in interpersonal relationships including partnerships [1, 2]. This is the true selfsufficiency which is different that one of the “traumatic narcissism” which reflects a closed system of buffering entities presented as strength despite a rather weak self.

32  Recovery from Dissociative Identity Disorder

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Fig. 32.5  Maintaining the dyad of master and slave in Dialectical Dynamic Therapy (DDT)

Ratification of the Acquisitions The repaired master identity of the patient is to be challenged by the therapist in a controlled manner. This is the “working through” phase, which validates the achievements obtained in the previous phases of the therapy. This phase also works as a “follow up” procedure to support the patient against spontaneous challenges of “normal” life.

Conclusions The phenomenon and coping strategy of dissociation confirm that the human individual is a social creature in that detachment from the environment disturbs the coherence of one’s internal world [47]. However, “socialization” is the niche where he/she meets the evil too. In a quote usually misattributed to Darwin, a North American business professor [51] stated: “It is not the strongest or the most intelligent

who survive but those who can best manage change.” An entire volume has been devoted to whether identity may be flexible over life [52]. In fact, what is meant by managing change is not over-adjustment or conformist adaptation to the demands of the environment but being able to grow and overcoming the fear of freedom, which is a struggle covering the entire life. Thus, psychotherapy of DID should follow emancipation as the leitmotiv. In fact, this is not only about managing change in the external but also in one’s internal world. Even post-traumatic growth is possible. This cannot simply be the result of fusions between distinct personality states or unification of a fragmented sociological self, but rather a more thorough integration that reaches out to one’s psychological self. The patient should be made aware of this opportunity and that everyone has a chance to do so. Acknowledgments  The author wishes to thank Görkem Ayas (medical intern at Koc University School of Medicine, Istanbul) for his valuable assistance in the preparation of this book chapter, including the composition of the illustrations.

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33

Prognosis of DID Justin Mark, Miguel Belaunzaran, Qaas Shoukat, and Amar Gill

 nalysis of Dissociative Identity Disorder A through Longitudinal Cohort Studies One of the earliest documented cases consistent with DID occurred in the late 1800s and revolved around an individual by the name of Louis Auguste Vivet. As a child, Louis suffered from physical abuse and neglect, which was thought to incite the emergence of additional personalities (or alters). His transitions from one alter to another reportedly cycled on a time scale of months to years and would cause him to undergo drastic changes with respect to both his character and physical ability. Ongoing observation by medical experts described transformations as subtle as appetite changes, as well as more noticeable differences such as periods of time in which the patient would lose complete physical functionality of his legs. DID was first recognized as a legitimate diagnosis in 1918 when it was incorporated into the DSM-II as “Hysterical Neurosis, Dissociative Type.” [1] It was not until the DSM-­ III that DID was reclassified as one of the dissociative disorders under the now outdated term, Multiple Identity Disorder. The DSM-IV and V went on to adopt the name, “Dissociative Identity Disorder,” as it more appropriately fits the current criterion of a) undergoing changes in identity observable to self or others and b) the occurrence of gaps in recall/memory for everyday events. J. Mark (*) University of Miami Miller School of Medicine, Fort Lauderdale, FL, USA e-mail: [email protected] M. Belaunzaran University of Florida College of Medicine, Gainesville, FL, USA Q. Shoukat HCA Florida Aventura Hospital, Aventura, FL, USA e-mail: [email protected] A. Gill Broward Health Medical Center, Fort Lauderdale, FL, USA e-mail: [email protected]

The medical community’s understanding of this disorder is continuously evolving, likely due to the currently limited body of research/studies surrounding DID, as well as difficulties in discerning DID from other psychiatric conditions that can closely mimic its presentation. However, continuous efforts have been made in attempts to longitudinally follow DID patients in order to more accurately understand their long-term prognosis with and without the use of therapy. [2, 3]

Würzburg, Germany Study One such study was conducted through the Department of Child and Adolescent Psychiatry of Wuerzburg University in Germany. Researchers aimed to assess long-term outcomes of pediatric patients who were treated at the hospital for dissociative disorder between the late 1980s and early 1990s. 44% of the original patients were able to be reassessed, with a mean follow-up time of 12.4 years [4]. Medical intervention during the time of initial psychiatric hospitalization revolved heavily around psychoanalytic therapy, with very sparse use of pharmacotherapy. Following the completion of initial psychiatric treatment, 89% of the hospital’s patients reported full resolution or marked reduction of dissociative symptoms. Upon follow-up in adulthood, 26% of individuals fit the criteria for still suffering dissociative disorder, while 41% reported at least one episode of recurrence that required treatment during the follow-up period. Additionally, 83% suffered from at least one psychiatric disorder of any form. Results seem to show that although the early intervention of dissociative disorder displays a favorable short-term outcome, a patient’s long-term prognosis may not be as stable and is prone to the recurrence of dissociative symptoms and the emergence of other psychiatric comorbidities. Long-term prognostic studies of dissociative disorders have been limited; however, the study at hand points towards the potential necessity for periodic follow-up and intervention (if needed)

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_33

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to minimize the recurrence of dissociative symptoms and the onset of new psychiatric conditions.

 reatment of Patients with Dissociative T Disorders Study (TOP DD) Another study conducted out of Towson University, Maryland in 2013 followed a large sample of outpatient community therapists over the course of 6  years to assess potentially beneficial outcomes of therapies among a patient population that included patients with dissociative and/or post-traumatic symptoms [5]. The type of therapy utilized by these clinicians largely used a stepwise, stage-oriented treatment of trauma and dissociation. This included a focus on stabilization/safety (stage 1), a gradual transition to the processing of traumatic memories (stage 3), and ultimately, ending with societal integration/reconnection (stage 5). Follow-up was primarily conducted following 6 months and then 6 years of outpatient psychotherapy. At these times, clinicians were asked to quantify the degree to which various stressors were negatively impacting their patient’s lives. Six-­year measures demonstrated improvement in the overall quality of life and functioning and in the reduction of stressors. A table displaying the time point values of measured variables can be seen below, with Time 2 corresponding to the 6-month follow-up and Time 5 corresponding to the 6-year follow-up (Fig. 33.1).

J. Mark et al.

among patients with dissociative disorders (DD) compared to the general public. One such study conducted out of GATA Haydarpasa Hospital, Istanbul, between 2004 and 2006 evaluated patients with Dissociative Disorders against patients with Major Depressive Disorder (MDD) in regards to self-­ mutilation risk. [2] The test group consisted of 50 patients with a dissociative disorder diagnosis admitted to the psychiatric unit at GATA Haydarpasa. This was compared to a control group of 50 patients with a diagnosis of Major Depressive Disorder. Results of this study showed that a positive history of self-­ mutilating behavior among the DD group compared to the MDD group was 82% vs 20%, and that the average duration of self-mutilating behavior lasted approximately 4.9  years among the DD group compared to 2.0 years among the MDD group. Similarly, a positive history of suicide attempt among the DD group compared to the MDD group was 88% vs 34%.

 issociative Identity Disorder and Other D Psychiatric Comorbidities

The occurrence of psychiatric comorbidities among patients with a primary psychiatric diagnosis has been and continues to be a field of prominent study. One of the changes that occurred during the transition from the DSM-IV to DSM-V was the elimination of the multiaxial system, which used a classification system to compartmentalize various psychiatIncreased Incidence of Suicidality ric conditions during the diagnostic process. Prior to this and Self-Mutilation change, a 2011 study conducted through the Department of Psychiatry at Hannover Medical School aimed to investigate Self-mutilating behavior is characterized by deliberate self-­ the prevalence of comorbid conditions among female patients harm without active suicidal intent. A number of studies have with DID. [6] demonstrated the increased risk for self-mutilating behavior

Fig. 33.1  The following table displays the qualitative changes in the Towson study patients’ responses to stressors, global assessment of functioning, and quality of life over a 6-year follow-up

33  Prognosis of DID

From a sample size of 44 patients with DID, researchers were able to estimate that patients suffered from an average of 7.9 comorbid disorders. Moreover, 82% of these patients were diagnosed with at least one comorbid axis-1 disorder, which included mental health and substance use disorders. [6, 7] MDD was found to be the most common comorbid disorder associated with DID, with a prevalence between 88–97%. A comorbid substance use disorder occurred in 50–65% of patients, and more than 90% of patients suffered from comorbid anxiety. Somatoform symptoms and disorders (i.e., headache, pain syndromes, gastrointestinal symptoms, asthma, etc.) were diagnosed in 25–65% of patients. The high prevalence of comorbidities among patients with DID suggests that many of these additional conditions may go undiagnosed in practice, and emphasizes the necessity for holistic clinical evaluations for appropriate treatment of all aspects of a patient’s health.

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 ate of Recurrence with Pharmacological R Monotherapy Currently, there are no pharmacological agents that can be used to directly treat dissociative symptoms in patients with DID. [8, 9] Psychotropic medication is not a primary treatment for dissociative processes, and specific recommendations for pharmacotherapy for most dissociative symptoms await systematic research [10]. However, therapists report that most DID patients have received medication as one element of their treatment [11]. In the only naturalistic study of outpatient dissociative disorder treatment, 80% of patients received adjunctive medication [12]. However, the other concomitant symptoms that arise in patients with DID can be treated with their associated classes of drugs [2]. These drug classes are summarised in the table (Fig. 33.2)

Therapies for Concomitant Psychiatric Conditions in Patients with D.I.D. PTSD, Affective Disorders, Anxiety, OCD Selective Serotonin Reuptake Inhibitors Tricyclic Antidepressants Monoamine oxidase inhibitors Electroconvulsive Therapy Mood stabilizers Valproic acid Lamotrigine Topiramate Carbamazepine Benzodiazepines Atypical neuroleptics Clonidine Prazosin Low dose trazadone Low dose mirtazapine Zolpidem Anticholinergic agents Naltrexone Fig. 33.2  Various medications utilized in the treatment of DID and associated comorbidities

J. Mark et al.

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 ate of Recurrence with Pharmacological R and Psychiatric Combined Therapy Although studies regarding treatment for DID date back more than a century, rigorous research on the outcomes of DID treatment is still in its infancy. Several factors complicate research in this area, including the lengthy treatment that is usually required and the pragmatic need for a flexible treatment approach to managing the complex clinical situations of DID patients [13]. Despite the challenges, DID treatment has been explored through case studies, case series, cost-efficacy studies, and naturalistic outcome studies of therapeutic effectiveness. Taken as a whole, this body of work provides evidence of effective treatments for DID and a wide range of associated symptoms. Systematically collected outcome data from case series and treatment studies indicated that 16.7–33% of those DID patients achieved full integration. [8]

Need for Individualized Treatment Plans The nature of DID and its unique course in each individual patient necessitates an individualized treatment plan. Specific emphasis should be placed on: 1. The inciting traumatic events that led to the development of the disorder 2. The patient’s understanding of their condition/compliance with the treatment 3. The patient’s relationship with the treating physician(s)/ therapist(s) 4. Comorbid psychiatric and/or other medical disorders Due to a complex constellation of factors that can affect the patient’s response to treatment, it is essential that those treating the patient remain adaptable in the face of new changes, so as to tailor the treatment plan according to the changing circumstances affecting the patient’s life and their condition. The need for individualized plans is also outlined in the Guidelines for Treating Dissociative Identity Disorder in Adults developed by the International Society For The Study Of Trauma And Dissociation [8, 9].

Need for Family Involvement Group Therapy Group therapy is generally not considered useful for patients with DID [10]. The emergence of altered personalities, labile mood of the patients, and traumatic flashbacks can disrupt the group dynamic. DID patients can, however, benefit from

group therapy by developing social skills, coping mechanisms, and learning that they are not alone in dealing with DID. If any group therapy is considered, it should be with other DID patients, be strictly timed, carefully structured, and focused on coping skills and adaptation.

Family Therapy Family therapy can be useful in addressing issues that arise in family dynamics due to the patient’s condition [8, 9]. Education about the patient’s condition and coping mechanisms and skills to help family members successfully interact with and care for the patient can be extremely useful. Family members can help provide information about the patient outside of clinical settings and thus lead to more well-informed treatment plans. Family therapy involving the family of origin of the DID patient can be extremely distressing to the patient because it can often lead to patients confronting the cause of their trauma. However, if such meetings are constructed for the purpose of clarifying/resolving conflictual emotions faced by patients towards their family members, this can be helpful for the patient. [10]

Multi-Modal Approach to Treatment of DID An optimal approach to the treatment of DID in order to optimize success is through the use of long-term and specialized treatment. Ultimately, the aim is to reduce psychological symptoms and decrease self-harm that is often noted in these patients. Prior treatment approaches relied on individualized approaches with use of either pharmacological or psychological monotherapy. However, a more multi-modal approach has been deemed to be optimal, which relies on a combined psychiatric and behavioral approach as well as use of psychopharmacological agents. Longitudinal studies revealed many key findings with this approach, including decreased need for hospitalizations, improved patient-reported quality of life, marked decreased revictimization, and improved family related stressors [4, 5]

Predictors of Clinical Course Negative predictors are very important when determining prognosis. The most important of these include age of onset and the number of dissociative symptoms. The median age of onset of dissociative disorder was 11.7. 26.1% of patients were still experiencing symptoms after reassessment at mean age 24.8. The researchers identified a negative correlation between age of onset and psychosocial functioning in adults. Furthermore, the number of dissociative symptoms is also

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33  Prognosis of DID

inversely correlated with this psychosocial functioning later in adulthood. Positive predictors of sustained illness include the severity of symptoms, dissociative convulsions, comorbid anxiety/personality disorders, setting, length of follow-up periods, and ending treatment against disease. The higher the prevalence of any or all of these, the more likely the symptoms will persist into adulthood.

Adults vs. Children Prognosis The prognosis of dissociative identity disorder (DID) is complex to determine with certainty due to the number of variables that take place in the recognition, assessment, and management of this condition. These patients may not be recognized or diagnosed with other conditions, which usually delay the diagnosis until adulthood [14]. The long-term prognosis of patients relies on several factors such as comorbid psychiatric conditions, the extent of trauma experienced, ability to process trauma in adult life, and others [15]. The prognosis has been described previously based on three groups. In individuals with DID with high functioning capabilities, these patients suffer less from other comorbidities, which allows for a good prognosis of the disease. The second group includes patients with DID with comorbid psychiatric conditions, which may limit the complete integration of their dissociated identities; the process for these patients is also longer. Lastly, patients who do not benefit from the therapeutic alliance to progress through treatment stages have unfavorable prognoses; these individuals respond better to acute management and stabilization of symptoms [15]. Baars and colleagues developed a prognostic model for complex post-traumatic stress disorder and DID.  They ­surveyed 42 therapists with knowledge in these two areas. A list of factors was developed with estimated prognostic effects clustered together based on content. A total of 8 clusters were developed, which include lack of motivation, psychiatric comorbidities of serious axis I/II, lack of healthy relationships, poor attachment, lack of healthy therapeutic relationships, self-destruction, and lack of other internal and external resources. [16]

Role of Psychotherapy Individual psychotherapy is currently the most commonly provided treatment for patients with DID. The International Society for the Study of Trauma and Dissociation (ISSTD) suggests that the treatment of DID patients be delivered in three sequenced phases [9]. A patient cannot move to the last phase without going through the preceding ones. The first one encompasses stabilization of symptoms and obtaining patient

safety. The second phase dives into the past of the patient in search of traumatic memories believed to be contributing to symptoms; these can be addressed and processed through the therapeutic alliance between psychiatrist and patient. The last phase aims at identity integration [9]. Integration incorporates several things. In essence, an individual attempts to take responsibility and accept and incorporate all the dissociated parts, thoughts, fears, memories, experiences, and feelings. It is a process that takes place throughout therapy [17]. The severity of the illness may vary substantially as well. For acute stressors involving extreme depression, anxiety, and consistent dissociation, improving current coping strategies and supportive interventions are better indicated [17]. Psychodynamic psychotherapy can be utilized when symptoms are mild. This encourages the patient to self-­ reflect and self-assess the current patterns that may be present. A therapeutic alliance between patient and psychiatrist should aim to develop adequate coping strategies, discover the unconscious elements in a patient that leads to dysfunction, and pay close attention to areas of resistance as this revelation process is occurring. [17] Schema therapy is another potential option for patients with DID. This form of therapy integrates cognitive behavioral therapy with experiences and other interpersonal elements. Its purpose is to increase the level of consciousness among the dissociated parts, improve communication and functioning, and address past traumatic memories [18]. It addresses the dissociated parts of patients as different modes of a human, rather than separates states, which aids the patient in appropriate normalization [18].

Conclusion The prognosis of DID improves with a multimodal treatment approach. This includes psychotherapy, proper management of acute stressors, family therapy, and an emphasis on the patient-physician therapeutic alliance. Outcomes are improved with early detection and diagnosis of the condition. Generally speaking, diagnosis in childhood promotes better outcomes, presumably due to sustained management and appropriate processing of potential early trauma. Lingering symptoms into adulthood have been associated with poorer outcomes.

References 1. North CS.  The classification of hysteria and related disorders: historical and phenomenological considerations. Behav Sci. 2015;5:496–517. 2. Ebrinc S, et al. Self-mutilating behavior in patients with dissociative disorders: the role of innate hypnotic capacity. Isr J Psychiatry Relat Sci. 2008;45:39–48.

202 3. Brand BL, et  al. Separating Fact from Fiction: An Empirical Examination of Six Myths about Dissociative Identity Disorder. Harv Rev Psychiatry. 2016;24:257–70. 4. Jans T, et  al. Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence. Child Adolesc Psychiatry Ment Health. 2008;2:19. 5. Myrick AC, et al. Six-year follow-up of the treatment of patients with dissociative disorders study. Eur J Psychotraumatol. 2017;8:1344080. 6. Rodewald F, Wilhelm-Göling C, Emrich HM, Reddemann L, Gast U. Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. J Nerv Ment Dis. 2011;199:122–31. 7. Ellason JW, Ross CA, Fuchs DL. Lifetime axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry. 1996;59:255–66. 8. Coons PM, Bowman EAS.  Ten-year follow-up study of patients with dissociative identity disorder. J Trauma Dissociation. 2001;2:73–89. 9. Study, I.  S. F.  T. & International Society for the Study. Guidelines for treating dissociative identity disorder in adults, third revision: summary version. J Trauma Dissociation. 2011;12:188–212. 10. Figueroa G. Kaplan & Sadock’s Comprehensive textbook of psychiatry. In: Sadock BJ, Sadock VA, editors. Revista chilena de neuro-psiquiatría, vol. 40. 7th ed; 2002.

J. Mark et al. 11. Putnam FW, Loewenstein RJ.  Treatment of multiple personality disorder: a survey of current practices. Am J Psychiatry. 1993;150:1048–52. 12. Brand BL, et al. A longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. Psychol Trauma. 2013;5:301–8. 13. Brand BL, Classen CC, McNary SW, Zaveri P. A review of dissociative disorders treatment studies. J Nerv Ment Dis. 2009;197:646–54. 14. Mitra P, Jain A.  Dissociative Identity Disorder. In: StatPearls. StatPearls Publishing; 2021. 15. Cronin E, Brand BL, Mattanah JF. The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. Eur J Psychotraumatol. 2014;5:22676. 16. Baars EW, et al. Predicting stabilizing treatment outcomes for complex posttraumatic stress disorder and dissociative identity disorder: an expertise-based prognostic model. J Trauma Dissociation. 2011;12:67–87. 17. Gentile JP, Dillon KS, Gillig PM.  Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innov Clin Neurosci. 2013;10:22–9. 18. Huntjens RJC, Rijkeboer MM, Arntz A.  Schema therapy for dissociative identity disorder (DID): rationale and study protocol. Eur J Psychotraumatol. 2019;10:1571377.

The Impact of DID on a Family’s Life

34

Jill D. Chasse

Introduction

Discussion

Dissociative disorders are a mental health condition where the patient feels a disconnect from reality [1]. The individual’s thoughts, identity, consciousness, and memory become detached and almost alienated. This escape is involuntary, although it can be triggered by certain factors specific to the individual, especially in the case of trauma [2]. In graduate school, I learned briefly about this family of disorders. I never focused much on them except remembering that when I started my undergrad psych program, Dissociative Identity Disorder was just renamed from Multiple Personality Disorder [1]. As with many young adults of my time, I associated it with unrealistic movies about split personalities such as Sybil and The Three Faces of Eve. After graduation, I didn’t think much about it anymore. Years later, I was working deep in public health and epidemiology. I had left psychology behind for the glory of infectious diseases and maternal global health. I loved the part that mental health played in the health of the mother-­ baby dyad, but as a career, it wasn’t really marketable for me. Until the pandemic hit, and I was ironically thrown head first back into the psych world. As an epidemiologist, I was expecting my public health career to flourish. Early in 2020, I was fully utilized and was indeed brought into many opportunities, but public health experts were soon overshadowed by a neighbor’s cousin’s wife’s uncle who watched a YouTube video on the internet and would no longer wear a mask or be injected by microchips. That frustrated me immensely, but it turned out that being at home was where I was needed.

After the pandemic hit, mental health issues were going through the roof, including my own. My daughter, who had been diagnosed with anxiety, PTSD, and pediatric bipolar disorder over 4 years prior, was not reacting well to the quarantines and virtual learning thrust upon her. My other children had struggles as well, but “L” was hit the hardest. Her anxiety turned into panic attacks, and her bipolar rages were getting worse. Her physical and verbal aggression increased in frequency, duration, and intensity, but she seemed to be falling further and further away from the clinical criteria that led to her diagnosis. Not only that, but her mental health team and I noticed something very specific, very stark, and very distinct. Her outgoing, calm, happy, articulate manner clicked off when she was triggered, and she zoned out, never remembering any of her rages. She dissociated. During these episodes, she not only experienced amnesia, she also was totally detached from herself. She would talk about times when she didn’t recognize herself in the mirror, and other times she’d run away from me, saying she didn’t know who I was. After a few months of noticing and attempting to work through this, the director of her treatment team suggested that this dissociation could very well be a response to the traumatic events she had experienced. From growing up witnessing domestic violence, then the suicide of her father, the loss of his youngest daughter, that was stillborn shortly after he died, all the way to the tragic drowning of her little brother right before the pandemic hit. It seemed that every time life was starting to get back on track for her, something tragic, traumatic, and agonizing occurred. The emotional and psychological stress of the pandemic had probably pushed those symptoms into the light as they pushed her over the edge. Her therapy team tried many different angles. “L” was flooded with clinical diagnostic tools such as the Dissociative Experiences Scale (DES) and the Multidimensional Inventory of Dissociation (MID), both of which she scored high on [3, 4]. I found it both a surprise and

J. D. Chasse (*) Department of Public Health, William Paterson University, Wayne, NJ, USA

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a comfort that she completed them with relief. This poor, misunderstood 12-year-old girl exclaimed in excitement as her feelings were validated. She nodded in agreement when her psychiatrist asked about the voices that were talking to her and seemed almost surprised that everyone didn’t have parts they could see and hear in their mind telling them what to do or threatening them. She very clearly explained the world she saw when she “zoned out” or “blacked out” as she explained. When we would see her go blank, she would be listening to voices arguing or bullying her. She said she would hear them clearly, but all the people around her were faded voices- like she was deep underwater and they were pulling her further and further away, so we were just echoes.

Negative Aspects By far, the worst part of it is her violent dissociation. When your child rages and breaks the new TV, screams bloody murder in the front yard or tells you are a worthless piece of crap that deserves to die slowly and painfully, you want to punish them, then crawl into a ball and cry yourself to sleep. But I cannot do either. I have to understand that my child is unable to resolve her trauma. Her reaction is a survival tactic, no matter how misplaced. Her little brain thinks it is protecting her [5]. She can only react by dissociating and eventually learning to repress and hide these unwanted thoughts, feelings, emotions… and pain.

Emotional Dysregulation Now I understand why people in the old days believed they were possessed. I could watch my sweet, calm, caring, loving child turn into a violent growling demon in mere seconds, then act like nothing happened moments later. One day my husband and I walked into the kitchen and she was hiding under the kitchen table. “They are here!” she screamed ‘They came out of my head and they are real and they said I have to—no! No! I can’t!” Please mommy’ She yelled in fear and looked up blankly at me. I tried to hold her, help her, it’s okay baby, I’m here—they have no power over you—Your kingdom is as great—no power, sweetie,” I repeated our calming mantra from Labyrinth but she continued getting agitated. Then the agitation turned into anger and she threw her chair down. “Shut up mom, just shut up you are making it worse now,” she stood up tall and looked me right in the eye “Get. Me. Food.” I took a deep breath and walked to the fridge, “sure sweetie, what are you in the mood—” “Food! Now! If you don’t get me food right now I will fucking kill you.” She

threw another chair and raised her voice again. “Now or I will die and I will kill you and you will regret ever breathing.” “L” continued to scream as I went through the cabinets frantically. She pushed the table over into me as I came near her and looked me dead in the eye “I am a cat and you are just a stupid human. I hate humans. They all need to die.” Then she went under the table and ripped up pieces of paper until she came to. She then looked around the room—said, “mom? I have no idea what I did, but I’m very sorry.” That’s the bad. Just a peek into the window of our world. The bad is terrifying and hurtful. The bad is when I cannot help my baby and I feel like I am failing. The bad is when she scares her brothers during a dissociative rage then wonders why they don’t want to play with her. The bad is when she tells me she hates me and tells me to die. But the worst is when she hates herself for not being able to be in control and doesn’t want to live because she is afraid of hurting someone when she blacks out.

Positive Aspects Believe it or not, there are positive aspects of living with DID in the family. I remember early on talking to my therapist about how amazing it was to learn about everything she was telling me. Her amazing, articulate details of what she can see and hear so clearly inside her. I said, if she was a case study, I would be so amazed with every single detail, but as my little girl, it was a mix of incredible and terrifying. I wanted to do all I could to learn more about what she was going through and find ways to help her. So I decided to study clinical trauma. Not only did this allow me a different perspective and in depth understanding of what was going on in my daughter’s mind and head and brain. It also gave me a chance to help others. It gave me a reason to go back to psychology, back to the mental health focus, and utilize what I was learning for the processing of my own traumatic memories. Trauma is scary but the human body is absolutely amazing. I learned that dissociation can occur as a coping strategy to protect her from the horrible emotional trauma that would otherwise make living unbearable [5]. I learned that both her and her older brother’s memory loss was not abnormal, especially in almost every memory that involved their father. The trauma produced biological changes and stress responses [2]. I learned that her eerie descriptions she gave me of being physically detached from her body was a just symptom and that for her disorder, it was a completely normal experience [6]. Once I understood that, I would listen to her for hours explaining how she was like a spirit at times watching her back and her hair, or how she was floating above herself listening to her words like a stranger.

34  The Impact of DID on a Family’s Life

The human brain is absolutely amazing, and my daughter was learning this as she learned more about herself. She wanted to know the inner workings of her brain in order to stop the mean ones from taking over. She wanted to learn why there were hours she felt like a cat or talked like a baby, and why she would sometimes start crying out of nowhere. She was curious, interested, intrigued and enthralled and that passionate intensity and curiosity kept her going in the hard times, sad days and angry, burnt out, emotionally distanced moments when it was easier to hide under a rock and pretend this entire complicated neurodivergent existence was just a dream. Significant memory loss of specific times, people and events allow her to forget traumatic memories but leave her with a sense of disconnect. Out-of-body experiences, such as feeling as though you are watching a movie of yourself make her think she is an alien, or a spirit. She often talks of past lives and seeing ghosts. Sometimes it is the only way to explain and justify the experience. Mental health problems such as depression, anxiety and thoughts of suicide are all over her files, but they are the only part that people can understand [6]. The dissociation makes her more of a leper. More of an outsider with a continuing sense of detachment from emotions, or emotional numbness, which unfortunately leads to a lack of a sense of self-identity. This is why it is vital to acknowledge the reality of the experience. To normalize it and take away the stigma, so she is not a floating spirit in a foreign land. She is an important, creative, loveable, amazing human being suffering from a mental illness.

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Conclusion My notebook is filled with drawings of faceless persecutors and angry figures from her mind. Telling her what she did when dissociated and disconnected has been the hardest part. She is scared of herself and confused why she would ever want to hurt herself after so much sadness and death and why she’d ever be mean to me. But then I know I am doing okay, when she reaches out to hold me and says “mommy, you are the reason I am a good person, you are the reason that I have the happiness that keeps me going. It is all you. How could I ever want to hurt you?”

References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013. 2. Improvement Protocol (TIP) Series, No. 57. Chapter 3, Understanding the impact of trauma. https://www.ncbi.nlm.nih.gov/ books/NBK207191/. 3. Dell PF.  The multidimensional inventory of dissociation (MID): a comprehensive measure of pathological dissociation. J Trauma Dissociation. 2006;7(2):77–106. 4. Carlson EB, Putnam FW. An update on the dissociative experiences scale. Dissociation. 1993;6(1):16–27. 5. van der Kolk B, Roth S, Pelcovitz D, Mandel F. Complex PTSD: results of the PTSD field trials for DSM-IV.  Washington, DC: American Psychiatric Association; 1993. 6. Center for Substance Abuse Treatment (US). Trauma-informed care in behavioral health services. Rockville (MD): Substance abuse and mental health services administration (US) (Treatment). 2014.

Pharmacological Treatment of Dissociative Identity Disorder

35

Jordan Kalosieh and Acelyne Summerson

Introduction The first step in evaluating appropriate treatment options for any patient is to begin with a full psychiatric evaluation. In addition to assessing whether a patient meets the full criteria for DID, is essential to evaluate for the presence of comorbid psychiatric conditions. Often times, addressing comorbid conditions will be the first step in psychiatric treatment for patients with DID. There are several pharmacological treatments being assessed in ordered to attempt to relieve the symptoms of dissociation or dissociative experiences in association with DID and other disorders [1]. Pharmaceutical treatment of persons with dissociative identity disorder is complicated by several factors including comorbidities, lack of research, and a relatively limited understanding of the neurobiological basis of the disorder. There is no FDA-approved medication at this time to treat dissociation [2]. As dissociative identity disorder is rooted in trauma, treating frequently associated comorbid disorders, including major depressive disorder and/or post-traumatic stress disorder, is an important part of the process of treatment. This is often an essential first step of treating persons with dissociative identity disorder. As dissociative identity disorder is a rare disorder, research surrounding any specific treatment tends to be rare as well. As a result of this, potential treatment options are related to neurobiological basis of the disorder, comorbid conditions, and easing the participation in psychotherapy. In addition, recognizing comorbid psychiatric illnesses in DID is imperative. It is important to note that dissociation in the setting of PTSD does not preclude patients from benefitting from psychotherapy, and that the combination of pharmacological treatment and psychotherapy is indicated [2]. Treatment options should always be discussed thoroughly with a patient prior to initiating any pharmacological regimen. However, as mentioned, the proper diagnosis of all psychiatric illnesses in a patient with DID is imperative prior to discussing J. Kalosieh (*) · A. Summerson HCA Florida East Division—Aventura Hospital, Aventura, FL, USA

treatment options. The criteria to diagnose a patient with DID as defined by The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5) includes the following: “a total of 5 criteria that must be met before diagnosis someone with DID: two or more distinct identities or personality states are present, amnesia must occur, the person must be distressed by the disorder, the disturbance is not part of normal cultural or religious practices and the symptoms are not due to the direct physiological effects of a substance.” [3, 4]. The discovery of an effective treatment regimen is always based on the individual patient, and ideally the patient would follow up with their psychiatrist continuously to assure the medication regimen continues to be appropriate and efficacious throughout the treatment course. As with most psychiatric illnesses, resolving particular symptoms may be achieved through pharmacotherapy but, in order to treat the disorder entirely, psychotherapy and continuous re-­ assessment of medication regimen is necessary. Although there is sparse evidence in the use of pharmacological agents in patients with DID, current evidence reveals a high response rate in those treated with a variety of medications including antidepressants, anxiolytics, antipsychotics and others [5].

 he Importance of Treating and Evaluating T Comorbid Conditions As a part of any full psychiatric evaluation, the identification of all psychiatric conditions is vital. Dissociative identity disorder is linked with traumatic experiences, often occurring in childhood [6]. These experiences can also lead to major depressive disorder, and post-traumatic stress disorder. Being able to relieve symptoms created by comorbid disorders can improve quality of life and may be beneficial in allowing for patients to participate more fully in psychotherapy, which is generally regarded as the gold standard of treatment for trauma-related disorders, including specifically, dissociative identity disorder [6].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_35

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Neuropsychiatric manifestations that are involved in DID may include anxiety, depression, delusions, memory loss, and suicidal ideation, which may present at any time along the course of the disease. In light of this, practitioners should seek treatment options that address the concerns of each individual patient on the basis of history of present illness and the success or failure of prior treatment interventions in each particular patient. Patient’s personalities may vary and should be examined thoroughly while discussing the patient’s history of present illness, as this could affect treatment plans. The goal of treatment for patients with dissociative identity disorder is to integrate the different identities as fully as possible so that the individual may function with as much control and awareness as possible [6]. More common psychiatric disorders may be easier to assess and are often identifiable on an initial evaluation; treatment for comorbid conditions should be initiated immediately. It is advisable to follow the guidelines with regard to identifiable disorders. It is important not to delay treatment for comorbid conditions as each may carry its own compounded risk factors for symptoms, including suicidal ideation. Additionally, mood stabilization in general can be beneficial in the individual’s ability to maintain control over other identities during stressful situations [7]. Furthermore, as psychotherapy is the mainstay of treatment for DID, and it should be incorporated into any treatment plan as early as is appropriate for the individual, in combination with their medication regimen.

Pharmacologic Treatments for DID [7]

Pharmacologic Treatment for Dissociative Disorders Dissociative identity disorder may present with the most identifiable symptoms of dissociative amnesia and/or dissociative fugue. Once the disorder has been identified, assessing the individual’s symptomatology can help to dictate appropriate pharmaceutical intervention. Antipsychotics When considering whether or not an antipsychotic may be indicated in an individual with dissociative identity disorder it is important to note that individuals DID may have episodes where they “hear” other distinctive identities [8]. While auditory hallucinations may suggest psychosis to clinicians, ensuring that there are other symptoms

J. Kalosieh and A. Summerson

of psychosis present prior to diagnosing a comorbid psychotic condition is necessary. Isolated auditory hallucinations in these cases may not be indicative of a comorbid psychotic disorder and rather a misinterpretation of the symptoms of DID. It should be noted that the use of antipsychotic medications in patients with borderline personality disorder may potentiate dissociative symptoms and therefore should be used with caution [9]. Therefore, the temporal relationship between dissociative symptomatology in a patient with borderline personality disorder should be assessed if placed on an antipsychotic, and causation should be taken into consideration.

Antidepressants Antidepressants may play a role in the treatment for dissociative identity disorder for a number of reasons. Not only are the patients at higher risk of depression due to their history of childhood trauma but additionally, from the disorder itself. There have been few trials exploring antidepressants on dissociative symptoms. One study found the treatment response rate of a pharmacotherapy group to be significantly higher than placebo for Paroxetine, while negative for Fluoxetine [7]. Another example is an open-longitudinal study of Venlafaxine on patients with panic disorder with dissociative symptoms which had demonstrated some improvement in symptoms of the dissociation [10]. While this information may not be generalizable it does provide an interesting into what may be an area of future research. Furthermore, it highlights that different antidepressants may be more beneficial than others in regard to dissociative ­symptoms, though not enough research has been completed to make a concrete determination.

Anxiolytics Dissociation without distinct identities is a known symptom associated with panic disorder [10]. It has also been theorized that those who dissociate may represent a subtype of patients experiencing PTSD with less favorable response to treatment however, there has been contradictory data [11, 12]. As such, the thought process has been explored that using antidepressants and anxiolytics may be incorporated into a treatment plan for those with dissociative identity disorder.

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35  Pharmacological Treatment of Dissociative Identity Disorder

One such way anxiolytics have been utilized into treatment process of patients with DID is via benzodiazepine assisted interviewing. As psychotherapy is an essential part of treatment in patients with DID, being able to recall memories in order to work through them is essential. This creates a major barrier to treatment as, due to the nature of DID, patients typically have a difficult time accessing all the memories of the trauma. Using anxiolytics in order to access those memories has been explored by several clinicians. There have been several case reports exploring how benzodiazepine assisted interviewing can beneficial. One case report explores the outcome of a patient with dissociative amnesia from whom Lorazepam was used prior to an interview in order for the patient to be able to recall the specific events leading up to the dissociative amnesia. This case was determined to have improvement of symptoms shortly after the interview [13]. While this treatment may only resolve a portion of the symptoms, and the medications studied are relatively short acting, it is theorized improve patient’s ability to participate in therapy [13]. With an improved ability to work through the trauma associated with the disorder with the patient’s clinicians, these purposed protocols could possibly improve overall treatment outcomes and shorter the duration treatment.

benefits in patients with severe anxiety who also demonstrate dissociation [7]. As mentioned, DID can result in a plethora of neuropsychiatric symptoms, of which, anxiety is frequently the most prominent. More specifically, anxiety induced by post-traumatic stress disorder (PTSD), has been identified as a comorbid condition in DID and has been shown to be reduced with the use of beta blockers. Specifically, literature has demonstrated that beta-blockers can help reduce intrusive symptoms and stabilize mood [16].

Anticonvulsants Evidence based studies have demonstrated a correlation in successful treatments with anticonvulsants in patients with DID who are found to have mood symptoms including aggression and impulsivity. Possible suggestions for pharmacological interventions for DID have included the use of carbamazepine to reduce aggression [7]. Additionally, studies have revealed the efficacy of lamotrigine (200–250 mg/day) alone or combined with other treatments in patients who experience dissociation as a symptom secondary to other psychiatric diseases (Table 35.1) [17].

Experimental Pharmacological Treatments Naltrexone It has been postulated that there is a mis-regulation of endogenous opioids may play a role in dissociative symptoms [14]. As a result of this theory, the use of Naltrexone hydrochloride, an opioid antagonist, has been evaluated as a therapeutic treatment option for patients with dissociation. In a small, prospective open trial treatment study there was success in reduction dissociative symptoms [15]. While this is not a definitive indication to incorporate an additional medication to a treatment regimen, it may prove to be a promising area of study.

Beta-Blockers and Clonidine Recent studies have analyzed the use of beta-blockers in the patients with DID with comorbid anxiety disorders [7]. Additionally, some studies show that clonidine has

Table 35.1  The table includes the currently most commonly used pharmacological treatments for DID and the purposes of their use in treatment Antidepressants/anxiolytics (e.g., selective serotonin reuptake inhibitors, nonselective reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors) Treat comorbid symptoms, stabilize mood, and reduce intrusive symptoms, hyperarousal, and anxiety Benzodiazepines Use with caution to decrease anxiety; this medication class may exacerbate dissociation Beta blockers, clonidine Stabilize mood and reduce intrusive symptoms, hyperarousal, and anxiety Atypical (second generation) antipsychotics Stabilize mood and reduce overwhelming anxiety and intrusive symptoms Prazosin Reduce nightmares Carbamazepine and other mood stabilizers Reduce aggression, intrusive symptoms, hyperarousal Naltrexone Reduce self-injurious behavior

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Treatment Outcomes In order to evaluate treatment outcomes in any patient population it is essential to control for variables. This is a particular challenge for evaluating outcomes in psychiatric illnesses as there are often an excess of variables that cannot be accounted, much less controlled for. When evaluating treatment outcomes in DID it is complicated even further by the rarity of the disorder, a lack of a singular approved treatment option, the importance of participation in psychotherapy, and the focus on treating comorbid conditions. Furthermore, a clear endpoint of treatment is complicated in patients with DID. Being treated and completely lacking symptoms or having full integration of all of the personalities may be the eventual end goal for patients but, may not be realistic as a primary endpoint of a study. This is in part due to the length of time to achieve these goals. Instead, being able to live a subjectively stable life may be considered a successfully treated patient. Additionally, the lack of research alone makes generalizing potential outcomes a challenge. As such, the treatment outcomes for patients with DID are widely variable. Some studies reveal the most success in treating dissociative symptoms with anxiolytics, possibly attributable to the fact that there are very often comorbid anxiety disorders present. Also, several case reports published explore how providing an intravenous benzodiazepine prior to or during an interview allowed for a patients to participate in an interview more comfortably and openly, with improvement of symptoms after the interview [18, 19]. Some studies use depersonalization experiences to determine whether a treatment option has a positive outcome, while others evaluate for wide range of dissociative symptoms [20, 21]. While depersonalization events as well as dissociative symptoms are important factors for patients, it is difficult to appreciate if this is the most appropriate endpoint for studies. In one metanalysis, which focused primarily on psychosocial interventions, studies were included with a wide range of outcomes [20]. It may also be beneficial to assess for quality of life improvements in patients with DID as the primary outcome.

The Future of Treatment In regard to treatment outcomes for individual pharmacological treatment, it is difficult to achieve success with a singular treatment at this time. As dissociative identity disorder is a rare condition, all of the treatment options evaluated are in a relatively small population. This makes it difficult to fully appreciate the effects that any singular pharmacological intervention has or may have in a larger sample size.

J. Kalosieh and A. Summerson

Due to the rarity of the disease case reports may provide some insight into where clinicians may be finding success in individuals. One such case report discussed how the combination of mirtazapine with risperidone lead to symptom improvement in a patient [5]. Another case report described success using Perospirone as monotherapy for a patient diagnosed with dissociative identity disorder with success [22]. While no conclusions can be drawn or generalizations made in these cases, either can provide insight into what research areas clinicians may explore next. In order to determine appropriate treatment options for medical disease or mental health disorder physicians relay on evidence-based research in order to dictate their decision making. Treatment in DID should be similar to that process as with any other disorder however, the lack of evidence-­ based studies to dictate treatment strategy has been a limiting factor. Few meta-analyses have been performed evaluating the efficacy of different pharmacotherapy treatment regimens for this reason. Illustrated below is one example of how the screening process for appropriate studies can be limited by available applicable studies [21].

Conclusion Properly and fully evaluating patients is always the appropriate first step in determining appropriate treatment for patients with dissociative identity disorder, or any psychiatric disorder. Current medication regimens that have shown efficacy in treating comorbid psychiatric manifestations associated with DID include antidepressants, anxiolytics, antipsychotics, anticonvulsants, and other experimental medications mentioned above. Such regimens have therapeutic potential in patients with DID who have associated psychiatric symptoms, such as depression, anxiety, delusions, memory impairment, and suicidal ideation. Further investigation would be recommended to develop a proper understanding of the mechanism of action of these medications in regard to dissociative symptoms, as patients can potentially benefit from such pharmacological treatment following a diagnosis of DID.  Within this chapter, it is illustrated that patients may require the sustained use of several pharmacological regimens. This calls attention to the necessity of long-term follow-­up and continuous evaluation of patients with DID. Through pharmacological treatment for neuropsychiatric manifestations in patients with DID and by utilizing consistent routine follow-ups, healthcare providers may successfully improve symptoms experienced by their patients. In turn, this may improve compliance with medication regimens and encourage patients to continue striving for a more full, comfortable life despite the hardship of symptoms that encompasses in patients with DID. Healthcare providers can be confronted by a plethora of symptoms brought on by

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DID; this chapter calls attention to hardships of identifying an appropriate medication regimen for patients with DID and how that regimen may be chosen based on the patient’s full symptomatology rather than just one specific diagnosis. This chapter seeks to emphasize how essential attentiveness to detail is when deciding which approach may be most appropriate for each individual diagnosed with DID. It is recommended that further cohort and prospective studies of larger patient populations be conducted to further evaluate therapeutic response to psychotropic regimen, to assess for interplay between improvement of symptoms, side effect profile, and overall change in quality of life. The authors anticipate that the evidence-based treatment regimens discussed in this chapter can ultimately reframe the prognosis that previously may have negatively impacted the way dissociative disorders are experienced and managed.

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medication. Neuropsychiatr Dis Treat. 2018;14:3253–7. https://doi. org/10.2147/NDT.S179091. 10. Ural C, Belli H, Tabo A, Akbudak M. Open-longitudinal study of the effect of dissociative symptoms on the response of patients with panic disorder to venlafaxine. Compr Psychiatry. 2015;57:112–6. https://doi.org/10.1016/j.comppsych.2014.11.016. 11. Burton MS, Feeny NC, Connell AM, Zoellner LA. Exploring evidence of a dissociative subtype in PTSD: baseline symptom structure, etiology, and treatment efficacy for those who dissociate. J Consult Clin Psychol. 2018;86(5):439–51. https://doi.org/10.1037/ ccp0000297. 12. Prasko J, Grambal A, Kasalova P, Kamardova D, Ociskova M, Holubova M, Vrbova K, Sigmundova Z, Latalova K, Slepecky M, Zatkova M. Impact of dissociation on treatment of depressive and anxiety spectrum disorders with and without personality disorders. Neuropsychiatr Dis Treat. 2016;12:2659–76. https://doi. org/10.2147/NDT.S118058. 13. Seo Y, Shin MH, Kim SG, Kim JH.  Effectiveness of lorazepam-­ assisted interviews in an adolescent with dissociative amnesia: a case report. Neural Regen Res. 2013;8(2):186–90. https://doi. org/10.3969/j.issn.1673-­5374.2013.02.012. 14. Toubia T, Khalife T.  The endogenous opioid system: role and dysfunction caused by opioid therapy. Clin Obstet References Gynecol. 2019;62(1):3–10. https://doi.org/10.1097/ GRF.0000000000000409. 1. Sierra M, Phillips ML, Ivin G, Krystal J, David AS.  A placebo-­ 15. Simeon D, Knutelska M. An open trial of naltrexone in the treatcontrolled, cross-over trial of lamotrigine in depersonalization disment of depersonalization disorder. J Clin Psychopharmacol. order. J Psychopharmacol. 2003;17(1):103–5. https://doi.org/10.11 2005 Jun;25(3):267–70. https://doi.org/10.1097/01. 77/0269881103017001712. jcp.0000162803.61700.4f. 2. Hoeboer CM, De Kleine RA, Molendijk ML, Schoorl M, Oprel 16. Stern TA, Fava M, Wilens TE.  Massachusetts General Hospital DAC, Mouthaan J, van der Does W, Van Minnen A. Impact of disComprehensive clinical psychiatry. Elsevier; 2016. sociation on the effectiveness of psychotherapy for post-traumatic 17. Sierra M, Phillips ML, Lambert MV, Senior C, David AS, Krystal stress disorder: meta-analysis. BJPsych open. 2020;6:e53. JH.  Lamotrigine in the treatment of depersonalization disorder. J 3. Brand BL, Loewenstein RJ, Spiegel D.  Dispelling myths about Clin Psychiatry. 2001;62(10):826–7. https://doi.org/10.4088/jcp. dissociative identity disorder treatment: an empirically based v62n1012b. approach. Psychiatry. 2014;77(2):169–89. https://doi.org/10.1521/ 18. Mushtaq R, Shoib S, Arif T, Shah T, Mushtaq S. First reported case psyc.2014.77.2.169. of lorazepam-assisted interview in a young Indian female present4. American Psychiatric Association. Diagnostic and statistical maning with dissociative identity disorder and improvement in sympual of mental disorders. 5th ed; 2013. https://doi.org/10.1176/appi. toms after the interview. Case Rep Psychiatry. 2014;2014:346939. books.9780890425596. https://doi.org/10.1155/2014/346939. 5. Lai CH.  Dissociative identity disorder may be relieved by the 19. Ballew L, Morgan Y, Lippmann S. Intravenous diazepam for discombined treatments of mirtazapine and risperidone: case report sociative disorder: memory lost and found. Psychosomatics. of an adolescent. J Neuropsychiatr Clin Neurosci. 2012;24(2):E34. 2003;44(4):346–7. https://doi.org/10.1176/appi.psy.44.4.346. https://doi.org/10.1176/appi.neuropsych.11040083. 20. Ganslev CA, Storebø OJ, Callesen HE, Ruddy R, Søgaard 6. International Society for the Study of trauma and dissociaU. Psychosocial interventions for conversion and dissociative disortion. Guidelines for treating dissociative identity disorder in ders in adults. Cochrane Database Syst Rev. 2020;7(7):CD005331. adults, third revision: summary version. J Trauma Dissociation. 21. Sutar R, Sahu S.  Pharmacotherapy for dissociative dis2011;12:188–212. orders: a systematic review. Elsevier; 2019. https:// 7. Gentile JP, Dillon KS, Gillig PM.  Psychotherapy and pharmacow w w. c l i n i c a l k ey. c o m / # ! / c o n t e n t / p l a y C o n t e n t / 1 -­s 2 . 0 -­ therapy for patients with dissociative identity disorder. Innov Clin S0165178119311874?scrollTo=%23hl0000945. Accessed 15 May Neurosci. 2013;10(2):22–9. 2022. 8. Gentile JP, Snyder M, Marie Gillig P. STRESS AND TRAUMA: 22. Okugawa G, Nobuhara K, Kitashiro M, Kinoshita psychotherapy and pharmacotherapy for depersonalization/ T.  Perospirone for treatment of dissociative identity disorDerealization disorder. Innov Clin Neurosci. 2014;11(7–8):37–41. der. Psychiatry Clin Neurosci. 2005;59(5):624. https://doi. 9. Pec O, Bob P, Simek J, Raboch J.  Dissociative states in borderorg/10.1111/j.1440-­1819.2005.01427.x. line personality disorder and their relationships to psychotropic

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Charmi Balsara, Steven Garcia, Skyler Coetzee, Miguel Belaunzaran, and Clara Villalba-Alvarez

Introduction The primary treatment of dissociative identity disorder (DID) is psychotherapy. While medications may help treat comorbid psychiatric conditions, they do not help treat dissociation. Treatment is vital as DID is associated with high impairments [1], high suicidal and self-injurious behavior [2, 99], treatment utilization, and treatment cost [3, 4]. Research on treatment outcomes and costs of dissociative disorders (DD) is understudied. Research on the efficacy and effectiveness of DID treatments is still in its infancy due to the challenges of conducting randomized controlled trials on DD. Most of the current research is uncontrolled case studies/case series and prospective longitudinal studies. These case studies demonstrate the positive effects of various treatment approaches including cognitive behavioral therapy (CBT), hypnosis, psychodynamic therapy, cognitive analytic therapy, and eye movement desensitization and reprocessing (EMDR) [5, 6]. A review of prospective longitudinal studies of a variety of dissociative disorders found that treatment was associated with improvement of dissociative symptoms (mean effect size Hedges g  =  0.71) as well as associated symptoms of depression, anxiety, and Axis I and Axis II disorder; the mean overall effect size was g = 0.72 at discharge and 0.66 at long-term follow up ranging from 3 months to 2 years [5, 6]. These findings are subject to methodological limitations including a lack of a control group, selection bias, small sample size, and high dropout rates. However, the preliminary findings are encouraging. Though no formal, evidence-based treatment guidelines are available for DID, there is widespread agreement among clinicians experienced in the treatment of DD that a sound foundation in individual psychodynamic psychotherapy is C. Balsara (*) · C. Villalba-Alvarez HCA Florida Aventura Hospital, Aventura, FL, USA S. Garcia · S. Coetzee · M. Belaunzaran Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA

fundamental to the successful treatment of DID patients [7– 13]. The practice-based guidelines by the International Society for the Study of Trauma and Dissociation (ISSTD) recommend treatment in three phases with the goal being integrated functioning, though not all patients can achieve this and/or see it as desirable. The main aim of treatment involves increasing coordination and communication among identities, facilitating the processing of traumatic memories, and integrating separate identities [9]. A study of 36 international experts on DD also recommends a core set of foundational treatment techniques to be used across all stages of treatment [14]. This core set targets affect modulation and impulse control, crisis stabilization, and interpersonal skill improvement. These experts also recommend grounding, containment, ego strengthening, cognitive behavior work for trauma-based cognition, and safety. Treatment with psychotherapy can be complicated and approaches can fluctuate based on the patient’s present functional status and ability. Supportive therapy such as crisis intervention and working on existing coping skills and strategies might be better suited during periods of acute stressors, frequent disassociation, and exacerbation of psychiatric comorbidities while psychodynamic therapy focusing on self-reflection and introspection might be better suited during periods of relatively mild symptoms [15].

Treatment Goals and Modalities The fundamental goal of the treatment of DID patients is integration. R.  P. Kluft defined integration as an “ongoing process of undoing all aspects of dissociative dividedness that begins long before there is any reduction in the number or distinctness of the identities, persists through their fusion, and continues at a deeper level even after the identities have blended into one” [27]. Integration occurs spontaneously. As alternative identities share memories of the traumatic past and origin stories, amnestic barriers between them tend to blur and become less separate. Sometimes, the identities

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coordinate their coming together. When neither of these methods occurs, the clinician can facilitate integration with imagery and suggestion [16]. Ultimately, DID patients ­ultimately make the choice of integration, not the clinician. However, not all patients are able to achieve this and/or see it as desirable. Alternatively, achieving a cooperative arrangement for optimal functioning among identities could also be a reasonable and/or preferred goal, though the patient can be more vulnerable to decompensation when overly stressed [9, 17]. Treatment plans should be reevaluated regularly, especially when patients are in crisis or a new development occurs. Alternate identities represent attempts to cope with stressors, and patients can feel afraid at the prospect of reducing these adaptive childhood identities. Therefore, it is important to emphasize to patients that the identities’ experiences, emotions, beliefs, and memories will not be lost during integration, that no identity will be abandoned, and that no identity can be coerced to integrate [17]). Factors that hinder integration include chronic stress, avoidance of traumatic memories, lack of finances for treatment, comorbid medical or psychiatric illness, and advanced age, among others [9]. Patients should not be viewed as failures if integration is not achieved.

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20–22]. A typical session can last from 45 min to an hour, but many clinicians find extended sessions (e.g. 75–90 min) to be beneficial at certain phases of treatment, particularly for prearranged trauma work or when circumstances require infrequent and consequently lengthy sessions [9]. Each therapy session must be adequately paced in order to prevent the patient from being overwhelmed by the matters discussed. Kluft describes his “rule of thirds” for each session: when planning on discussing painful material, the therapist should address it in the first third of the session and end it by the second third so as to debrief and restabilize the patient in the last third [16]. This may not be possible at times when painful material emerges as the session progresses, but it is important to try to leave the patient feeling safe and in a good mental state.

Inpatient Hospitalization

When patients with DID are at risk for hurting themselves or others and when traumatic and/or dissociative symptoms feel overwhelming, inpatient hospitalization is necessary. The most common reasons for hospitalizations include suicidal impulses or behavior, self-injurious behavior, violent threats, and severe anxiety and depression [11]. Reasons for hospitalization vary throughout the patient’s course of treatment. Outpatient Treatment Initially, the symptoms that lead to the diagnosis of DID, overwhelming feelings about the diagnosis, first experience Patients with DID are generally treated on an individual out- with traumatic memories, or first evidence of alternative patient basis using a psychodynamic or cognitive behavioral identities can lead to hospitalization [11]. Later, self-­ approach with adjunctive treatment using other modalities injurious behavior and suicidal attempts triggered by the (i.e. hypnosis, EMDR, family therapy, etc.), as will be dis- emergence and exploration of difficult, painful material or cussed below. Similar to other complex posttraumatic psy- inner battles between identities can lead to hospitalization chopathologies, treating DID typically requires long-term [11]. DID patients may also be admitted by their therapist psychotherapy over years with the frequency of sessions preemptively to facilitate abreactive work within a protecdepending upon the patient’s stability, functionality, treat- tive, structured hospital setting. ment goals, clinician availability, and finances [9, 16]. Most The goal of inpatient hospitalization is establishing safety, DID patients will require a minimum of one weekly session managing crises, and stabilizing the patient [9]. For this, it is while experts recommend two to three sessions weekly. important to identify factors that have destabilized the DID While once-weekly sessions are often appropriate for higher-­ patient, including major life events, interpersonal conflict, functioning patients, this would likely be insufficient for substance use, conflict among alters, etc., and develop a plan patients with unstable lives due to active symptoms [9]. It to mitigate these stressors [9, 11]. The structure and safety of should be noted that most of the rapid treatment responses the hospital provide an effective setting for the (re)learning reported in earlier studies were the result of three to four of skills and coping strategies to restore the functioning of weekly sessions [18, 19]. High-frequency sessions (i.e. three patients so that they may quickly resume outpatient treator more weekly) may be warranted for the restabilization of ment. Inpatient hospitalization can also be an opportunity for acutely decompensated patients so as to preserve their adap- not only a multidisciplinary evaluation, but also to clarify tive functioning as well as suppress self-destructive behav- diagnoses, optimize medication regimens, and treat comoriors [9]. However, such a frequency of sessions should be bid psychopathologies. time-limited to prevent over-dependence on the clinician In the past, certain severely decompensated DID patients which may result in regression or only temporary improve- could be hospitalized for weeks to months [11]. In the presment as well as decompensation and failure to progress [9, ent day, however, hospitalizations are usually brief and for

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the purpose of crisis stabilization. If resources allow, a prolonged hospitalization can be beneficial for therapeutic work. The safety and structure of inpatient treatment can allow for work on traumatic memories that might otherwise be too overwhelming, and even destabilizing, on an outpatient basis and/or approach aggressive or self-destructive alternate identities that threaten to harm the patient. Specialized inpatient units focused on trauma treatment or DID may be helpful for the evaluation and treatment of difficult cases, long-term treatment of the severely decompensated DID patient and facilitation of abreactive work that might be challenging and/or ill-equipped by a general inpatient unit [11]. These specialized programs have specially trained staff and provide services that are not available at a general inpatient psychiatric facility. With the help of specialized diagnostic assessments, intensive individual therapy, specialized group therapies, psychopharmacological interventions, and specialized trauma-focused work, patients can develop skills and learn coping strategies to be stabilized [9]. According to Kluft, patients who have a specific goal in mind benefit the most from these units [11]. It is important to keep in mind that the hospital can be a place of retraumatization for the DID patient. The restrictive inpatient setting and staff members that enforce the rules and policies of the unit can be perceived as recapitulations of past traumatic experiences and relationships and react accordingly [11]. If patients behave violently towards themselves or others, chemical restraints and seclusion may become necessary if they do not respond to verbal or behavioral de-­ escalation. Medications such as benzodiazepine and neuroleptics can be helpful to calm the agitated patient and avoid a crisis. While the use of physical restraint and seclusion is traumatizing for any patient, it can be especially retraumatizing for patients with DID and/or PTSD. Consequently, it is important to develop safety strategies in advance. Some hospitals may require patients to develop a “personal safety plan” that includes triggering factors and measures to mitigate them [9]. For DID patients, specific behavioral interventions include accessing a helper alternate identity and using imagery to “dial down” or find an inner “safe place” for aggressive identities [9].

Partial Hospitalization Program A partial hospitalization program (PHP) is helpful as a step down from inpatient hospitalization or a more intensive outpatient treatment and can help prevent rehospitalizations or teach intensive skills [9]. These specialized programs can provide optimal support and structure through daily group sessions and vocational training. Individual treatment plans may include psychotherapy, hypnotherapy,

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substance use or eating disorder counseling, and other educational programs focusing on learning self-soothing techniques, symptom-­ management skills, autonomy, and relationship/social skills [23]. During PHP, patients work directly with the treatment team coordinator to identify problematic areas such as dissociative/other symptoms, autonomy, and relationship issues; establish concrete and clear short and long-term goals with specific timeframes; and determine resources or strategies to meet those goals [23]. Patients are encouraged to actively participate in the treatment plan and take responsibility for their behavior and recovery. PHP serves as a transitional step before integrating into the community.

Group Therapy Generally, patients with DID do poorly in heterogeneous group therapy, in which individuals have mixed diagnoses and clinical problems. DID patients can be disruptive, as non-DID group members consider them to be narcissistic and malingering; conversely, DID patients can be subject to disruptions as they consider non-DID group members to be uncaring and rejecting [24]. A homogenous group specific for DID can be helpful for certain, select patients with DID. Groups should be highly structured and task-focused, aimed at psychoeducation of trauma and dissociation and development of coping techniques, social skills, and symptom management, rather than focusing on the traumatic past [9]. Group therapy can be advantageous in several ways. First, firsthand experience of seeing other members dissociate can shatter denial and lead to acceptance of the diagnosis, dispelling the feelings of uniqueness and isolation that come with having this disorder; the presence of other peers who are in various stages of acceptance also helps to facilitate progress towards treatment [25]. Group therapy also provides peer context as members share stories, providing mutual support, acceptance, and validation [25]. Finally, members learn that talking helps. Talking not only comforts oneself but also facilitates insight, revealing how alternate identities were created for psychological survival during abuse [25]. According to Coons and Bradley’s homogenous group therapy, feeling hope and universality was one of the most important therapeutic factors [24]. The downsides to group therapy are also numerous. Without the presence of members who are actively disassociating or switching personalities to speak about the benefits of integration, other members may be unable to progress [25]. A sense of fragmented identity is also perpetuated due to not only amnestic barriers among alters but also the fact that denial of various alters belonging to one person is often

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tolerated and accepted [25]. Finally, competition among members for the attention of therapists may destabilize the group. Members may compete to recount the most terrible stories, leading to retraumatization of others present, or express sadism by using trigger words, leading to distress and dissociation of others present [25]. It is important to note that group therapy should not be the primary treatment modality, but rather an adjunct to individual therapy and other treatment modalities depending on the needs of the DID patient. Group therapy can provide ongoing support and reinforce the goals of individual therapy. Nonprofessional groups that are “self-led” are contraindicated for DID patients. These unregulated groups can trigger emotional flooding and other emotional distress.

Specific Considerations Boundaries As victims of childhood trauma and abuse, DID patients have had their boundaries invaded, and consequently, have poor boundary development growing up. Throughout the course of therapy, there is potential for breaches in boundaries between the clinician and the patient. Transference and countertransference may occur and may complicate treatment progress. In order to prevent the recapitulation of childhood transgressions, the importance of clearly defining treatment frames and therapeutic relationships cannot be stressed enough. Boundary issues can arise at any point in the treatment, and it is necessary to discuss them as they occur, though experts agree that it is prudent to address these concerns at the beginning of treatment [9]. Alternate identities may try to extend or alter the parameters of the boundaries, but it is important for clinicians to maintain firm and consistent boundaries in a compassionate way. Expert consultation and/or supervision may help to address complex issues related to boundaries [26–28]. In terms of establishing a treatment frame, therapists should discuss a designated, predictable time and place with a predetermined session length, methods of payments, confidentiality and its limits, and therapist availability between sessions and during a crisis [9]. Therapists should always meet the patient in an inpatient or outpatient setting, usually face to face, never in the patient’s home. Phone contact between sessions should be available, though it is important to frame the conversation in a way so as to prevent abuse or promote dependency and regression. Ideally, conversations regarding emergencies should be had in advance and should be clear regarding therapist availability and access to other resources. In terms of establishing and maintaining a therapeutic relationship, therapists should not have personal relation-

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ships with the patient or their family members. Physical contact with a DID patient is also not recommended, though some therapists afford brief physical touch (i.e. briefly holding hand, lying hand on patient’s arm) to help patients stay grounded to reality when they are intensely reliving a disturbing experience; other therapists argue that this physical touch can be misinterpreted or cause flashbacks of traumatic memories [9]. Sexual relationships with the patient during or after the completion of treatment are never appropriate or ethical.

Therapeutic Alliance As victims of childhood abuse and trauma, DID patients also likely find it difficult to trust others and thus, find it difficult to form and maintain relationships growing up [29]. A strong therapeutic relationship is critical in positively impacting health outcomes, and so despite initial difficulties in forming an alliance, DID patients who are able to develop a strong relationship with their therapists have lower levels of dissociation, PTSD symptoms, and general distress along with greater adaptive capacities [29]. As a result, efforts must be made throughout the entire treatment process to maintain a strong therapeutic alliance. Central to the therapeutic alliance is that DID patients voluntarily participate and make active efforts in their treatment; conversely, the therapist must take a warm, active approach with a wide range of effects at a low level of intensity [26–28]. A good therapeutic alliance also allows for the therapist to confront a resistant and/or noncompliant patient. If there appears to be a good therapeutic alliance but treatment progress is poor, it may be that the DID patient, who is nurture-seeking by nature, is trying to appease the therapist and enduring the therapy to gain care and attention from the therapist, rather than considering the therapy itself to be beneficial [26–28]. Therapeutic alliance may be different among different identities, and even with a given identity, the therapeutic alliance may vary with stressors, with the influence of other identities, and with therapeutic-induced or spontaneous reconfigurations of the system of identities [26–28]. Efforts to bolster therapeutic alliance may be to ask the patient how they feel about discussing a certain topic and even ask for permission.

Dealing with Alternative Identities Therapists can take various treatment stances, including strategic internationalism, tactical integrationism, and personality-­oriented therapy, adaptationism, and minimization. While most therapies are dominated by one of these

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stances, a combination of strategic internationalism, tactical integrationism, personality-oriented therapy can lead to the complete resolution of DID psychopathology because the goal of these tactics is integration, as opposed to focus on improvement in function in adaptionalism and disregard of DID symptomatology in minimization [16]. In order to achieve integration, Kluft argues that it is important to address the alternative identities rather than disregard them, which he considers to be counterproductive and may prolong therapy [30]. He argues that eliciting the identities, rather than waiting for them to emerge, has many benefits, including understanding the system of alters via mapping; making alters stakeholders in treatment; enhancing empathetic expressions; understanding behaviors of alters as communications; allowing for negotiations with alters; resolving shame; avoiding reenactments of neglect and rejection; enlisting mature alters to help with child alters; eroding amnestic barriers; and accessing and utilizing inaccessible skills, among others [30]. It is important for the therapist to deal with each identity evenhandedly and consistently as DID is a condition related to inconsistencies of important attachment figures in childhood [26–28]. If the therapist is consistent and avoids favoritism no matter which identity is in place, then it is made clear that therapy is for the whole person, not just identities who are more cooperative [26–28].

Informed Consent Obtaining informed consent from DID patients may not be straightforward, though it is important to obtain consent according to current standards of care. Generally, consent obtained from one identity is applied to the patient as a whole. It is best to discuss such matters in a way that encourages all identities, especially the ones that identify as protectors, to listen, though this can get logistically problematic, not to mention that some identities can disagree, lie, or try to harm the patient [31]. Therefore, it is important to document clearly, and per Applebaum and Gutheil’s recommendation regarding informed consent as a process rather than a moment in time [16]. In medically complicated situations, it is recommended to obtain temporary guardianship early on [31].

Theoretical Explanations Defenses The theoretical explanations underlying psychodynamic psychotherapy for DID and other dissociative disorders may be best approached by first distinguishing dissociation itself

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from repression and splitting—related though distinct terms that, like dissociation, were originally elaborated in the psychodynamic literature. While these and other defenses typically blur into each other in practice, the distinctions made here serve to provide psychodynamic grounding for distinguishing patients with similar clinical presentations and should be considered when treating patients whose conditions are typified by these defenses.

 issociation vs. Repression D Dissociation may be broadly defined as “a disruption in the continuity of mental experience” (i.e. consciousness, memory, perception, identity, or sense of self) [188]. These disruptions vary widely in their severity and scope, ranging from minor, innocuous gaps in memory or attention (e.g. “spacing out” or “highway hypnosis”) to the severe, protracted disintegration of memory, affective regulation, and a sense of self observed in DID patients [32]. Therefore, in contrast to repression and splitting, dissociation need not always be construed as defensive [33–35]. Though dissociation has in common with repression the premise of precluding mental contents from conscious awareness (i.e. a “splitting” of the ego), they differ in how each defense processes these contents. Repression is a particular form of dissociation that has been described as occurring through a “horizontal split”, whereby specific, pre-formulated, fully encoded memories are relegated to the dynamic unconscious and should these memories return to consciousness, they are fully intact. By contrast, the dissociation typical of DID is mediated by a “vertical split” by which aspects of effectively fraught experiences, rather than specific contents, reside separately among coexisting, compartmentalized consciousnesses or self-states [34, 36, 37]. Whereas repression is a defense against remaining conscious of unpleasant or disturbing memories, Stern [38] refers to dissociation as “unformulated experience” clarifying its function as “the unconscious decision not to interpret experience, to leave it in its unformulated state for defensive reasons” (p. 31). This interpretation is consistent with evidence indicating hyperarousal mediated by glucocorticoids during traumatic experiences results in hippocampal damage (due to the high distribution of glucocorticoid receptors in the hippocampus) and consequent impairment in episodic memory [39–41]. Hippocampal dysfunction may be implicated in persistent amnesia which frequently occurs in traumatized patients of narrative elements of their trauma [42, 43]. Unlike repressed memories, dissociated experiences are not fully assimilated in the first place and are encoded only partially, often via sensorimotor processing and at times only with certain sensory modalities at the exclusion of others. Thus, dissociated experiences are highly susceptible to being elicited in contexts similar to those in which they originally occurred—often encroaching upon conscious experience by

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way of flashbacks, dissociative visual imagery, intrusive thoughts, and unpleasant bodily sensations [34, 35, 44]. In contrast, repressed memories are less likely to spontaneously resurface into consciousness, as they are typically repressed fully formulated and independently of context [34].

 issociation vs. Splitting D In common with repression, splitting may also be viewed as a form of dissociation. Originally formulating splitting as “mutually dissociated ego states” and later as “primitive dissociation or splitting”, Kernberg [45–47] describes it as a defense that isolates libidinal and aggressive object relational units (i.e. all-good and all-bad representations). Taking a more specific view, Howell [33, 48, 49] interprets splitting as a dissociative defense resulting from relational trauma, employing Ferenczi’s concept of “identification with the aggressor” to explain the oppositional self-states typical of borderline personality disorder (BPD) [34, 50]. The alternating of these dissociated self-states is similar to the state switches between alternate identities seen in DID, however in splitting this is predominantly an affective switch without amnesia, allowing for its characterization as a partial dissociation [48]. In contrast, the dissociation demonstrated by DID patients is a much broader defense, generating numerous splits affecting both memory and consciousness with the resulting self-states typically being more numerous and having more in common with each other than the polarized, contradictory self-states reflective of splitting in BPD [51, 52]. The dissociation in DID and splitting (or partial dissociation) in BPD may be further distinguished with respect to differences between splits of self and splits of objects in each case. While dissociation in DID involves complete splits in self-­states more so than splits in objects, the splitting of objects predominates in BPD, resulting in the isolation of “good” and “bad” objects which undergirds the affective switching between self-states in borderline personalities [11, 13, 53].

 he Theory of the Structural Dissociation T of the Personality Prominent in recent psychodynamic literature on trauma and dissociation are clinicians who consider the structure of the mind to be fundamentally dissociative [33–35, 38, 54–62]. A comprehensive, integrative framework called the Theory of the Structural Dissociation of the Personality is provided by Van der Hart et  al. [63] in The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. This theory offers insight into the antagonism between alternate identities in DID as well as dissociated self-states in other trauma-based psychopathologies. Drawing on the work of Charles Myers [64], who originated the terms “emotional

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personality” and “apparently normal personality”, Van der Hart et al. [63] adopt these into the “emotional part of the personality” (EP) and “apparently normal part of the personality” (ANP). This change is meant to convey that though the ANP may demonstrate greater functionality, it remains a dissociative part of the personality like the EP. The ANP must not be equated with the premorbid self-state of traumatized patients given its constricted responses compared to the patient’s pretraumatic personality and its vulnerability to interference by the EP. In the interest of accuracy and respect for the patient’s experience, the term ANP is preferable to “true” or “host” identity when describing whichever alternate identity presently commands executive functioning or may usually serve as the primary interface with the external world [34, 35, 63]. The EP and ANP each correspond to distinct sets of psychobiological action systems, which have been alternately termed “motivational systems”, “emotional operating systems”, or “action systems”. Each of these innate action systems is organized according to homeostatic demands and primary effects, complete with their own neural networks [21, 63, 65–68, 189]. The action systems corresponding to the EP and the ANP are broadly involved in defensive behavior under threat and activities of daily living, respectively. The EP is responsive to limited cues relevant to traumatic experiences, thus remaining fixated on and often reenacting the trauma. The EP may be considered “stuck in traumatime”, remaining fixed in a defensive action system that severely constricts its range of behavior to basic threat responses of fight, flight, freeze, hypervigilance, or complete submission. The ANP is typically capable of performing the functioning of daily life but is often chronically depersonalized, hypervigilant, avoidant, and constricted in terms of both its attachment to others and its relation to the EP [21, 35]. The ANP is understood to maintain what functional status the DID patient has due to its phobia of the EP and any affect, cognition, or aspect of memory related to traumatic experiences. Consequently, the ANP is prone to partial or complete amnesia of the patient’s trauma with material related to it either passively avoided or actively suppressed. These avoidant responses become automatized over time, leading to the development of chronic dissociative personality organizations, especially when patients are exposed to traumatic stress for too great a duration or too frequently. These dissociatively organized personality structures are typified by persistent dissociative self-states or continuous depersonalization as well as alexithymia, amnesia, and affective dysregulation. However, this avoidance is often disrupted by interference from the EP including somatoform symptoms, nightmares, flashbacks, intrusive thoughts, or somnambulism [21, 35, 63, 69–71].

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The constriction of the ANP and limited responses of the EP reflects the central problem faced by DID patients: not that a single person has more than one personality, but that they have less than one, only ever experiencing one dissociated self-state or another [72]. The multiplicity of EPs and ANPs a patient may have is dependent on the extent of their trauma-related dissociation which Van der Hart et  al. [63] describe using a multi-tiered model. In this model, primary dissociation consists of one EP and one ANP, represented by simple PTSD and simple somatoform disorders. In primary dissociation, we find ANPs with amnesia of varying degrees with EPs that are hypermnesic and thus re-experience and reenact the patient’s trauma. Secondary dissociation is characterized by one ANP and multiple EPs which are organized by defensive action subsystems. Thus, different EPs may be engaged in separate aspects of the patient’s trauma responses (i.e. fight/flight, freeze, submission). Secondary dissociation is thought to be present in cases of complex PTSD, BPD, complex somatoform disorders, and dissociative disorder not otherwise specified (DDNOS). DID is characterized by tertiary dissociation in which there are multiple EPs and multiple ANPs. Consequently, different ANPs may be devoted to different aspects of daily life (e.g. sociability, reproduction, attachment, work, and play) just as different EPs may engage different defensive subsystems, as in secondary dissociation [34, 35, 63, 73]. As will be discussed further, the theory of the structural dissociation of the personality finds empirical support via operationalization of the EP and the ANP in neuroimaging studies demonstrating “one brain, two selves” [74, 75].

sexual abuse specifically) should be anticipated and addressed accordingly when providing therapy of any modality to DID patients [83]. Such patients typically have difficulty establishing what roles each member of the therapeutic dyad is to play, a confusion usually reflecting the highly conflictual object relations they internalized as children put in a position to gratify the needs of abusive parents. These patients are typically distrustful of any notion that the therapist is there to help them address their needs and may try to quell their own anxiety over the matter by determining what their therapist wants of them and attempts to address the therapist’s needs rather than their own [51]. This dynamic may best be addressed with the central aim of affirming the patient’s sense of agency. Killingmo [84] recommends affirmative rather than interpretive interventions for psychopathology derivative of structural deficits, such as in DID patients, so as to first establish the validity of the patient’s experience (i.e. that he or she is entitled to feel what they are feeling). This approach serves to build a strong therapeutic alliance early upon which later interpretive work may be based. Affirmative interventions are a broad category that may encompass such strategies as “holding” and “containment” as well as any empathic, reconstructive interventions. These approaches, unlike traditional interpretive work designed to reveal meaning to the patient, aim to establish the meaning of the experience itself, forming a foundation to defend against the anxiety of loss or fragmentation of self [85–88]. In cases of severely traumatized DID patients, an initial approach with interpretive methods may be construed as an attack or provocation, with these patients often feeling invalidated and even retraumatized [51, 84].

Common Themes in DID Treatment

 evictimization, Perpetration, and Self-­ R Destructive Behavior Traumatized patients with histories of childhood abuse and incest (DID patients among them) share common patterns of revictimization and other self-destructive behaviors [89]. DID patients experience high rates of adult traumatization, including sexual assault and intimate partner violence (IPV) [90]. The internalized object relations evidenced in the abusive adult relationships of patients traumatized by childhood familial abuse are thought to be informed by histories of seeking comfort from their abusers in the absence of healthy attachment figures. These patients may at the same time unconsciously enact these traumatic object relations in adulthood as a way of actively seeking control over the trauma they felt helpless to passively endure as children [51, 91]. However, it is also important to account for how dissociative symptomatology itself may contribute to patterns of revictimization as well as perpetration in DID and other DD. In addition to the high frequency of IPV (especially emotional IPV) in DD patients, studies indicate dissociative symptoms are predictive of IPV exposure [92, 93]. There is also evi-

Through the course of treating DID patients, common themes emerge in therapy amenable to psychodynamic interpretations. This understanding may assist clinicians in making sense of their patients’ individual presentations, anticipate their needs, and provide guidance in addressing these needs effectively and responsibly. Several of these themes are par for the course with traumatized patients generally, though some are unique or especially relevant to DID patients in particular.

Confusion of Roles A causal relationship between trauma and dissociation is supported by a multitude of studies employing diverse methodologies [76–80]. These studies corroborate earlier ones that established the association between DD and early life trauma, which found documented trauma histories for as many as 95% of children and adolescents with dissociative disorders [81, 82]. Thus, the psychodynamics common in traumatized patients generally (and victims of incestuous

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dence that dissociative as well as emotional dysregulation symptoms are predictors of dissociation in the context of IPV perpetration by DD patients [93]. Similarly, dissociative symptoms have been demonstrated to partially mediate the association between childhood sexual abuse and sexual IVP [94]. With respect to IPV perpetration by DD patients, it has been suggested that dissociation may allow perpetrators to detach emotionally from their victims, this lack of empathy enabling them to inflict similar abuse as their own in childhood [95, 96]. More than 70% of DID outpatients have attempted suicide and DID patients commonly have histories of multiple suicide attempts and other self-injurious behavior [32]. Preliminary evidence indicates the association of traumatic experiences with both nonsuicidal self-injury (NSSI) and acute suicidality may be mediated in part by dissociative as well as posttraumatic symptomatology [97]. Conferring greater specificity to the matter, Franzke et al. [98] isolated dissociation as the sole mediator between childhood trauma and NSSI in 87 female patients with histories of child abuse and neglect when dissociative, depressive, and posttraumatic symptoms were accounted for. The severity of dissociative symptoms has also been demonstrated to be predictive of NSSI and suicidality in a large sample of DD patients [99]. In addition, the reasons for self-injury reported by patients enrolled in the TOP DD study fall under particular themes, including trauma-related cues, dissociative experiences, emotional dysregulation, stressors, ineffective coping as well as symptoms of comorbid psychiatric and physical conditions. However, 92.3% of these patients reported being at least partially unaware of what urges them toward self-injury [100, 101]. These findings concerning revictimization patterns and self-destructive behavior in DD may be reflective of the learned helplessness exhibited by many DID patients. Due to such poor self-efficacy to change their circumstances or cope with their symptoms, these patients may feel they have no other option than to capitulate to abuse or harm themselves under the previously mentioned conditions for self-injury [51, 101, 102]. In addition, the findings of Myrick et al. [103] suggest a relative lack of emphasis on stabilization and safety as well as underutilization of grounding and containment techniques among clinicians of DD patients. Taking into consideration their particular vulnerability to self-injury in response to trauma-related dissociative and intrusive symptoms, Nester et al. [101] recommend regularly assessing DD patients for self-injury, exploring their triggers, and educating them in grounding, containment, and distinguishing past from future.

 istorical Accuracy of Traumatic Memories H It is important in the treatment of DID patients that the clinician avoids assuming the position of, as Gabbard [51] terms

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it, the “arbiter of historical truth” with respect to judging the ultimate veracity of traumatic memories, especially when such memories are newly recalled in the course of treatment. Much of the early controversy concerning the supposed iatrogenesis of DID by naive or unscrupulous clinicians coincided with disputes over the truth or falsehood of “recovered memories” of childhood sexual abuse [16, 51, 104]. However, the reconstructive nature of memory is now widely acknowledged, as is the wide spectrum of accuracy in memories relayed in therapeutic settings, from completely false memories suggested by clinicians or fabricated by patients to consistently and clearly recalled memories with corroborating documentation [105–108]. Interpreting the accuracy of traumatic memories in patients with prominent dissociative pathology presents even greater complications, taking into account the previously discussed deficient assimilation of dissociated experiences. Due to damage of episodic memory encoding wrought by trauma, it is often apparent a patient has been traumatized well before how exactly they were traumatized is known, if ever [43, 109]. Taking all these considerations into account, it is prudent to establish before beginning trauma work with DID patients that should traumatic memories emerge, they cannot be taken for granted as historical truth [16, 51]. The processing of such material should be construed as exclusively for the sake of the patient’s recovery, not the recovery of memories per se. In addition, it may be helpful to clarify for patients that feelings they associate with recovered material and relief or improvement that may follow after it is addressed are no proof of its fidelity to actual events [16]. However, for the purposes of integration and greater functionality, any material presented by the patient as traumatic should be addressed regardless of its plausibility or historical accuracy, though giving greater priority to the most credible material may be more productive [16, 110, 111]. Ultimately, it is the work of interpreting traumatic enactments and the unconscious patterns of internalized object relations underlying them that offers DID patients the insight for positive change in their intra- and interpersonal functioning [51, 53, 112]. Though memories may arise that cohere with these unconscious patterns, their accuracy will always remain uncertain, and change in episodic declarative memory is not necessarily required for symptomatic improvement [51, 113, 114].

Separateness vs. Wholeness The most unique and uniquely challenging aspect of DID treatment may be the work requisite of the clinician in addressing the patient’s alternate identities or dissociated self-states. Abundant evidence indicates it is essential to an ultimately successful treatment that the existence of alternate identities be validated by the clinician and that their presence be taken into account at any given moment when addressing

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the patient [16, 26–28, 30]. Likewise, alternate identities should not be passively addressed as they present themselves, but proactively elicited to avoid unduly prolonging treatment and to fully account for the patient’s functional deficits, internal conflicts, and trauma. Neglecting to make this full accounting risks overlooking dangerous symptoms and behaviors (e.g. substance abuse, self-harm, suicidality, aggression, and violence) which may be associated with alternate identities that are not readily apparent to the clinician or even the patient’s previously accessed identities. Accordingly, it is in service of the patient’s safety as well as eventual integration that mapping the patient’s identity system is often employed as a means of appreciating its baseline structure on presentation and any changes to it throughout treatment [16]. Whether a DID patient can ultimately gain a model of their own identity system is often dependent on the clinician’s capacity to do so. This process typically requires mending ruptures of the therapeutic alliance that may occur throughout treatment and especially when engaging alternate identities that developed in traumatic circumstances with the patient still “not wanting to know now what was not known then” [51, 115]. Common methods for mapping include asking an alternate identity usually in command of the patient’s functioning (typically an ANP) to write its name and invite other identities to do likewise or to ask identities unwilling to be named or not yet named to indicate their presence by making a mark instead [16, 116, 117]. However, it is inadvisable to address and discuss alternate identities as if they are truly different people or to isolate one identity as the “real person”. Given the ultimate therapeutic goals of optimizing functionality and integration into a coherent personality structure, it is counterproductive to provide a premise for attributing responsibility for the patient’s actions to one or another alternate identity. Indeed, DID patients should be held accountable for all the behavior exhibited by their alternate identities in acknowledgment of the patient as the greater sum of which the identities are parts [9, 51, 118]. The technique of “talking through” is useful as a means of eliciting individual alternate identities as well as addressing the identity system as a whole and is based on the invitation of as many identities as is safe and feasible to engage in the therapeutic process [119–121]. This approach accounts for the possibility that identities which are not externally presenting themselves may still be “listening” and may thus be encouraged to take part in the patient’s treatment. Over time, a pattern develops such that the clinician may address one alternate identity or a grouping of them as well as the entire identity system simultaneously. This technique serves to validate the perception of the alternative identities as separate from each other while also undermining the dissociative barriers between them in a way conducive to their integration [16].

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The quasi-delusional investment typical of DID patients in the separateness of their identity systems often contributes to what presents clinically as a “closed system”, phobic to attachment and thus unamenable to engagement with the external world at any functional scale [19, 34]. This bears resemblance to Fairbairn’s endopsychic structure of the mind, as he described closed systems composed of internal objects (analogous to identity systems in DID) sustained in part by an individual’s fear of disintegration or fragmentation of self [35, 61]. With respect to maintaining the stability of the identity system as a means of coping and defense, the closed or partially closed identity systems of DID patients are also comparable to the “self-care system” of Kalsched [122] as well as the “third reality” described by Kluft [35, 123]. Van der Hart et al. [63] advise accessing the closed system of a DID patient by way of addressing their generalized attachment phobia and later, phobia of attachment to the clinician specifically. Attachment between clinician and patient, fully within professional bounds, is essential to gradually undermine the self-sufficiency of the patient’s closed system and thus make eventual integration of the system possible [34]. Since forming an attachment relationship with the patient also means doing so with alternate identities, Bromberg [56] conceives of the clinician as a “relational bridge” between them, allowing the attachment of different identities with the clinician to serve as a basis for attachment between the identities themselves. It is the DID patient’s internalization of these “separate” attachments with the clinician, a single, consistent point of contact with the external world, that fosters increasing communication and consistency within the identity system and possibly its integration into a coherent whole [34].

Phase Oriented Treatment Model This expert consensus finds compelling validation in the Treatment of Patients with Dissociative Disorders (TOP DD) study, the largest study of treatment outcomes in DD patients. A prospective, naturalistic paradigm was employed with a large, outpatient, international sample of DD patients treated by community therapists using a phase-oriented treatment model. The study’s initial cross-sectional findings included 98% of patients diagnosed with DID and 49% percent of participating therapists reporting a psychodynamic orientation. Patients in the last phase of treatment demonstrated lower incidence of self-injury, fewer suicide attempts, fewer hospitalizations, and greater adaptive functioning as well as decreased PTSD, dissociative, and distress symptomatology than patients in the initial phase [5, 6]. At 30-month follow­up, these findings persisted in addition to decreased physical pain, drug use, and depressive symptoms [124]. In a 6-year

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follow-up study, therapists reported their patients had fewer stressors (especially relating to conflict between alternate identities and family relationships), fewer hospitalizations, lower incidence of sexual revictimization, and global improvements in functioning with no assessed outcome worsening over the course of the study [125]. While the phase-oriented treatment model of DID and the variants which it encompasses provide general therapeutic guidelines, it must be adapted to individual cases. Consistent with the original phase-oriented treatment for posttraumatic stress in DD patients pioneered by Pierre Janet, current guidelines do not provide any definite, predetermined course for implementation of each phase of treatment [9, 126]. However, generally, the phase-oriented treatment approach is composed of three phases that have overlapping and distinct features. Collectively, the goal of these phases is to increase awareness, communication, and integration of the different identities [9].

Phase I Phase I of the phase-oriented treatment focuses on establishing safety, stabilization, and symptom reduction. Common safety problems include self-harm behavior such as suicide attempts/impulses and self-destructive behavior, danger to others including minor children or vulnerable adults, risky behaviors, substance abuse, eating disorders, continuing embroilment in abusive or traumatizing relationships, homelessness, and lack of access to and/or avoidance of medical care [127]. Consequently, it is important for the therapist to educate patients on the importance of safety, assess current functionality, develop a reserve of positive behaviors should unsafe urges emerge, identify destructive alternative identities, employ symptom management techniques (i.e. grounding, self-hypnosis, crisis planning, and medications), and refer to appropriate resources (i.e. substance use and eating disorder programs, domestic violence support, and child or adult protective services) [9]. If a more emergent level of care is needed, then hospitalization may be required. Concurrently, the therapist creates a safe and empathic atmosphere as the foundation for the therapeutic alliance; teaches skills (i.e. strengthening emotional awareness and emotional regulation, building tolerance to stressful events, and improving relationships) to manage dissociative, posttraumatic, and affective symptomology; and develops a sense of internal cooperation and awareness among the alternative identities by considering the needs and wishes of each identity in decision-making and progressively accepting forgotten traumatic memories and feelings of each identity. Safety is a major concern that must be addressed before processing traumatic memories in Phase II and must be continually assessed throughout the duration of therapy.

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However, it is important to consider that patients with DID vary in treatment responses, and some patients may stay in Phase I for a very long time or even may be unable to move past the first phase. These patients may improve with regard to their safety and functioning but may be unable to process their traumatic past.

Phase II While not all patients may be appropriate or even have the desire to progress to the next phase, Phase 2 focuses on confronting, working through, and integrating traumatic memories [9]. This involves exploring the alternative identities and traumatic past in depth. As the patient recalls difficult memories, the therapist learns about the origins of each identity, their relation to each other, and their concerns, allowing for a better understanding of the system of alternative identities and their response to specific issues or stressors [16]. The therapist helps the patients to process and progressively tolerate traumatic past events. Through this process, patients may experience a phenomenon known as abreaction, which involves “the release of strong emotions in connection with an experience or perception” [9]. Simultaneous abreactions of multiple identities can occur if the identities share overlapping trauma. Abreaction has been shown to help symptomatology, though its use for only emotional discharge of trauma may be retraumatizing; consequently, current approaches aim to additionally involve making cognitive changes with abreactive work [9]. This involves “working through” traumatic memories by using techniques such as cognitive reframing and countering irrational guilt and shame, among others to help patients understand their adaptive responses that occurred during the traumatic event. Repeated exploration and exposure to dissociated traumatic memories slowly integrate them to form more cohesive “narrative memories”. Gradually, the patient can recall traumatic memories from various identities, a term called “synthesis”. “Fusions” can also occur, either spontaneously or aided by the therapist, as the identities become more cohesive. It is important for the patient to reflect on the significant impact that the traumatic past had on their lives, realize that this past indeed is the past, and develop a more complete and cohesive autography and sense of self [9]. Logistically, it is crucial that traumatic memories be planned, carefully scheduled, and appropriately paced. The therapist and patient must agree on which traumatic memories to focus on, how they will be addressed, and at what intensity the memory will be processed. Additionally, they must discuss safety measures, specifically when working through these memories and when the memories become too intense. Fractionating the amount of traumatic processing and pacing can help to make this stage more tolerable for the

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patient. However, patients should be educated on the possibility of worsening symptoms due to exposure to traumatic memories but also on the benefit of processing and integrating the memories. During this phase, patients are susceptible to destabilization and focus may be shifted back towards Phase I.

Phase III The final phase involves integration and rehabilitation. It involves the continual processing of traumatic material but with more internal cooperation and communication among alternative identities, leading to integration or resolution [9]. As patients become more unified and develop a cohesive sense of self, they become calmer, improve resiliency to be able to deal with current problems, and focus on living in the present rather than the past. This phase also continues to postunification, in which the patient learns to function in the world without dissociative coping [127]. Patients may need help with issues concerning everyday life, such as handling daily stress, dealing with disappointments, and managing relationships. With time, patients may achieve their full potential in functionality.

Therapeutic Interventions Trauma-Focused Psychotherapy Histories of severe physical and sexual abuse among DID patients are pervasive and well documented in this population, including abuse during infancy [81, 82, 95, 128–132, 190]. Accordingly, the accessing and processing of traumatic material are among the most important concerns in treating DID, often requiring a wide range of clinical interventions (e.g. hypnosis, EMDR, ego state therapy, and sensorimotor therapy) to be done productively and in a manner minimally disruptive to the patient [16, 116, 117, 133–146, 191]. In contrast to claims that trauma-focused psychotherapy is harmful to DID patients, this modality is consistent with current treatment guidelines and empirical evidence supports its association with global improvement in dissociative symptoms and functioning as well as fewer hospitalizations and lower treatment costs [9, 147, 148]. Many considerations need to be taken in preparing a DID patient for trauma work, including which memories will be accessed and how intensively they will be processed during a given session, in addition to which interventions the clinician may use to facilitate this process, ensure safety, and contain overwhelming memories. The patient should also be informed of the risk of decompensation as well as the potential benefits of successfully processing

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their trauma [9]. In addition, instructing patients in titration techniques is useful in enabling them to self-regulate the extent of traumatic material that emerges at a given time [9, 21, 63, 117, 147, 148]. There is a common consensus that relentless focus on the DID patient’s trauma, even at such time in phase-oriented treatment when trauma work is indicated, can be counterproductive to their stability and treatment progression [16]. Gabbard [51] insists that simple abreaction (i.e. the exhaustive discharge of emotion) associated with the DID patient’s trauma is not conducive to symptomatic recovery or integration. Abreaction for its own sake and frequently recapitulating traumatic material may only serve to retraumatize patients or reinforce their fixation on traumatic experiences and is therefore contraindicated [9, 89] Alternatively, through judiciously paced iterations of re-accessing and re-­ associating, previously dissociated components of traumatic memories may be integrated into more coherent, intelligible form, giving rise to the conversion of this material into narrative memory [9, 149]. The clinician should be prepared to engage with alternate identities that demonstrate recall of traumatic memories that other identities are either unaware of or do not recognize as their own. The term synthesis has been used to describe the process of facilitating the sharing of these traumatic memories to progressively greater proportions of a DID patient’s identity system [63, 150]. However, once full synthesis or coherent awareness of the trauma across the patient’s identity system is achieved, it must be followed by realization or acceptance of the trauma and its consequences in the absence of dissociative defenses. This involves assisting the patient in gaining a mature, adaptive understanding of traumatic experiences with respect to their role and the role others played in those events as well as an autobiographical memory common to the identity system as a whole [21]. The grief, shame, or guilt patients may experience in the course of reckoning with irrevocable or current consequences of their trauma will require significant supportive care [9]. Due to the risk of decompensation and its consequences for the DID patient’s safety and functioning, clinicians are obligated to assist patients in reorienting themselves to present reality before the end of any session involving trauma work [9, 16]. To this end, the “rule of thirds” proposed by Kluft [28] provides a convenient guideline by which to pace a session involving traumatic material. However, DID patients may decompensate despite the clinician’s best efforts, which will require tending to issues of previous treatment phases, such as safety and symptom management as well as containment [9]. Whether a DID patient is ultimately a candidate for full integration (i.e. whether integration is a realistic therapeutic goal) will depend predominantly on the patient’s capacity for processing traumatic material [16]. Only a minority of DID patients achieve full integration, thus

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care must be taken in determining whether treatment should proceed with that aim or if a patient would benefit more from supportive treatment [14, 16]. For those DID patients who are not candidates for definitive treatment, significant ­therapeutic achievements are still feasible, such as greater distress tolerance, maintenance or improvement in functional status, as well as more adaptive communication and collaboration between alternate identities [151, 152].

Cognitive Behavioral Therapy In CBT, dissociation is a strategy to avoid or cope with trauma and therapy aims to challenge these maintaining, maladaptive factors. This is done by addressing avoiding behaviors, including depersonalization, somatization, amnesia, and identity fragmentation, and not reinforcing dissociative beliefs or behaviors by using trauma-focused therapy [153]. The hope is that by addressing and treating the trauma, dissociative symptoms lose their function, are no longer needed, and decrease [153]. CBT can also be used to address self-harm behaviors which can serve multiple functions including inflicting self-punishment, reexperiencing physical trauma, and inducing/halting dissociation. Once the underlying motivation behind self-injurious behavior is attained, they can be addressed by optimizing tolerance of emotions and self-regard that discourage self-harm and instill more adaptive coping behaviors as an alternative [154]. Fine [155] describes CBT protocols for DD.  Common techniques to address dissociation or dissociative reactions include techniques such as trigger avoidance, grounding, distraction, refocusing, graded exposure, problem-solving, and restructuring of distorted, dichotomous, and catastrophic cognitions are used. Techniques employed to help the patient process traumatic memories include exposure, image reconstruction, and storyline alteration.

Hypnosis The use of hypnosis as an adjunctive therapy for DID patients is supported by substantial literature detailing its broad applications at every phase of treatment [9, 120, 121, 133– 136, 146, 156–162]. Given the high hypnotizability of DID patients compared to other clinical populations, they are more likely to garner therapeutic benefits from hypnosis including the use of autohypnotic techniques (i.e. DID patients hypnotizing themselves) to be employed both in and out of the therapeutic frame [9, 163, 164]. In the initial phase of treatment, patients may use autohypnosis to promote relaxation, develop coping skills, practice grounding in the present, and accrue greater psychological resources in prepa-

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ration for trauma work [9, 21, 120, 136, 157, 159]. Autohypnosis may be employed subsequently to contain traumatic material within tolerable bounds as well as facilitate more adaptive communication between alternate identities [9]. Such communication may serve many aims, such as engaging alternate identities that do not readily present themselves to invite them into the therapeutic process as well as reconfiguring a patient’s identity system in order to not overwhelm any one identity with traumatic material or the management of daily life [9, 35]. Within the therapeutic setting, hypnosis has demonstrated clinical efficacy in the treatment of posttraumatic symptoms and as adjunctive therapy in the successful treatment of DID [9, 18, 19, 28, 156, 157]. Numerous hypnotherapeutic methods, alternatively called “fractionating”, “temporizing” or “titrating” techniques, may be useful in the processing of traumatic material by allowing a gradual exposure to disparate elements of traumatic memories while keeping the patient grounded in the present. These techniques are meant to build tolerance over time for appreciating more coherent and intense iterations of traumatic memories in a similar manner to systematic desensitization, as opposed to abreactive models of trauma work more aligned with flooding or implosion [16, 21, 116, 117, 120, 136, 137, 157, 159]. Hypnotic regression techniques may be used judiciously for the recollection of traumatic memories, though this practice has invited considerable controversy due to concerns of retrieving confabulated, “false memories” or distortions of memory by fantasy [9, 16, 123, 157, 165–167]. However, these complications are more likely the result of misleading cues and other inappropriate suggestions than an inherent capacity of hypnosis to distort memories [9, 168, 169]. Thus, rigorous use of hypnosis in DID treatment requires clinicians to be adequately trained in the modality and in its use with this patient population as well as minimizing suggestive interventions (e.g. leading questions and dropping hints) that may unduly influence the patient’s recalled material [9, 157]. In line with our previous discussion on the historical accuracy of traumatic memories, patients may feel undue confidence in the fidelity of memories recovered during hypnosis and should be reminded to regard the accuracy of any such material as tentative and warranting deeper exploration, just as specific informed consent should be obtained in anticipation of this issue [9, 156, 157].

 ye Movement and Desensitization E Reprocessing EMDR began as a treatment of PTSD, and its utility in trauma work has expanded to encompass a wide range of psychopathology, including DD [170]. The eight-step protocol, originally conceived by Dr. Shapiro, includes history

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taking, client preparation, assessment, desensitization, installation, body scan, closure, and reevaluation of treatment effect. The standard protocol involves the patient focusing on a traumatic memory while a stimulus (e.g. the therapist’s hand) induces eye movements with the goal of transforming the memory into a less disturbing one. [171]. A similar protocol is employed for DID.  Briefly, the patient identifies an image or scene from a distressing memory as well as a negative self-belief associated with that memory (negative cognition) and an alternative positive belief that the patient would like to believe (positive cognition). The patient rates subjective units of distress (SUD) of the negative cognition and validity of positive cognition (VoC) before and after eye movement sets and the session is concluded typically once the SUDs/VoCs are sufficiently reduced. The session is concluded with the traumatic image paired again with a positive cognition and another eye movement set is performed to solidify the connection. If the trauma is not completely processed, grounding techniques can be employed. Patients are informed that even after the session concludes, they may continue to experience trauma processing and that they should make note of any reemergence of trauma that occurs in the interval, such as in dreams or thoughts. [138]. Through bilateral, alternating hemispheric stimulation, EMDR aims to reduce the intensity of traumatic memories [172, 173], which allows the patient to metabolize and integrate them through abreaction [172]. As a therapeutic technique, it is both effective and efficient. Its comparatively rapid results could be attributed to engaging in multiple stages (van der Hart’s stages of synthesis, realization, and integration) of trauma work concomitantly as well as efficiently processing information gained from alternating attention [138]. It is also more authentic and patient-structured, with less potentially suggestive input by the therapist. EMDR can be used in conjunction with other psychotherapeutic techniques. Fine and Berkowitz describe the Wreathing Protocol, which combines EMDR with hypnosis for treatment [172]. Wade and Wade describe an integrative psychotherapy approach, which combines EMDR, hypnosis, with ego state therapy in a psychosocial developmental context [174]. Therapists are advised to approach this therapy with caution [16, 138, 172]. Patients with DID often have affective instability, and precipitous initiation of treatment can overload the patient with trauma. This may unintentionally reinforce the perception that traumatic memories are too challenging to manage and lead to “regression, decompensation, uncontrolled affect bridges, and relapse of post-­ traumatic symptoms” [172]. Therefore, it is important that the therapist be knowledgeable of EMDR protocol and initiate this therapy only after assessing the patient’s readiness. Before initiating EMDR, therapists must also ensure that the patient is generally stable, has adequate coping skills, and

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has enough cooperation among internal identities [9, 138]. Another method to make EMDR processing more manageable is fractionated trauma work to isolate the target memory as well as serial desensitization to process different elements of a memory held by separate identities [9]. These modifications were incorporated in the original protocol for DID patients so as to not overwhelm and make it more tolerable [63, 175–180]. These precautions necessitate multiple EMDR sessions and sometimes longer sessions to help patients recoup and integrate traumatic material for restabilization [9]. If EMDR sessions prove to be too intense, it is best to stop and go back to talk therapy to discuss the emerging difficulties [138].

Dialectical Behavioral Therapy About 30% to 70% of patients with DID are diagnosed with BPD [9]. BPD and DID have several overlapping features in their presentation and risk factors, including a history of childhood trauma, an inclination towards self-harm and suicidal actions, difficulty with regulating emotions, and dissociation [181]. The current consensus on the treatment of BPD is through dialectical behavioral therapy (DBT). Both BPD and DID have similarities in their treatment as conditions are treated through several stages, with a focus on patient stabilization, safety, and increased functionality. Stage one of DBT aims to reduce suicidal actions and self-harm and to establish safety, followed by Stage Two which aims to improve functionality and quality of life while addressing trauma. Foote and colleagues adapt Stage One of DBT for the treatment of DID [181]. This adaptation relies on three treatment principles. The first principle is to stabilize symptoms of behavioral dysregulation (e.g. suicidality and impulsivity) before addressing traumatic material. The second principle aims to target behaviors that affect therapy, functionality, and quality of life in stage one. These behaviors include impulsive actions, self-harm, and opposing motivations between personality states, and others. The third principle of DBT adaption for DID states that “switching” is not assumed to be maladaptive. Rather, it can serve numerous functions and should be assessed with behavioral analysis. Switching indicates the substitution of personalities. From the standpoint of DBT, switching between personalities should only be addressed if it leads to maladaptive behavior, a distinction which indicates that switching itself is not to be addressed [181]. Though research is limited in using DBT for DID, Ross and colleagues propose a prospective randomized clinical trial to establish the effectiveness of the Trauma Model Therapy and DBT on DID and BPD [182]. They point out that the strength of evidence of DBT for the treatment of BPD is greater than Trauma Model Therapy for

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DID.  Although many patients with one disorder are often comorbid with the other, Ross and colleagues propose creating three subject groups and two treatment conditions. The subject groups would include patients with DID but without BPD, patients with BPD and without DID, and patients with both. Treatment conditions would be DBT or trauma model therapy. This would provide more accurate answers to the doubts surrounding the treatment of DID and BPD.

memories in a “top-down” approach, sensorimotor psychotherapy focuses on addressing the implicit, somatic, and autonomic components of trauma from a “bottom-up” direction [9, 139]. Patients frequently “re-experience autonomic dysregulation, dissociative defenses associated with hyperand hypo arousal states, intrusive sensory experiences, and involuntary movement” while narrating their traumatic experience which can perpetuate the trauma [139]. Sensorimotor therapy aims to transform these physical experiences using mindfulness techniques to increase awareness of sensory, Ego State Therapy perceptual, autonomic, motor, and cognitive experiences and to develop a reorganized sense of self somatically [139]. In personality development, one goes through processes of Patients are prompted to perform a soothing or reorientation integration and differentiation, both of which are normal and exercise (i.e. taking a deep breath, adjusting the spine, reoriadaptive; it allows one to understand one set of behaviors as enting perceptually and physically to the environment) to appropriate in one setting while inappropriate in another focus on the present while acknowledging their traumatic [183]. Differentiation results in ego states, which Watkins past [9, 139]. As patients make these changes, patients learn and Watkins define as “an organized system of behavior and to separate somatic sensations from emotions and regain the experience whose elements are bound together by some ability to regulate dysregulated body states that lead to discommon principle but is separated from other such states by sociation [9]. Sensorimotor intervention also allows for the boundaries that are more or less permeable [142, 183]. When full expression and mobilization of defensive actions that differentiation becomes extreme and maladaptive, disasso- were truncated in the setting of trauma and allows the patient ciation results. While ego states and alternative identities are to witness this transformation. When mobilizing defenses sometimes used interchangeably, Watkins and Watkins dif- are activated in the place of immobilizing defenses, the ferentiate this concept because alternative identities consider patient no longer feels helpless, but rather capable of adethemselves to have their own identities, characteristic self-­ quately defending themselves [139]. representation, and autobiographical memories [142]. Ego Sensorimotor psychotherapy recognizes that in DID, each states do not become apparent for communication and treat- identity may have distinct physical characteristics that can ment without hypnosis, except in the case of DID. reveal qualities of the trauma itself. Changes in sensory, perEgo state therapy is a psychodynamic technique that uses ceptual, autonomic, and motor qualities may even be early group and family therapy techniques to resolve conflict indicators of identity-switching. By promoting increased between different ego states that make up a “family of self” awareness of the “witnessing self,” and promoting its return, within a single individual [183]. It works to reduce the rigid- sensorimotor therapy can enhance the patient’s ability to ity of these boundaries by reducing conflicts, internally sense these changes with the ultimate aim of controlling meeting the needs, and promoting mutual understanding switching. [9]. through communication of different ego states or alternative The International Society for the Study of Trauma and identities [183]. Because alternative identities fight amongst Dissociation recommends that clinicians be proficient in themselves, like whole people, in not challenging the distinc- phase-oriented treatment before employing sensorimotor tive identities but rather increasing communication, ego state therapy in their practice. The phase-oriented stages for treattherapy encourages integration. Any behavioral, abreactive, ment can be applied to sensorimotor therapy. In Phase 1, or analytic techniques may be used to achieve this end, usu- patients are taught somatic skills towards improving stabilally under hypnosis [183]. As conflicts are resolved and ity; in Phase 2, patients maintain their stability while begininternal needs are met, the internal family of alternate identi- ning to integrate their trauma; and finally, in Phase 3, patients ties is happy and the whole person is well-adjusted [183]. are taught behaviors that allow continued integration of their trauma and living a well-adjusted life [9].

Sensorimotor Therapy Many patients affected by trauma experience an effective reversal of the normal organizational pattern in which the intensity of their sensory and emotional hyperarousal effectively overrides their higher-order cortical control over behavior and cognition [139]. While other psychotherapeutic modalities focus on explicit, verbally accessible traumatic

Family Therapy Family therapy addresses the patient, the family system as a whole, and the relatives within the family system as individuals. There are several components of family therapy recommended by Dr. Mary Beth Williams. First, therapists must gain a comprehensive understanding of the family system

36  Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder

dynamics as well as the mental health issues and characteristics of the patients’ partners or family members to determine the appropriate level of involvement in therapy [184]. Therapists play a major role in the psychoeducation of the family regarding the DID diagnosis, trauma history, and alternative identities. Therapists can train partners to cope with identities, set boundaries for hostile or aggressive identities, develop strategies to intervene in switching, and de-­ escalate conflict. Partners can additionally help to identify alternative identities and recognize switching and triggers. Involving patients’ loved ones proves to be valuable as family members can help prevent self-injurious and suicidal behavior in the DID patient using grounding techniques, safety contracts, and crisis management skills. Intimacy training within the relationship is also important. Therapy must also simultaneously allow for the needs of partners and children to be met. Treatment of DID is demanding and the family may not be prepared to deal with the emotions it can provoke, including confusion, helplessness, anger, pain, and fear. Partners are individuals, and they may also have complex histories that include abuse, trauma, or substance use. It is important to address these emotions and factors, emphasize self-care, and reinforce autonomy; ultimately, family members identify their own limits to involvement in caring for their loved one with DID [184]. Children may adopt trauma and dissociative reactions from the DID parent, and thus attention should be paid to them as well [184]. Social-skills training in problem-solving, communication, conflict resolution, and empathy as well as appropriate familial system coping strategies, can bring the patient and their family together towards the common therapeutic goal. A focus on hope is emphasized by Williams as necessary for the patient and their family [184]. Kluft discusses the disadvantages and advantages of family therapy. Therapists must be cognizant of possible sources of abuse within the family and confrontation may be disruptive to the family dynamic [16]. Further, he warns that the stability of the family support system may be at risk if accusations of abuse are made and later found to be inaccurate [16]. However, if conducted appropriately, family therapy can benefit both the patient and their family system.

Electroconvulsive Therapy ECT use has been documented in the use of DID patients with comorbid MDD [185–187], but it is not effective in the treatment of DID [9]. Kluft [19] reported that the successful treatment of depression did not treat disassociation and vice versa. Some practitioners express concerns about worsening DID symptomatology, specifically cognitive deficits after ECT in an already vulnerable, fragmented patient. A more recent case report, however, demonstrates ECT to play a part

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in the integration of a DID patient with MDD [187]. After receiving weekly ECT for 2 years with concurrent psychotherapy and psychopharmacological treatment, the patient’s depression, psychosis, and suicidal ideations improved which the authors believe allowed the patient to process her traumatic past without resorting to self-destructive coping mechanisms and render the protective properties of the alters unnecessary, allowing for integration [187]. Additional research is clearly indicated for the role of ECT in DID.

Conclusion While psychopharmacology may help with comorbid psychiatric conditions, individual psychotherapy remains the cornerstone of the treatment of DID along with adjunctive use of other psychotherapies as needed. Using a psychodynamic phase-oriented a treatment approach that is carefully paced and matched to the patient’s needs and capacity, improvement in DID symptomatology is possible over time. Given the dysfunction, severity, chronicity, and costs associated with DID, treatment that is consistent with expert treatment guidelines in ISSTD and future research is strongly indicated for DID.

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36  Psychotherapy and Non-Pharmacologic Treatment of Dissociative Identity Disorder 148. Brand BL, Loewenstein RJ, Lanius RA. Chapter 24, Dissociative identity disorder. In: Gabbard’s treatment of psychiatric disorders. 5th ed. Washington, DC: American Psychiatric Press; 2014b. p. 439–58. 149. Van der Hart O, Brown P. Abreaction re-evaluated. Dissociation. 1992;5(3):127–40. 150. Van der Hart O, Steele K, Boon S, Brown P.  The treatment of traumatic memories: synthesis, realization, and integration. Dissociation. 1993;6(2/3):162–80. 151. Boon S. The treatment of traumatic memories in DID: indications and contraindications. Dissociation. 1997;10(2):65–79. 152. Van der Hart O, Boon S.  Treatment strategies for complex dissociative disorders: two Dutch case examples. Dissociation. 1997;10(3):157–65. 153. van Minnen A, Tibben M.  A brief cognitive-behavioural treatment approach for PTSD and dissociative identity disorder, a case report. J Behav Ther Exp Psychiatry. 2021;72:101655. 154. Kennerley H. Cognitive therapy of dissociative symptoms associated with trauma. Br J Clin Psychol. 1996;35(3):325–40. 155. Fine CG.  Multiple personality disorder. In: Comprehensive casebook of cognitive therapy. Boston, MA: Springer; 1992. p. 347–60. 156. Cardeña E, Maldonado J, van der Hart O, Spiegel D. Chapter 17, Hypnosis. In: Effective treatments for PTSD: Practical guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press; 2009. p. 427–57. 157. Kluft RP. Applications of hypnotic interventions. J Eur Soc Hypn. 1994;21:205–23. 158. Kluft RP. Hypnotherapeutic crisis intervention with multiple personality. Am J Clin Hypn. 1983;26(2):73–83. 159. Kluft RP.  Playing for time: temporizing techniques in the treatment of multiple personality disorder. Am J Clin Hypn. 1989;32(2):90–8. 160. Kluft RP.  The use of hypnosis with dissociative disorders. Psychiatr Med. 1992;10(4):31–46. 161. Phillips M, Frederick C.  Healing the divided self: clinical and Ericksonian hypnotherapy for post-traumatic and dissociative conditions. W. W. Norton & Co; 1995. 162. Ross CA, Norton GR. Effects of hypnosis on the features of multiple personality disorder. Am J Clin Hypn. 1989;32(2):99–106. 163. Bliss EL.  Multiple personality, allied disorders, and hypnosis. New York: Oxford University Press; 1986. 164. Frischholz EJ, Lipman LS, Braun BG, Sachs RG. Psychopathology, hypnotizability, and dissociation. Am J Psychiatry. 1992;149(11):1521–5. 165. Brown D, Frischholz EJ, Scheflin AW.  Iatrogenic dissociative identity disorder—an evaluation of the scientific evidence. J Psychiatry & Law. 1999;27(3–4):549–637. 166. Kluft RP. The confirmation and disconfirmation of memories of abuse in DID patients: a naturalistic clinical study. Dissociation. 1995;8(4):253–8. 167. Maldonado JR, Spiegel D.  Trauma, dissociation, and hypnotizability. In: Trauma, memory and dissociation; 1998. p. 57–106. 168. McConkey KM. Chapter 15, The effects of hypnotic procedures on remembering: The experimental findings and their implications for forensic hypnosis. In: Contemporary hypnosis research. New York: Guilford Press; 1992. p. 405–26. 169. Scoboria A, Mazzoni G, Kirsch I. Effects of misleading questions and hypnotic memory suggestion on memory reports: a signal-­ detection analysis. Int J Clin Exp Hypn. 2006;54(3):340–59. 170. van der Hart O, Groenendijk M, Gonzalez A, Mosquera D, Solomon R. Dissociation of the personality and EMDR therapy in complex trauma-related disorders: applications in the stabilization phase. J EMDR Pract Res. 2013;7(2):81–94. 171. Shapiro F.  Eye movement desensitization and reprocessing (EMDR): evaluation of controlled PTSD research. J Behav Ther Exp Psychiatry. 1996;27(3):209–18.

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Dissociative Identity Disorder and the Law

37

Vikram Kumar and Krithika Krishnamurthy

Introduction In this chapter, we begin to provide an overview of American Jurisprudence as it applies to psychiatry and in the context of dissociative identity disorder. We will then delve into the legal statutes and the link between DID and crime. Dissociation and its association with Forensic aspects of DID will be covered. From there, the writer will attempt to provide an approach to DID by a forensic expert in this chapter. We will then cover essential topics relevant to DID, such as duty to warn, competency, insanity plea, ritual abuse, and mind control. DID and its association with malingering will be explored. Of course, no chapter on the Law is complete without portraying some of the famous “likes, hearts and millions of views” grabbing cases.

 n Overview of the Law as It Applies A to Psychiatry Throughout history, severe forms of punishment have been dealt to people without due legal process, including lynching, murder, and even extending to mass genocide. However, we have only begun to develop sound processes to understand the Criminal Mind during the last century. Albeit mournfully, even Freud had commented to his secretary about the terrible treatment of mentally ill offenders [1]. Santa Barbara Superior Court Judge Atwell Westwick wrote an article in 1940 essaying the value of forensic psychoanalysis in a study of criminality. As is the case with myriad other scenarios, there is an overarching need for Psychiatry and

V. Kumar (*) Forensic Psychiatry Fellowship, SUNY Upstate Medical University, Syracuse, NY, USA K. Krishnamurthy Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA

Psychiatrists in the American Justice System, be it Civil or Criminal proceedings [2]. The Forensic Psychiatrist’s core tenets are determining the mental capacity, including fitness to stand trial, and most importantly, the need for continued psychiatric treatment. The onus is on the Forensic Psychiatrist to have a reasonable degree of familiarization with the Justice System, as it aids mental health professionals in ensuring that no principles are overlooked. Traditionally, Forensic Psychiatrists are not bound, in many and most situations, to a Doctor-Patient relationship and confidentiality, which makes this field of psychiatry unique. The primary sources of Law as illustrated in Fig.  37.1 include Regulations, Case Laws, and Statutes, and we will aim to appraise each reader in this book briefly [2]. Understanding basic state mental health laws is essential for any clinical psychiatrist. A psychiatrist would highly likely be called, during their career, to testify as a witness. Two broad categories of witnesses exist in the American Justice System: Expert and Fact. Expert witnesses have a wider breadth of testification, which raises concerns in the judicial system of being given too much power and skewing the accurate adjudicatory process. These testimonies may be well beyond the adjudicator’s knowledge but are vital for the assessment of facts [2]. However, the necessity of mental health professionals in the legal system cannot be overstated. Based on the facts presented during the trial, the expert witness can provide their analysis and conclusions and introduce different facts pertinent to the case. A Fact witness would testify regarding things they have perceived with their five senses. These observations may include, for example, a psychiatrist treating a patient who committed a crime and providing valuable information regarding the patient’s mental state during treatment [2]. Therefore, the legal system needs and cannot function without mental health professionals and Forensic psychiatrists. The concept of “Dissociation,” including dissociative amnesia and dissociative states, involves separating psycho-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_37

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234 Fig. 37.1  Primary sources of Law that help aid the Forensic Psychiatrist

V. Kumar and K. Krishnamurthy

Regulations

Case Laws

Statutes

logical processes such as consciousness, perception, identity, and memory, which are all integrated [3]. Dissociative episodes can further be characterized as negative or positive. [4]. These states have been linked to violent crimes, with the extent of dissociation and level of violence showing direct proportionality. Such dissociative episodes usually involve a lack of premeditation and planning and have been linked to states of heightened emotions, substance use such as alcohol, and severe abuse in the past. [4]. Known previously as “multiple personality disorder,” which was later renamed “dissociative identity disorder” in the DSM V (2013), this disorder is characterized by distinct personality states and recurrent gaps in daily events [5]. It is a rare disorder of considerable controversy which is challenging to diagnose. Many clinicians still believe that such “states” or “alters” are iatrogenic and that they are also seen in highly suggestible patients as an artifact of psychotherapy, for example, in the case of Sybil (Nathan, 2011) [5]. Most mental health professionals would have entire careers having never seen or diagnosed a single case. Childhood memories become less clear as we age and undergo constant modifications and reconfigurations based on our current environment. Memory researchers have often described them as fallible and can be suggested or altered. Therefore, most legitimate studies in the forensic field and DID are usually on whether it is a real psychiatric disorder or not [5]. As we go deeper into this chapter, we will define DID’s scope and extent in Law and the role of the forensic psychiatrist in assisting the judicial system. Insanity pleas based on a DID defense have played a role in numerous cases (State v Jones 1998, State V Green 1998) but have largely been rejected [5]. Orne et al. even described the case of a murderer who admitted to malingering DID symptoms [5]. These pleas rarely work as they are near impossible to prove, having happened at one moment, unlike the chronic course of most other psychiatric illnesses. Furthermore, the dissociative states themselves are also easy to fabricate. Finally, the accused is left with no alternate defense [5].

Often set by legislative bodies appointed by Governors, regulations are a guide to matters which are technical and not otherwise easily understood. Case Laws are decisions that arise from the higher courts based on appeals from lower courts. They focus on the legal standards of practice. Laws written and passed by Legislatures of states and U.S. Congress. Statutes provide guidance on a wide variety of legal issues.

To summarize, dissociative identity disorder is a complex, difficult-to-diagnose mental health disorder involving distinct personality states and a total disruption of identity. These states are ascribed to possession in various religious contexts. In a court of Law, DID has proven challenging on many levels. It has predominantly been rejected as a solid defense. This chapter will attempt to bridge the concepts of dissociative identity disorder and the Law while shedding some light on the most famous court rulings in which DID has played a vital role.

Discussion  issociative Identity Disorder and Legal D Statues: What the Law Says At its core, dissociative identity disorder involves the presence of distinct personalities colloquially termed “alters” [5]. These personalities may range from two to hundreds [6]. This disorder almost always involves a history of abuse, neglect, or trauma stemming from childhood. These personalities are theorized as an escape from their harsh realities.

Discussion Emerging during the nineteenth century, the early conceptualization of this disorder involved associations with sleepwalking, also known as somnambulism. “Double consciousness” or “dédoublement” was the initial term used almost as a precursor to MPD or DID, which was thought to be associated with forms of Epilepsy [7, 8]. Only close to three decades ago did we see the emergence of this elusive disorder in the American Criminal Justice System [6]. Even today, many clinicians continue to question the validity of the DID diagnosis [9]. This insanity defense, or the “M’Naghten Rule,” established in 1843 by the House of Lords, is often sought when individuals with DID face the courts for severe crimes [10].

37  Dissociative Identity Disorder and the Law

Persons with mental illness avoid conviction and can be sentenced to preventive, treatment-based commitments when mental illness plays a role in the crime [11]. This defense is one of the only things standing between the person and likely a life or a death sentence. There is an onus on the defense to prove beyond a reasonable doubt that mental illness played a clear role in committing the crime. As DID started emerging in courts, many early challenges were faced: the competency of persons diagnosed with DID to stand trial and whether they were truly responsible for their acts [6]. Many of these defendants who took the stand claimed insanity or diminished capacity defenses. This led to the courts working with mental health professionals to help aid in the proper diagnosis of DID and provide expert testimony on the mental states of the persons committing the crimes [6]. Evidence has shown that these personalities often do not retain awareness of the other alters and are not able to access memories during the times the other personalities control the person. Most of the time, the personality in control is termed “host” personality. All the personalities are collectively referred to as “multiple.” DID involves the presence of various personalities or alters that differ in gender, race, personality, emotional states, and age. Since hundreds of personalities may reside in one person, the proper diagnosis of DID and its admissibility in courts is paramount.

Discussion This brings us to the question of how scientific evidence is admitted in courts. In State v Greene, the Washington courts used a two-step process to determine the validity and admissibility of scientific evidence. One, they used the Frye test to determine the reliability and degree of acceptance of the scientific principles. Two, the relevance of the evidence was investigated under ER 702 and 401. Evidence is considered relevant under ER 702 if it aids the trier of fact (the Judge) in understanding the psychological problem. Courts determine whether the evidence has gained acceptance in the Frye test in the general scientific community. Second, they look at the reliability of the principles put forth [6]. In State V Janes, the admissibility and relevance of expert testimony were the focus. The Supreme Court of Washington reversed the decision of a trial court that excluded the evidence of Battered Child Syndrome. The court deemed that under ER 702, it found the evidence relevant to the trial. Another essential factor to consider is the sixth amendment, as state courts’ refusal to admit specific evidence may impinge on the people’s right to it. When it comes to insanity or diminished capacity defense, the burden of proof is on the

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defendant; therefore, it is essential to ensure that the defendant has their sixth amendment rights. There are many challenges in the assessment of criminal responsibility for such patients [12]. In the case of Robin Grimsley, the defense presented that it was her alter, Jennifer, who was in control, and the host, Robin, did not have any knowledge or control of the crime. However, the court ultimately held Robin responsible and concluded that since she altered her personality, Jennifer was not insane at the time of the crime. That brings up an interesting question: Should the host personality be held criminally accountable for the actions of an Alter? The case of Denny-Schaffer addressed just that. Although Schaffer was convicted of kidnapping a newborn across state lines, while appealing the conviction, the court remanded the case to determine the accountability of the host in the criminal act. The Rodrigues case set the precedent of assessing each personality to determine the defendant’s degree of criminal responsibility.

Discussion The diagnosis of DID is the first step in assessing the degree of criminal responsibility held by the defendant. When it comes to DID, three important factors need to be considered in the courts: (a) An assessment of each personality being able to affect the defendant’s overall behavior should be done; (b) The capacity of each personality needs to be assessed to appreciate the degree of wrongfulness (c) Identification of each personality’s extent of control over the defendant’s behavior [13]. Whenever there is a question of insanity or incompetence, the issue of malingering arises. There is a great concern in the medical and legal communities regarding DID, as many clinicians believe that overutilizing hypnosis can cause the condition to be induced iatrogenically. DID presents many challenges to the legal system, including but not limited to the establishment of mental capacity and assessment of the degree of criminal responsibility. The first step in this process is a clinical evaluation of the patient, including the assessment of alters and personalities for characteristics known to change with each personality, such as voice changes, neurological symptoms such as headaches, and even imaging studies such as MRI and EEG. The next step involves psychological and psychiatric assessments, focusing on the patient’s mental state during the crime. Well-­ documented psychiatric evaluations along with legal investigation will aid in the judicial process [14].

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Discussion  ink between DID and Crime, Infanticidal L Attachment At its core, dissociative identity disorder is associated with prolonged, severe abuse stemming from childhood, ergo, crime [15]. Many patients with this disorder are continually involved in lifelong abuse. The patient may be a victim, a perpetrator, or even a witness, albeit silent. Therefore, most clinicians are concerned about the degree of abuse and what really happened in the patient’s childhood. When the patients have no choice or say in the abuse and crimes are committed, there is also the problem of criminal responsibility [15]. As we have seen in the subsection above, dissociative identity disorder is hard to prove in a Court of Law. The varying presentation of the disorder and contradictory information provided by patients have raised questions about the validity of dissociative disorders in psychiatric and legal settings [15]. Often associated with terms such as malingering and attention seeking, it only worsens the depth of trauma in true cases. In the DSM III and DSM IV, dissociative disorders were next to the category of “factitious disorders.” With associations with antisocial personality disorder, combined with periods of dissociation and amnesia, the potential for crime rises, especially violent crime. The trauma endured by true cases of dissociative identity disorder includes sexual abuse, incestuous abuse, ritual abuse, and human trafficking. Abuse is a daily part of life for most cases, unfortunately, and in many cases, lasting generations [15]. Literature shows many cases of DID confessing to committing violent crimes such as murder and abusing others. These events reveal a snippet of how patients with DID process memories and everyday events. Repression is a strong and lasting component of DID which involves the “burying away” of memories deep into one’s mind that it has no way of rising back. Due to enduring long-term trauma, many of these memories, including those committing the abuse, are dissociated. Substance use is also strongly associated with dissociative identity disorder [16], which increases the likelihood of criminal behavior.

Discussion In a study conducted with 21 cases of reported dissociative identity disorder, 35% of Women and 47% of men reported committing crimes [17]. It is remarkable to note that in the same study, more than half of the men committing crimes, over 19% admitted to homicide. In the presentation of DID, the host identity is often noted as docile, passive, and even depressed, with behavioral characteristics varying with each

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personality. During episodes of dissociation, many individuals have described entering a trance-like state, and in a study, two individuals even described it as astral projection [18]. During these states, patients report blacking out and having no memory of the events that occurred; for example, in a study of 12 subjects with DID, one of the subjects pulled out his toenails at night and had no memory of it in the morning. These examples show that it is entirely plausible for persons with DID to commit heinous crimes during their dissociative, trance-like states. Furthermore, there is a long history of malingering in patients suspected of suffering from DID.  Therefore, adequate data is necessary from multiple sources, including mental health professionals and law enforcement, to aid in differentiating the cases of malingering vs. cases of genuine DID. Malingering indicates that the defendant had been involved in planning and premeditation before the crime, waiting for the appropriate moment. In actual cases of DID, there is a history of symptoms, behaviors, and personality changes long before the crime and starting from childhood. Another essential factor is witness statements and statements of close family members who have been around the defendant since childhood. Due to the nature of maltreatment, many of these patients have aggressor and protector personalities, increasing violence. In males, most of the diagnosed cases of DID have been seen in correctional institutions and prisons where they have been incarcerated. Therefore, in many cases, DID is often overlooked and is usually regarded as sociopaths or antisocial personalities. Therefore, it is most prudent to collect as much data as possible about these individuals from multiple sources and various aspects of life. Diagnostic instruments such as SCID and other scales are also helpful in making the diagnosis.

Discussion Here, we emphasize an entity seen in the most severe cases of DID, namely infanticidal attachment [1]. Bowlby described many attachment styles, including secure, insecure, and disorganized. In a secure attachment, we see structure and organization for the developing child, which lays the foundation for relationships in the future, enabling survival in the long term. Although functional, insecure attachment has two types, avoidant and ambivalent. Although the children have consistent access to attachment figures, there are specific deficiencies in the relationship, resulting in a stable attachment style, but they may not be happy. Disorganized attachment is most closely related to trauma, with children not knowing comfort and safety. The parent figure is usually the perpetrator of the trauma.

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Clinicians and academics have long viewed disorganized attachment as a precursor to psychiatric illnesses such as PTSD, dissociative disorders, and criminal activity. These cases include severe abuse, neglect, and mental illness and are usually unintentional. However, some situations with the intent to harm or kill the child have been a source of infanticidal attachment. In this type of disorganized attachment, the child is close to the caregiver with murderous intent, which impacts the child’s safety and creates a type of attachment where the child tries to engage the caregiver with such murderous feelings. The infanticidal attachment has two subtypes, symbolic and concrete. Concrete infanticidal attachment has shown the most correlation with developing dissociative disorders. [4]. In concrete infanticidal attachment, acts of murder and torture are witnessed, endured, and in many cases, even committed by the child. This happens when it is intentional, repeated torture and death threats by the attachment figure. As infants mimic their caretakers’ attachment styles, the child’s comfort will be associated with thoughts of hate, death, and sadism. Seeing torture or severe abuse will bring a sense of comfort to the child and will even be connected to their feelings of love and safety. Such trauma is often generational as the parents themselves suffered unspeakable abuse. Unfortunately, many, if not most cases of DID involve concrete infanticidal attachment and are linked to crime.

Discussion  issociation and Its Association with Forensic D Aspects of DID At its core, DID includes symptoms of Dissociation and amnesia. These symptoms have been commonly linked to violent crimes, as we have attempted to illustrate above [19]. Dissociation is often conceptualized as the disruption of those functions typically integrated, including consciousness, memory, behavior, motor functions, and identity. Freud viewed Dissociation as a defense mechanism against conflicts, negative feelings, and experiences. Holmes et al. and Brown further streamlined the Dissociation model into two categories: Compartmentalization and Detachment [19]. The phenomenon of compartmentalization includes the following four criteria: a deficit in the ability to maintain willful control of processes or actions that would typically be amenable to such control (including the inability to bring normally accessible information into conscious awareness); an act of will cannot overcome the deficit; the deficit is reversible, at least in principle; and it can be shown that the disrupted functions are usually working and continue to influence action and thoughts. This usually includes dissociative amnesia [19].

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In contrast, detachment is defined as a state in which consciousness is altered, and there is a sense of separation from daily experiences. During these states, there is usually a reduction in or even absence of emotions, most associated with fear and trauma. This fear and trauma lead to a state of depersonalization where there is a sense of detachment from one’s own body and derealization where the external world is experienced as bizarre and unreal. These states are involved when there are pathological attachment styles detrimental to the child’s emotional maturity and ineffective coping strategies. Dissociation is also commonly associated with psychiatric disorders such as acute stress, PTSD, and borderline personality disorder. Patients with PTSD often experience flashbacks which cause Dissociation and amnesia related to the traumatic event. Dissociation is often associated with higher rates of psychiatric treatment and economic burden on the patient and often has higher relapse rates. Such patients also have a higher degree of suicidality and self-­ harming behaviors. Therefore, clinicians need to take a trauma-informed approach while approaching dissociative disorders [20].

Discussion From the forensic psychiatric perspective, we have already discussed the link between dissociation, DID, and crime. Many defendants claim periods of dissociation and amnesia immediately preceding, during, and after the criminal act and do not retain the memory of committing the act. The forensic psychiatrist must consider multiple sources of information collected from the patient, close family, and friends and attempt to understand the patient’s mental state during the commission of the crime. While making the diagnosis, one of the most important factors to consider is malingering, which needs to be ruled out. Dissociation is not just exclusive to DID but other disorders such as psychotic disorders like Schizophrenia and PTSD [19]. Based on the competency standards set by Dusky v United States, a defendant can be made incompetent to stand trial due to dissociative amnesia as the loss of memory can prevent any reasonable degree of understanding rationally and impede the defendant’s ability to assist in preparing their defense. In the Wilson v United States case, the ruling was that memory loss of a crime was insufficient for the defendant to be incompetent. In essence, dissociation and amnesia play a critical role in DID.  These symptoms contribute to memory gaps and are strongly linked to crime. From a legal perspective, a thorough examination of the facts, an interview, an examination of the patient from a psychiatric perspective, and a collection of witness statements and history from family members all

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aid the trier of fact to better understand and deliver a just verdict. Malingering is a definite possibility that needs to be explored and ruled out while considering the facts. Finally, diminished capacity defense and insanity defenses are vital factors in establishing culpability, and research shows that all alter must be questioned and examined before coming to a verdict.

Discussion  Forensic Expert’s Approach to Dissociative A Identity Disorder The central tenets of the forensic psychiatrist include doing a complete evaluation, compiling a forensic report, and testify-

Fig. 37.2  Ethical Principles of a Forensic Psychiatrist as essayed in the AAPL

V. Kumar and K. Krishnamurthy

ing in trials [2]. The role of the forensic psychiatrist is distinct from that of a general psychiatrist because words such as confidentiality and beneficence have different meanings. Forensic psychiatrists take on the role of a scientist rather than a traditional physician or psychiatrist, especially while testifying. The primary goal of the forensic psychiatrist is to help bridge the fields of behavioral health and Law and in aiding the trier of fact to better understand and assimilate the facts of the case. In that venture, forensic psychiatrists are not bound by the rules of traditional physician-patient confidentiality. Figure  37.2 shows the ethical principles of a forensic psychiatrist, as outlined by the American Academy of Psychiatry and Law (AAPL): The primary factor to consider within the scope of the forensic psychiatrist is a significant concern for malingering [2]. Here is where the usefulness of gathering collateral

37  Dissociative Identity Disorder and the Law

239

information plays a key role. Compared to traditional psychiatric evaluations done for treatment, forensic evaluations differ in their style, rules of confidentiality, and informed consent. The interview follows an open-ended style not to lead the defendant. When it comes to forensic psychiatric interviews, the evaluator adopts a neutral approach without bias or judgment. These evaluations can occur in correctional institutions, the forensic psychiatrist’s private office, or the attorney’s office. Beyond traditional note-taking, evaluators rely on audio and video recording, which the referring attorneys or the courts can request. In certain situations, such as psychological autopsies, and suicide malpractice suits, evaluators can conduct assessments without a structured interview process.

Discussion As we have mentioned, a patient interview alone is insufficient for a forensic evaluation. The evaluator must obtain history and information from multiple sources, including family and close relationships. The evaluator can also obtain the educational history, which can provide helpful information regarding learning disabilities, developmental delays, and issues with authority figures. Obtaining an occupational history is also especially important in employment-related cases. One main factor which must always be considered includes medical and surgical history. Defendants can suffer from medical conditions with psychiatric sequelae, rendering them incapacitated when committing a crime. Assessment instruments are also used to gauge specific questions of a forensic connotation. The forensic psychiatrist usually works as part of a multidisciplinary team that includes forensic psychologists, who can help with the complete neuropsychological testing of the defendant. This may be especially useful in cases of brain injuries and cognitive disorders [14]. Upon obtaining a complete and thorough history using multiple domains and resources, as mentioned above, the defendant usually undergoes a physical examination. This is important for multiple reasons as it helps in the formulation of the final opinions of the psychiatrist. Defendants may have tattoos, many of which can be highly descriptive and “tell a life story” of the patient, so to speak, including the history of gang or organized crime activity. A physical exam could reveal a potential organic pathology and may aid the forensic psychiatrist in making an assessment. Finally, the forensic psychiatrist compiles all the information in a forensic report, shown in Fig. 37.3. Fig. 37.3  An overview of a forensic report

V. Kumar and K. Krishnamurthy

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Discussion Competency and DID The number of criminal cases involving DID has continued to rise in the past 20 years. Since many professionals in the mental health field do not recognize DID’s existence, it makes it harder to prove in the courts. There are specific challenges to consider when evaluating civil competence as the concept usually applies to one person and not multiple personalities within a single person. The number of alters can vary from case to case, and literature shows they may be two or even 100 [21]. Although it is prudent to consider that with the advent of social media and general awareness, the cases of DID continue to rise, many of these cases have been clustered around specific areas of North America, raising questions about validity. The diagnosis of DID alone does not render a patient incompetent by default. The forensic evaluator must assess the extent of the deficits faced by the defendant, especially those that impact their ability to confer and consult with their attorney and understand the charges against them [22]. The forensic evaluator ultimately aids the trier of fact in better understanding the defendant’s mental state and provides an assessment of how DID plays a role in the defendant’s behavior and cognition. When evaluating decision-making capacity, there are four domains: Understanding, Expressing a choice, Reasoning, and Appreciation [23, 24]. Understanding is the defendant’s ability to comprehend and perceive the information needed to decide. The reasoning is the ability of the defendant to weigh the facts and manipulate information. The ability to comprehend and appreciate the outcome of the defendant’s choice as it applies to them is known as appreciation.

Discussion The concepts of decision-making capacity and competency are not umbrella terms. They are precise and usually pertain to assessing capacity or competency for a single outcome, for example, assessing the decision-making capacity for choosing to have a blood test and competency to stand trial. These choices are highly nuanced, and the defendants must be assessed for each characteristic. Physicians can deem a patient capacitated to make a particular decision but not others. However, the other side of

the coin is that the patient may not possess sufficient capacity to make a particular decision for which they lack all the information needed to weigh the options and make a choice [23]. Decision-making capacity can fluctuate and change during the illness or trial. Courts usually determine competency, while physicians assess decisional capacities in most healthcare settings. When a crime is committed, and the case goes to trial, the defendant is usually assessed for competency to stand trial. At its core, the forensic psychiatrist assesses whether the defendant can understand the facts of the case and if they can work with the legal team on their defense. “Mens rea,” Latin for “guilty mind,” which is the knowledge of the wrongdoing of the crime, needs to be proved by the prosecution beyond any reasonable doubt. While establishing culpability, each alter personality needs to be examined individually with the host to assess for culpability [25]. The forensic psychiatrist may therefore be asked to testify regarding the competency to stand trial and competency for execution. They may also be asked to testify regarding the defendant’s state of mind, whether there was the intent, forethought, or premeditation involved in the crime with a deliberate intent to cause harm [25]. These considerations are usually uncommon, and most frequently, the forensic psychiatrist’s role involves providing information used by the trier of fact to understand the case better and reach a conclusion. In essence, competency and capacity are terms used when there is the establishment of decision-making capabilities, the ability of the defendant to stand trial and help in their legal defense. Due to the high degree of malingering involved when cases of DID go to courts for crimes, the spotlight is on the forensic psychiatrist, not to provide opinions but to provide facts that will aid the trier of fact in deciding the outcome of the case. Decision-making capacity involves four main components, which have been discussed above. Moreover, in a court of law, not just the host personality but all personalities, including the alters, need to be assessed on these concepts.

Discussion Dissociative Identity Disorder and Malingering Here, we feel it is poignant to include a discussion on malingering. We have sought to establish the vital link between DID and malingering, especially in forensic settings. Due to

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the rising attention and awareness of DID from physicians and media, the incidence of malingering has increased over the past 2–3 decades [26]. Defendants malinger DID symptoms to get lighter sentences and avoid responsibility for their crimes. Some other reasons that defendants may malinger symptoms include attention and interest from peers, media, and clinicians. DID can also be induced and propagated by mental health professionals. Research has shown that some patients started thinking that DID was the explanation for their symptoms when influenced by their primary care physician. Patients who usually malinger DID symptoms have gleaned prior knowledge about DID and its presentation. From literature and media, these patients collect information to help them simulate symptoms. Simulated cases usually involve dramatic symptomatology, with selective amnesia to events, exaggerated symptoms, and constant lying. These patients are usually uncomfortable, allowing clinicians to collect further corroborating collateral information. The intent behind simulating such symptoms included either primary or secondary gains, that is, to either play the sick role or get out of punishment for their crimes. Therefore, it is important to use accurate scales like the SCID-D or Dissociative experiences scales which help clinicians probe deeper into the subjective experiences of the dissociation and gauge the authenticity [26, 27].

Discussion Brain imaging studies have also been used to determine actual and simulated cases of DID [20]. In DID patients compared to controls, MRI has shown reduced volume in the amygdala, hippocampus, and parahippocampal regions. Imaging studies have also reported differences in cerebral blood flow in the brain’s left lateral temporal and bilateral orbitofrontal regions compared to individuals with simulated DID. Positron emission tomography studies have also been used to study cerebral blood flow, noting differences in the medial prefrontal gyrus and cortex, which were again not seen in simulated cases. As mentioned above, struc-

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tured assessments play a vital role in helping distinguish cases of malingering [20]. Compared to actual DID cases that endorse fear, depression, trauma, and deep conflict in such scales, simulated cases tend to align with how DID is portrayed in media, with exaggerated symptoms and antisocial behaviors. Therefore, the malingering of DID diagnosis and symptoms has been consistently seen in the legal setting. Defendants malinger DID symptoms for various reasons, from secondary gains to attention and fame. False cases tend to exaggerate symptoms and show inconsistencies in the history and evolution of the disorder. Therefore, the forensic psychiatrist must conduct a complete assessment, including gathering helpful collateral information from multiple sources, Dissociative and personality scale measurements, neuropsychological testing if warranted, and observe the patient in their natural state as well, unimpeded. All the concepts shall help the forensic psychiatrist understand the case themselves and aid the trier of fact to arrive at a just verdict.

Discussion Court Cases Involving DID No chapter on the discussion of dissociative identity disorder and the Law is complete without an overview of some of the most famous court cases involving DID.  These cases have helped set guidelines and legal precedents for justly trying individuals with DID. Also, many of these cases have handled intense media scrutiny and have been subject to controversies. We aim to appraise and educate the reader on each case’s takeaways and how these helped shape the course of DID in Jurisprudence. These cases have all played a significant role in how dissociative identity disorder has come to be viewed by the American courts. They have set precedents for approaching cases of dissociative identity disorder in courts. Table 37.1 below provides a brief background of the case, the cited defense, and the final court ruling.

V. Kumar and K. Krishnamurthy

242 Table 37.1  Prominent court cases involving Dissociative Identity Disorder along with ruling of the court Name of Case Background of case State V Greene was charged with indecent Greene [28] liberties and kidnapping his psychotherapist, and sexually assaulting her State V After committing multiple felonies and Milligan armed robberies, arrested for raping [29] three victims at OSU

Charges Murder

Rape

State V Jones [30]

Jones met Pauline Rodde in a bar, and Murder later strangled and sexually assaulted her body

Kirkland V State [31]

In 1981, between June and August, Phyllis Kirkland committed multiple armed robberies

State V Charged with murdering his father, Darnall [32] psychiatrists testified in court that his primary personality was weak and Darnall developed an aggressor personality to protect himself which led to the crime. State V Arrested for DUI, claimed alter was Grimsley under control while driving [33]

Robbery (Bank)

Murder

Year Cited defense 1998 Not guilty by reason of insanity (dissociative identity disorder) 1978 Not guilty by reason of insanity (multiple personality disorder) 1988 Not guilty by reason of insanity (multiple personality disorder) 1983 Not guilty by reason of insanity due to psychogenic fugue 1980 Not guilty by reason of insanity (multiple personality disorder)

DUI (drunk driving)

Not guilty by reason of insanity (multiple personality disorder) State V Carl Lockhart appealed convictions of Sexual assault 2000 Not guilty by Lockhart sexual assault, battery, burglary, and reason of insanity [34] assault during the commission of a (dissociative felony, citing alter personalities identity disorder) Orndorff v J.L. Orndorff appealed her conviction of Murder and use 2010 Not guilty by Comm [35] murder of her husband in circuit court of firearm felony reason of insanity and use of a firearm in committing a (dissociative felony identity disorder) US v Denny Shaffer, a labor and delivery nurse Kidnapping Shaffer [36] kidnapped and transported a baby across charge multiple state lines, to convince her ex-boyfriend that it was their child

1991 Insanity defense (due to multiple personality disorder)

State v Rodrigues [37]

Rape

1984 Insanity defense

Fraud and misdemeanors

1991 Not guilty but reason of insanity (dissociative identity disorder)

Kirby v State [38]

Rodrigo Rodrigues, a 23-year-old marine, was indicted on 3 counts of sodomy and 1 count of rape, appealed the ruling citing insanity defense due to DID Working as a used car salesman, appellant defrauded multiple people of nearly $300,000 worth of money

Ruling of the court Due to reliability standards not being met, expert testimony and evidence of DID are deemed inadmissible Defendant not culpable due to lack of integration in personalities

The inability to distinguish right from wrong due to altered personalities is not a viable excuse

In cases of criminal liability, the law does not inquire about other personalities and fugue states. Multiple personalities due to preclude criminal responsibility

Personality or states of consciousness are immaterial

Due to a lack of scientific evidence, DID was not allowed into the evidence

A new jury would not reach a different conclusion than the first trial. No evidence established that her psychiatric disorder (DID) made her legally insane Judge rejected the insanity defense citing that the alter personality Gidget in control during the commission of the crime was sane and able to understand the nature of the wrongdoing The judge found the defendant unable to assist in his own defense and deferred acquittal

Law adjudges culpability based on a person’s state of mind at the time of the commission of a crime and it does not extend to multiple personalities. The court ruled the appellant guilty but mentally ill

37  Dissociative Identity Disorder and the Law

Conclusion Dissociative identity disorder is a rare disorder of complex etiology and presentation. It is characterized by distinct personality states known as alters, and the patient is also known as the host personality. This disorder is associated with ­dissociation and amnesia and, in almost all cases, is accompanied by a childhood history of severe, traumatic, and pervasive physical and sexual abuse. The primary personality is known as the “host” personality, with the others being known as “alters.” Alter personalities can vary in number from one to thousands. This disorder became known to the courts only within the last 3–4 decades, and research shows DID’s strong link with crime. This chapter starts with a discussion on dissociative identity disorder and the legal statutes, which enable us to understand legal concepts such as sources of law, including regulations, case laws, and statutes. We also discuss the types of witnesses, namely expert and fact witnesses. We show how challenging this disorder has been to diagnose and identify in the legal system and its implications. As cases of DID go to court, specific challenges arise, such as the capacity to stand trial and the competency of persons, all of which have been explored in this chapter. The ethical principles of a forensic psychiatrist and the rules of admitting evidence have also been covered in this chapter. The strong link between DID and crime has been discussed, with notes on infanticidal attachment. The concepts of dissociative identity disorder and forensic psychiatry are melded together and explored from various perspectives. First, what the law says about DID is touched upon, and we get a bird’s eye view of how scientific evidence is admitted in courts. Dissociation and episodes of amnesia play a key role in DID’s link with crime. Defendants often take the “not guilty because of insanity” and cite DID and dissociative episodes as the reason for committing the crime. DID also significantly affects substance use disorders, increasing the likelihood of criminal behavior. It is well established that defendants with actual cases of DID can have myriad personalities. However, we have also sought to establish the types, such as aggressor and protector personalities, which play a significant role in initiating criminal activity.

Conclusion This chapter also covers the forensic expert’s approach to DID, where we look at the ethical responsibilities and the role of a forensic psychiatrist in helping aid the trier of fact. A complete and thorough evaluation of the defendant and all personalities, along with interviews with family and

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close friends, must be conducted. Also shown is an overview of how a forensic report is done. Decision-making capacity, capacity to stand trial, and competency of persons, include some of the essential concepts utilized by the forensic psychiatrist. These have been covered in the next section, along with the standards for competence to stand trial. An approach to determining decision-making capacity is covered as well. No chapter on DID and forensic psychiatry is complete without a discussion on malingering. Due to the rising media attention and awareness of DID, defendants on trial for criminal activities often malinger DID symptoms. Various approaches for investigating and differentiating actual cases of DID from malingerers have been covered. Finally, a section on the most famous court cases on DID has been included to better understand the course of DID through the American Judicial System.

References 1. Sachs A, Calton C, Galton G, editors. Forensic aspects of dissociative identity disorder. Karnac Books; 2008. 2. Gold LH, Frierson RL, editors. The American psychiatric association publishing textbook of forensic psychiatry. 3rd ed. American Psychiatric Publishing; 2017. 3. Farrell HM. Dissociative identity disorder: Medicolegal challenges. J Am Acad Psychiatry Law. 2011;39(3):402–4. 4. Paris J. Dissociative identity disorder: validity and use in the criminal justice system. BJPsych Adv. 2019;25(05):287–93. https://doi. org/10.1192/bja.2019.12. 5. Diagnostic and statistical manual of mental disorders (dsm-5(r)). 5th ed. American Psychiatric Publishing; 2013. 6. Crego ME. One crime, many convicted: dissociative identity disorder and the exclusion of expert testimony in state v. Greene. Wash L Rev. 2000;75(3):911. https://digitalcommons.law.uw.edu/wlr/ vol75/iss3/5. 7. Wikipedia contributors. Dissociative disorder. Wikipedia, The Free Encyclopedia. https://en.m.wikipedia.org/wiki/ Dissociative_disorder. 8. van der Kloet D, Merckelbach H, Giesbrecht T, Lynn SJ. Fragmented sleep, fragmented mind: the role of sleep in dissociative symptoms: the role of sleep in dissociative symptoms. Perspect Psychol Sci. 2012;7(2):159–75. https://doi.org/10.1177/1745691612437597. 9. Coons PM.  Iatrogenesis and malingering of multiple personality disorder in the forensic evaluation of homicide defendants. Psychiatr Clin North Am. 1991;14(3):757–68. 10. Coleman AH, Davidson AT. M’Naghten rule: the right or wrong of criminal law. J Natl Med Assoc. 1978;70(8):599. 11. Slobogin C. Rethinking legally relevant mental disorder, 29. Ohio NUL Rev. 2003;29:493. 12. Sinnott-Armstrong W, Behnke S.  Criminal law and multiple personality disorder: the vexing problems of personhood and responsibility. S Cal Interdisc LJ. 2000;10:277. 13. Steinberg M, Bancroft J, Buchanan J. Multiple personality disorder in criminal law. Bull Am Acad Psychiatry Law. 1993;21(3):345–56. 14. ICB-InterConsult Bulgaria Ltd. Psychiatric expertise and forensic management in cases of dissociative identity disorders. RAIS J Soc Sci. 2021;5(2):19–25. https://www.ceeol.com/search/ article-­detail?id=1041426.

244 15. Sachs A. Who done it, actually? Dissociative identity disorder for the criminologist. Int J Crime Justice Soc Democr. 2015;4(2):65– 76. https://doi.org/10.5204/ijcjsd.v4i2.219. 16. McDowell DM, Levin FR, Nunes EV. Dissociative identity disorder and substance abuse: the forgotten relationship. J Psychoactive Drugs. 1999;31(1):71–83. https://doi.org/10.1080/02791072.1999. 10471728. 17. Farrell HM. Dissociative identity disorder: no excuse for criminal activity. Curr Psychiatr Ther. 2011;10:33–40. 18. Lewis DO, Yeager CA, Swica Y, Pincus JH, Lewis M.  Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. Am J Psychiatry. 1997;154(12):1703– 10. https://doi.org/10.1176/ajp.154.12.1703. 19. Bourget D, Gagné P, Wood SF.  Dissociation: defining the concept in criminal forensic psychiatry. J Am Acad Psychiatry Law. 2017;45(2):147–60. 20. Lanfranco RC, Martínez-Aguayo JC, Arancibia M.  Assessing malingering and personality styles in dissociative identity disorder: a case report and literature review. PsyArXiv. 2021; https://doi. org/10.31234/osf.io/av62s. 21. Lin Y-J, Hsieh M-H, Liu S-K. Dissociative state and competence. J Formos Med Assoc. 2007;106(10):878–82. https://doi.org/10.1016/ S0929-­6646(08)60056-­X. 22. Waring SA. Dissociative identity disorder and competency to stand trial evaluations: searching for convergence among psychologists [dissertation]. Los Angeles: Alliant International University; 2010. p. 24. 23. Brennan T.  Determining medical decision-making capacity for patients with dissociative identity disorder: a patient-centered approach. 2020.

V. Kumar and K. Krishnamurthy 24. UpToDate. Uptodate.com. 2023. https://www.uptod a t e . c o m / c o n t e n t s / a s s e s s m e n t -­o f -­d e c i s i o n -­m a k i n g -­ c a p a c i t y -­i n -­a d u l t s ? s e a r c h = d e c i s i o n % 2 0 m a k i n g % 2 0 capacity&source=search_result&selectedTitle=1~64&usage_ type=default&display_rank=1. 25. Frankel AS, Dalenberg C. The forensic evaluation of dissociation and persons diagnosed with dissociative identity disorder: searching for convergence. Psychiatr Clin North Am. 2006;29(1):169–84. https://doi.org/10.1016/j.psc.2005.10.002. 26. Draijer N, Boon S. The imitation of dissociative identity disorder: patients at risk, therapists at risk. J Psychiatry Law 1999;27(3– 4):423–458. https://doi.org/10.1177/009318539902700304. 27. Carlson E, Putnam F.  An update of the dissociative experience scale. Dissociation. 1993;6:16–27. 28. State v. Greene, 960 P.2d 980 (Wash. Ct. App. 1998). 29. State v. Milligan, No. 77-CR-11-2908 (Franklin County, Ohio, December 4, 1978). 30. State v. Jones, 743 P.2d 276 (Wash. Ct. App. 1987) aff'd, 759 P.2d 1183, 1185 (Wash. 1998). 31. Kirkland v. State, 304 S.E.2d 561 (Ga. Ct. App. 1983). 32. State v. Darnall, 614 P.2d 120 (Or. Ct. App. 1980). 33. State v. Grimsley, 444 N.E.2d 1071 (Ohio Ct. App. 1982). 34. State v. Lockhart, 542 S.E.2d 443 (W. Va. 2000). 35. Orndorff v. Com., 691 SE 2d 177—Va: Supreme Court 2010. 36. US v. Denny-Shaffer, 2 F. 3d 999—Court of Appeals, 10th Circuit 1993. 37. State v. Rodrigues, 679 P. 2d 615—Haw: Supreme Court 1984. 38. Kirby v. State, 410 SE 2d 333—Ga: Court of Appeals 1991.

Popular Cases of Dissociative Identity Disorder

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Brian Blum and Samuel Neuhut

Introduction DID is an arcane conception that has fanned widespread controversy and uncertainty. In the medical community, there are arguing factions for and against its use as a biomedical diagnosis. DID at large often holds public fascination and interest. Formulations of the duality or multiplicity of the psyche are perennial whenever humans are examined in science, literature, or art. The Strange Case of Dr. Jekyll and Mr. Hyde (1886) is a captivating metaphor for this human capacity and its enduring appeal reflects the allure of this theme [1]. The rationale of this chapter is the qualitative study of published narratives that have risen in the public consciousness within the last century. These narratives can provide a further contextual understanding of the lived experience with DID among individuals. The very notion of truth present in biography and autobiography is under interpretation in a regurgitated account of personal history, especially when there is more than one distinct personality at play. In psychiatry, sharing or disclosure of another human’s lived experience continues to be the basis for all diagnostic criteria and we move forward with the assumption that we have to take such disclosure as the basis for the biopsychosocial approach to medicine. The primary aim is not to investigate veracity but to recognize accounts of a person’s subjective experience. Authors Kendal Tomlinson and Charley Baker have explored autobiographical and biographical accounts of the lived experience of dissociative identity disorder and identified thematic common threads, to serve the goal of deepening empathy and compassion in providing mental healthcare [2]. A close reading of the source material from these accounts can color and elucidate the symptoms and distress of those who experience B. Blum (*) Weill Cornell Psychiatry, New York, NY, USA S. Neuhut Aventura Hospital and Medical Center Psychiatry, Aventura, FL, USA e-mail: [email protected]

multiple personalities, where psychiatrists and therapists play an integral role in diagnosis and treatment. The cases highlighted below in this chapter share a common thread of exposure to traumatic stressors beyond the individual’s adaptable levels and illustrate the resulting prolonged defense of dissociation where distinct personality states develop.

The Three Faces of Eve Psychiatrists Corbett H.  Thigpen and Hervey M.  Cleckley Thigpen detail their diagnoses and treatment of patient Evelyn White in The Three Faces of Eve. Published in 1957 and adapted into a film the same year, Eve is noted for being one of the first publications to bring attention to the multiplicity of personalities. Ms. White is portrayed as a young housewife from Georgia who is self-effacing, timid, and demure. She presented for psychiatric consultation following severe headaches with blackouts. The psychiatrists found no significant childhood abuse but deemed several events that were traumatic in Eve’s childhood: witnessing a body being exhumed from a sewer and being forced by her mother to touch the corpse of her grandmother during the funeral. Additionally, she suffered a miscarriage before initiating therapy [3]. In the course of treatment, Eve Black reveals herself to the psychiatrists during treatment “Why, I’m Eve Black… I like to live and she don’t” [3]. During Eve White’s headaches and blackouts, Eve Black is active, with behavior, motivations, and affect as opposed to Eve White. For instance, Eve White does remember buying expensive clothes that she was unable to return, but Eve Black reports “I need something fit to wear when I do go out” [3]. Over subsequent therapy sessions, including hypnosis, a third personality known as Jane emerges, distinguished as “a capable and intelligent functional entity, as a sympathetic and understanding possible resource.” Each of the three personalities is reported to have separately distinct EEG patterns. The biography reports that

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the Eve Black and Jane personalities were reunited with the self of Evelyn White, as she divorced and remarried [3]. Chris Costner Sizemore, the actual Eve described by Dr. Thigpen and Cleckley, rendered her experience in I’m Eve (1997) and A Mind of My Own [4] and notes that the depiction of only three personalities who subsequently became integrated was false and that she possessed over 20 distinct and not integrated personalities [4, 5].

Sibyl Shirley Ardell Mason was documented as having multiple personality disorder in 1973  in the book Sybil: The True Story of a Woman Possessed by 16 Separate Personalities written by psychiatric journalist Flora Schreiber. The name Sybil Isabel Dorsett was used in the publication to protect the identity of Ms. Mason. The book purportedly documents Ms. Mason’s treatment by psychoanalyst Cornelia B. Wilbur. Sibyl initiated psychanalytic treatment in New York City in the early 1950s for social anxiety and memory loss led to the uncovering of 16 distinct personalities by Dr. Wilbur. Ultimately, Sibyl recollects her memories of sexual abuse and torture by her mother, who, Wilbur believed, had schizophrenia. “Her mother tortured and frightened Sibyl, and Sybil could do nothing about it.”(Schrieber 209). The trauma resulted in the fracturing of Sybil’s personality as Sibyl “The selves, the doctor was now convinced, were not conflicting parts of the total self, struggling for identity, but rather defenses against the intolerable environment that had produced the childhood traumas. After uncovering her past trauma, Sibyl can reintegrate by the end of the book [6]. Sibyl garnered widespread attention in popular culture and within the medical community, becoming a bestselling book in the 1970s, buoying the financial success and notoriety of its author and Dr. Wilbur. The story was adapted as a 1976 television mini-series starring Sally Field and Joanne Woodward, and again in 2007 with Tammy Blanchard and Jessica Lange. Schreiber’s book is recognized as launching multiple personality disorder into both the zeitgeist and the Diagnostic and Statistical Manual. The latter inclusion also is credited for the noticeable epidemic in diagnoses of multiple personality disorder, especially among women, in the following decades. Shirley Mason, the actual Sibyl, was identifiable to those in her hometown of Dodge Center, Minnesota. She moved to Lexington, Kentucky, and reportedly was addicted to barbiturates, which she remained dependent on Dr. Wilbur to supply, as reported in a critique by Debbie Nathan, entitled Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case. Nathan challenges the veracity of the accounts in Sibyl based on research of Schreiber’s manu-

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scripts stored at John Jay College of Criminal Justice, unsealed after Mason’s death. Nathan posits that untreated pernicious anemia bore the psychological symptoms Mason experienced and that Mason was inspired by prior readings on multiple personality disorder, encouraged by Dr. Wilbur, who had an interest in the subject. Nathan alleges “the woman who became Sybil fell in with a psychiatrist and a journalist and the three saw their project, a path-breaking book about female mental suffering, burst upon the world with perfect timing” [7]. Another psychiatrist, Dr. Herbert Speigel, also challenged Mason’s diagnosis of multiple personalities. Dr. Speigel saw Mason for several sessions while Dr. Wilbur was away on vacation and noted Sybil was, “a case of hysteria and not a multiple personality” in a 1997 interview with the New York Times [8]. This was further corroborated by Robert W. Rieder, a colleague of Flora Schreiber at John Jay College of Criminal Justice, who owned some of the tape recordings with Sibyl and Dr. Wilbur, and outlined how Sibyl’s memories were implanted by Dr. Wilbur while Sibyl was administered sodium pentothal as a “truth serum”, concluding that “In the final analysis Sybil is a phony multiple personality case at best. Furthermore, this tendency to go over the top and not know where to stop with multiple personalities will continue to persist until we cease to be proud of those things we should be ashamed of” [9].

Truddi Chase Truddi Chase constructed an autobiography that detailed her various personalities. Her autobiography, When Rabbit Howls, documents enduring physical, emotional, and sexual abuse by her stepfather beginning at the age of 2 in addition to being beaten and neglected by her mother for 14 years. At the age of 16, she ran away from her home in Honeoye Falls, New York, and changed her name to Trudi Chase to escape her parents. As an adult, Chase had no memories of her trauma but sought treatment for powerful headaches and large memory gaps. She reports remembering her trauma since the age of 2, but began to experience her other personalities in middle age and was treated by the hypnotherapist, Dr. Robert Phillips in Washington D.C. In the course of writing the book, ninety-two distinct personalities were encountered by the therapist. Not all 92 personalities were identified, but some of the more prominent personalities had identifiable characteristics, including Rabbit, a non-verbal child who howls at the moon remembering her rape at age 2. In her treatment, Truddi elected to utilize her personality in a cooperative treatment, known as “the Troops” to Truddi, rather than a whole integration into one personality. The book is narrated in the third person and employs various styles that

38  Popular Cases of Dissociative Identity Disorder

reflect the distinct personalities, including Sewer Mouth, Sister Mary Catherine, the Outrider, the Buffer, and Mean Joe. Wilbur, who writes both the introduction and epilogue to the book, states “The Troops cooperated to bring back the memories and comprise the pages. It has been a way of sorting and making sense of a very complex series of experiences, a way for various persons to reveal themselves and explain themselves” [10]. The autobiography ends ambiguously with two fictionalized endings, representing the alternative personalities’ motivations and desires, and echoes Truddi’s lived e­ xperience with her personality’s diverse motivations. In one ending, the Troops decide to kill the stepfather for his crimes. When Rabbit Howls became a New York Times bestseller in 1990 and was adapted into a two-part miniseries, titled Voices Within: The Lives of Trudi Chase, starring Shelley Long. Chase appeared on Oprah in 1990. Truddi Chase reports the motivation for the book was the raise awareness of the severity of repercussions of sexual child abuse, “Writing this book has been an important part of the unfolding “healing process” in that it became a means integrating awareness and spurring new awareness by opening new memories” and describes giving lectures to convicted child abusers to impart that “incest leaves the victim with no real connection to himor-herself or anyone else” [10].

Herschel Walker NFL player Herschel Walker details his experience with the diagnosis of DID in his book, Breaking Free: My Life with Dissociative Identity Disorder, written with Gary Brozek and Charlene Maxfield. He reports that he “had a form of mental illness that enabled me to be simultaneously a fierce competitor, consumed by a desire to be the best and to dominate, and a quiet unassuming man who let his actions do the talking.” He reports that “doctors explained to me that I had developed other personalities (alters) to help me cope with and survive the pain, alienation, and abuse I experienced as a child and adolescent” [11]. His testimony is notable as being male, the minority of DID cases. Under the care of Dr. Jerry Mundgaze, who reports “guiding hundreds of people struggling with dissociative disorder on the difficult path of recovery.” Herschel was spurred to seek the treatment of Dr. Mundgaze, with whom he had already been acquainted socially, after an incident where he describes two distinct personalities arguing about the decision to kill a man who had slighted him from purchasing a car. He reports multiple childhood traumas, from being verbally and physically abused by his classmates throughout grammar school for his weight and stutter. At the age of six, he describes witnessing Klansman in Georgia torment an African American boy with a mock lynching. As Herschel

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matured into a notable athlete, he describes his dissociation as a protective factor during the hazing process and performance anxiety in the course of college and then professional football. He reports on 12 distinct alters, including the Daredevil, the Hero, the Consoler, the Judge, the Enforcer, and the Warrior. He reports working with individual and group therapy to gain stability and “control my alter” [11]. He is now running for a US senator seat from Georgia at the time of this writing.

Roseanne Comedienne Roseanne Barr has long been forthright with her struggles with mental health and has disclosed her experience with dissociative identity disorder in multiple interviews and autobiography My Life, in which she documents recalling sexual abuse from her father after hearing that her daughter Jess experienced the same. According to Roseanne, different personalities come out according to the different kinds of threats she perceives, stating “I survived my childhood by birthing many separate identities to stand in for another in times of great stress and fear.” In her autobiography, Roseanne lists, “the people who share my body: 2, Baby, Cindy, Susan, Nobody, Somebody, Joey, Heather, Roger, Kevin, Evangelina, Vangie, Martha, Mother, Piggy, Fucker, Bambi, Rosey, Roseanne, ONE” [12]. Journalist Mike Sager describes the different genders, voices, and behaviors Roseanne exhibits when she allows him to question her “alters.” Such personality can only be reached by the male journalist by phone, due to the aversion of that distinct personality to males. She reported one of her splits occurred when Roseanne was 8  years old. She had been on a family trip to Disneyland with her father, mother, 7-year-old sister, and 13-month-old brother. On a gondola ride with her family, Roseanne witnessed her father dangle her youngest brother outside the gondola precariously. Roseanne reacted by screaming at her father before being disciplined and recounts how a split in her personality occurred as a result of supplying a new tougher persona that would retaliate and protect herself and her siblings from her father. Roseanne reported that many of her subsequent personalities stemmed from the need to protect a part of herself from others. Her two daughters believe that each has a different personality as a mother. Roseanne has stated that she had spent more than a decade working on integration with all of her personalities. She states that before integration, Roseanne would have difficulty controlling her different personalities and coordinating them to work together in her Hollywood career [13]. Further Reading  My Life with Multiple Personality Disorder Oxnam 2005

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First Person Plural: My Life as a Multiple, West 1999 The Minds of Billy Milligan Keyes 1994 The Three Faces of Eve When Rabbit Howls

References 1. Stevenson RL.  The strange case of Dr. Jekyll and Mr. Hyde. BookRix; 2018. 2. Tomlinson K, Baker C. Women’s auto/biography and dissociative identity disorder: implications for mental health practice. J Med Humanit. 2019;40(3):365–87. 3. Thigpen CH, Cleckley HM. The three faces of Eve; 1957. p. 308. https://psycnet.apa.org/fulltext/1957-04891-000.pdf.

B. Blum and S. Neuhut 4. Sizemore CC. A mind of my own: the woman who was known as “Eve” Tells the story of her triumph over multiple personality disorder. William Morrow & Company; 1989. 5. Sizemore, Chris Costner, and Elen Sain Pittillo. 1977. I’m Eve. 6. Schreiber FR. Sybil: The true story of a woman possessed by 16 separate personalities. Chicago: Regnery; 1973. 7. Nathan D. Sybil exposed: the extraordinary story behind the famous multiple personality case. Simon and Schuster; 2011. 8. Borch-Jacobsen M. Making psychiatric history: madness as Folie a Plusieurs. Hist Hum Sci. 2001;14(2):19–38. 9. Rieber RW.  Hypnosis, false memory and multiple personality: a trinity of affinity. Hist Psychiatry. 1999;10(37):003–11. 10. Chase T. When rabbit howls. Penguin; 1990. 11. Walker H. Breaking free: my life with dissociative identity disorder. Simon and Schuster; 2008. 12. Roseanne BR. Roseanne: my life as a woman. Harper & Row; 1990. 13. Sager M. I’ve learned: Roseanne. Esquire; 2001.

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Dating and DID Nadia Obaed and Ian Hunter Rutkofsky

Introduction Interpersonal Relationship Dynamics  eview of Relationship Dynamics R According to the American Psychological Association, interpersonal relations are defined as “the connections and interactions, especially ones that are socially and emotionally significant between two or more people,” and the “pattern or patterns observable in an individual’s dealing with other people” [1]. The ability to form a stable interpersonal relationship also depends on the interpersonal skill of the people involved such that their level of “aptitude enables them to carry on an effective interaction through communicating their thoughts and feelings and carrying out appropriate social responsibilities” [2]. Most interpersonal relationships can be grouped into familial, friendly, professional, and romantic categories. Each will fulfill a range of emotional and physical connections that can endure for various lengths of time. In general, a healthy relationship will be based on qualities determined by the nature of the relationship itself, some of which may overlap across relationship types. The most commonly cited shared qualities are trust, open communication, shared time, mutual respect, and mutual accountability for shared responsibilities. Healthy romantic relationships can be further qualified by shared power, support, intimacy with respect for each other’s boundaries and privacy, and physical affection [3]. Relationship dynamics will also change depending on whether persons involved are of similar age range, same sex, same educational background, same culture, and even simiN. Obaed (*) Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale/Davie, FL, USA I. H. Rutkofsky Amen Clinics, Washington DC, USA Convenient Psychiatry and Mental Health Services, Maryland, USA

lar personalities. The initial meeting between two persons is also of great significance such that it sets the tone for future meetings. It is widely known that the first impression establishes the kind of relationship people are engaged in and their perception of each other. However, time with each other may of course prove to slowly alter their perceptions of each other. The psychologist George Levinger summarizes the timeline of relationships as acquaintance, buildup, continuation, deterioration, and ending [4]. Although, the stage of continuation is not always followed by deterioration, nor is this timeline strictly linear. Relationships can fluctuate between stages depending on growth or drifting apart and together again. Multiple psychological theories relevant to the continuation stage describe the waning intensity of passionate love in romantic relationships towards a more companionate love as the foundation for this stage’s stability and endurance.

 ocus on Romantic Relationship Dynamics F The triangular theory of love formed by psychologist Robert Sternberg coins intimacy, passion, and decision or commitment as foundations for romantic love [5]. These components are not separate entities, but interact and facilitate each other. The types of love that can manifest from this are dependent on whether all three are involved, the absence of more than one component, the balance between each point, and the sheer amount of presence each component carries in a relationship. Sternberg then goes on to describe the generation of eight relationship manifestations from the combination or absence of certain points. These include nonlove, liking, infatuation, empty love, romantic love, companionate love, fatuous love, and consummate love [5]. The quality of romantic relationships can significantly impact a person’s well-being in terms of creating stress and affecting mental health. High partner responsiveness and sharing of interpersonal goals have been shown to enhance relationship quality [6]. On the other hand, impaired self-­ image, low social network overlap, and differing levels of

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emotional intelligence have been found to diminish romantic relationship quality [7–10]. Couple studies investigating the seemingly natural progression of passionate to companionate love have found that time’s effect on the type of love that endures in a relationship is complex and multifactorial. Hatfield et al. specifically studied the endurance of love by comparing newlyweds and long-term married couples and reported that time diminishes passionate love more than companionate love [11]. The lack of a comprehensive love measurement, large and diverse sample size, and convergent validation in the Hartfield et al. study were significant limitations [11]. Overall, the limitations to such relationship studies are variations in how each type of love is defined, how love is measured, and the lack of ample dyadic longitudinal studies with large sample sizes. Different Types of Love Understanding the different types of love allows a deeper discussion of how relationships are affected when one or both partners are afflicted by a mental illness. Companionate love was defined by Sternberg as the most complete form of love with equal and strong parts of intimacy, passion, and commitment. Love can also present itself as friendship— people have an affinity for each other and enjoy sharing time, but passion or commitment is absent to each other. In those with DID, each alter can be considered a unique individual with separate interests, consequently forming different friendships that other alters may not connect with. There is also the inherent struggle to feel comfortable with emotional intimacy because most people with DID have a history of trauma. Therefore, discussions centered around emotions and feelings can prove to be difficult and may create a distance that widens or cannot be overcome if conflict arises. Whether or not the friend knows the person has DID can also critically change friendships. Upon learning the person has DID, the friendship may continue with closeness, dwindle, dissolve, or even reform upon a friend’s understanding of mental illness. Companionate love is like friendship with the addition of a deeper commitment and passion. There is also a more secure feeling of relationship longevity when people share the same interests, backgrounds, and experiences because they have something to continually connect over. In stark contrast to companionate love, a person may develop a short-lived infatuation with someone who may be opposite of themselves. Infatuation occurs because the other person seems more “exotic,” and it may not be reciprocal. Our full attention becomes narrowed and driven mostly based on the other’s attraction and its effect on our senses. Another inverse of infatuation is empty love which is upheld by commitment, but devoid of passion or intimacy. In patients with DID, awareness of their mental illness can lead to alters upholding an empty love in which they have an understanding of their

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other self’s love interest and will continue the commitment solely for an alter. According to Fromm, romantic love becomes distinguishable from infatuation when admiration and affection give rise to attachment, trust, and coexisting feelings [12]. Romantic love can also give rise to consummate love, the most encompassing form meeting all three points of Sternberg’s triangle. Overall, it can seem that patients with DID may fall in and out of love and different love types as regularly as their alters switch. Gender Differences in Love Long-accepted societal influence and norms have dictated who to love and how to love one’s partner, largely based on stereotypical roles. The gender difference in love has changed over time and may reflect the evolving gender roles. The gender differences weighed are how each experiences and values the different types of intimacy–experiential (bonding over leisure activities), emotional (feeling safe while sharing both comfortable and uncomfortable feelings with each other), and intellectual (sharing ideas and opinions even when they disagree). As far as sex differences with DID, females are more likely than males to be affected, but the ratio can vary as much as 8–20% [13]. Women also spend longer time in the mental health care system from time of their first symptomatic presentation to time of diagnosis which may reflect a difference in psychiatric care provided between males and females rather than a difference in symptom manifestation [13, 14]. Whether a difference in the dating process is present between males and females with DID remains to be elucidated.

Discussion Dating in People with Mental Illness One measure of relationships is social distance. Social distance is a multi-layered construct that can be defined as the space between two people dependent on both intrinsic factors that may or may not be shared among the involved individuals and extrinsic factors independent of either person’s will. The extrinsic factors include demographics, socioeconomic status, and cultural background. Extrinsic factors can limit the opportunity for two individuals to meet, form, or continue any kind of relationship. Intrinsic factors are based on one’s prior experiences, attitude, and education creating either acceptance or discriminatory behavior towards individuals as well as the individual’s motivations for forming relationships. Regardless of the type of relationship, people may end up distancing themself from a person upon knowing their DID diagnosis due to the stigma against those dealing with mental health problems.

39  Dating and DID

 nderstanding Interpersonal Relationships U in People with Mental Illness Studies across the world have shown that our youth demonstrate increased social distance in association with mental health [15]. Mental illness is a so-called invisible disability in which people may successfully or unintentionally forgo disclosure of their illness during the formation of relationships. This can pose a dilemma for the person suffering from mental illness because they may worry about how the relationship changes once they “self-disclose.” This also brings to question whether such “self-disclosure” is even necessary. The concern may depend on the type of relationship as well as what the mental illness is. For example, someone with bipolar disorder who is not well controlled on medication or slips into a manic episode without previous self-disclosure may have those in a relationship with the person question the behavior and risk ending the relationship without proper understanding of what happened or how to prevent such an episode again. Those who do self-disclose may also benefit from having those in a relationship with the person more equipped to prevent, notice, or aid during such an episode. The same principle can apply to those with DID. The research on dating and self-disclosure of a mental illness is limited to one study investigating the response of the individual without mental illness after disclosure occurs while they are dating [16]. The study found through in-depth interviews on the experience and perspective of the person without mental illness dating someone with a severe mental illness that the disclosure process had a more positive outcome when it was detailed allowing a comprehensive understanding of what the illness means and how it is treated [16]. Although a later timing of disclosure while dating was associated with more negative feelings (i.e. shock, betrayal), there was an overall satisfaction felt that their partner had disclosed their illness [16]. The study was limited to only five couples, but post-disclosure produced more action in four out of the five couples to learn more about the illness and be a proactive supporter of their partner such as being present at appointments [16]. Although mental illness can be a barrier to interpersonal relationships, supportive interpersonal relationships themselves can promote mental health as it provides both comfort and connectedness. The power of supportive relationships that is highly emphasized by the National Alliance on Mental Illness should also be one of high quality. Powerful relationships yield positive outcomes when they exhibit both sensitivity and individualized responsiveness without the burden of recipient cost [17]. Given the increasing prevalence of mental health problems, most people will know or have any level of a relationship with someone suffering from a mental illness. Depending on the presence and quality of close inter-

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personal relationships, a mental health problem may be either precipitated or improved.

 ating in People with DID D Akin to Sternberg’s triangular theory of love, there is also the triad base of a relationship. The self, the other, and the situation are the foundations of a relationship. In those with dissociative identity disorder, the self can be an ever-changing part of the foundation posing a continual point of instability and possible relationship demise. This is where self-­ disclosure can be crucial for maintaining relationships. A clear picture of what the person is going through and an understanding of how to interact with people who have DID is essential in maintaining the relationship. Each alter can have their own preferences, different maturity levels, and different abilities when it comes to interacting with others. Those who have DID can exhibit profound difficulties in relationships, but that is not to say that it is impossible for relationships to be successful. People with DID not only experience internal struggles with their multiplicity but may be very aware of the mental health stigma, thus trying to conceal their multiplicity in efforts to not be seen as “other.” The fear of being different and the known stigma of mental health have implications beyond the relationship setting and can trickle into difficulties with job security and personal feelings of belonging and connectedness. Moreover, childhood experiences are directly linked to how we proceed to experience our ongoing world and affect how we interact with any stimuli. Experiences of abuse or neglect can become barriers to intimacy in adult relationships. This challenge is seen with child alters that enjoy cuddling but may confuse their partner with the perception that this is an initiation for sex. The host can often be caught in the middle of these states and find it difficult to safely express sexuality or have sex while simultaneously protecting their child’s state. Dating can provide many new experiences and is not a stagnant phase of life, but an ever-changing journey that can be affected by internal and external forces. This can disrupt the homeostasis of a person with DID system as they try to forge a new relationship with more intimacy and expose themselves to possibly uncomfortable situations. Benjamin and Benjamin identified seven types of partners based on experience with couples in which one of the partners had DID [18]. The types were new abusers, caretakers, “damaged goods,” obsessives, paranoids, schizotypal roommates, and closet dissociatives [18]. These seven types of partners exhibit overlap, but when placing the significant other in one or more of the categories, the reason for why the partner attracted the one with DID towards dating is crucial to maintaining homeostasis in a DID system. Moreover, the category or categories can shed light on the needs as well as goals of

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the person with DID, refine therapy, and improve clinical and dating outcomes.

likely to become a victim again than to ever hurt another person [19–21].

Navigating a Relationship

Advice on Dating Someone with DID

 rom the Lens of a Patient with DID F Different alters have different scripts, so relationships can be expected to change, sometimes merging of alter scripts is necessary to maintain them. High levels of stress can lead to more compartmentalization. Furthermore, it is not unknown that those with DID may have multiple partners at a time, as each alter could be dating someone. The matter of ­self-­disclosure can become important here, but may also not have a clear timing while dating someone. Different alters can fit in one setting which can make dates difficult and even unsafe for the person with DID when there are triggers in their surroundings. People with DID will typically have a system of alters. The inner world inside of a singular body can be vast and changing. Some relationships can be formed between the alters as the system can be seen as a collective of strangers sharing the same space. These relationships can take any form from friendly, familial in which there is a family hierarchy, or even romantic or intimate in which there are alters who can be dating or married. Although the system may have relationships within, this does not exclude each alter from having external relationships or sharing one external relationship with multiple alters. Some alters are capable of intimate experiences while the original host may not be, thus sharing and splitting of responsibilities in an external relationship may be necessary to continue to protect all alters.

Marriage or couple therapy can be a great adjunct to individual treatment in those with DID.  This can help work through frustrations in a relationship such as dispelling negative feelings for the responses from those with DID secondary to amnesia with changing alters. Different alters will also have different needs and struggles which reinforces the importance of the couple’s communication. The promotion of understanding the mental state of each alter allows the significant other to respond more appropriately. Compromise is also essential to achieve balance in a relationship. Knowing how to initiate, negotiate, and accept compromise among both partners brings the couple closer to meeting their own personal needs. Therapy can also allow the person with DID to address any of their childhood experiences, for example, so that they can learn what would work best with their partner to prevent actions of intimacy unintentionally producing negative behaviors from surfacing, such as abruptly leaving their presence, hiding, or displaying fear. Although, therapy may not always be the easiest or most readily available form of help when it comes to those who are in denial of their DID diagnosis, not appropriately treated with individual therapy, are unaware of their diagnosis completely, or do not have willing partners. When someone starts dating a person with DID, meeting each of the alters and seeing each as a unique person attached to a unique identity and personality is important. Upon meeting and spending time with each alter, equally important is learning what their preferences and boundaries are as people with DID can have multiple switches within any period of time which means the partner is likely to be seeing more than just the first host they were initially attracted to. By learning about each alter, the partner can interact respectfully, be supportive, and form individual relationships with each alter if that is what the atler wants. Not every alter will want a relationship or to spend time with the host’s partner, as DissociaDID states “dating one does not mean you are dating all” [22]. DissociaDID also states that setting rules for how the system dates can provide better structure for the system in order to avoid feelings of in-system jealousy or partner jealousy if different alters want to date different people [22]. Furthermore, having a conversation about triggers and not necessarily the trauma that occurred can help the partner be more aware of what to avoid, how to interact with, how to support someone with DID when a trigger does arise. Other advice based on DissociaDID includes checking in on the

 he Significant Other’s Perspective T The compartmentalization that takes place in someone with DID may lead their significant other to register this as a response of aloofness, an uncaring attitude that can lead to doubt in the relationship. This also can end conversations early or limit conversations about topics that are important to the significant other. Furthermore, if the significant other also has a mental health illness, this can complicate the relationship further because both partners can respond from places of emotional instability or exacerbate their symptoms when conflict arises. Acceptance, understanding, and empathy are necessary in a partner to someone who has DID. Based on multiple media interviews of those with DID, the one thing that many of those with DID would like those who are forming relationships with them to understand is to not cling to the portrayals of DID in the media (e.g., movies like Split), learn about the disorder, and to acknowledge that those with DID are more

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partner’s emotional or mental states before opening a conversation, not sharing information that occurs when seeing one alter with another alter as amnesia is a purposeful trauma response meant to protect the host, understanding the different types of alters (child, persecutor, protector, etc), and to differentiate your role as a partner versus the role of a therapist [22].

Conclusion Although interpersonal relationships are well studied among those without mental illness as well as those with a history of trauma, there is a paucity of research investigating these dynamics in the population with dissociative identity disorder. An understanding of DID’s pathology, origin, different alter states, and how all this affects relationships can help those with DID achieve not only a validation of what they are going through but also offers a path of concrete steps towards improving relationships, specifically dating. The importance of self-disclosure, couples therapy, and partner understanding of their roles as well as learning about DID make up a few of these steps. Overall, more studies, whether observational or interventional, can improve the perspective of dating and DID.

References 1. American Psychological Association. APA Dictionary of psychology: interpersonal relations. 2020. https://dictionary.apa.org/ interpersonal-­relations. 2. American Psychological Association. APA dictionary of psychology: interpersonal skill. 2020. https://dictionary.apa.org/ interpersonal. 3. Campbell University. Characteristics of HEALTHY romantic relationships. 2016. https://assets.campbell.edu/wp-­content/ uploads/2016/12/22122441/characteristics-­of-­healthy-­romantic-­ relationships.pdf. 4. Brehm SS.  Personal interactions: close relationships. Harold H. Kelley, Ellen Berscheid, Andrew Christensen, John H. Harvey, Ted L. Huston, George Levinger, Evie McClintock, Lititia Anne Peplau, and Donald R. Peterson. Freeman, New York, 1983. xviii, 572 pp., illus. Cloth, 28.95; paper, 17.50. Science. 1984;223(4633):274–5. https://doi.org/10.1126/science.223.4633.274. 5. Sternberg RJ.  A triangular theory of love. Psychol Rev. 1986;93(2):119–35.

253 6. Canevello A, Crocker J.  Creating good relationships: responsiveness, relationship quality, and interpersonal goals. J Pers Soc Psychol. 2010;99(1):78–106. 7. Doyle DM, Molix L.  How does stigma spoil relationships? Evidence that perceived discrimination harms romantic relationship quality through impaired self-image. J Appl Soc Psychol. 2014;44(9):600–10. 8. 7.4 romantic relationships. In: Interpersonal communication textbook. 2012. 9. Ciarrochi J, Deane FP, Anderson S. Emotional intelligence moderates the relationship between stress and mental health. Pers Individ Dif. 2002;32(2):197–209. 10. Zeidner M, Kaluda I. Romantic love: What’s emotional intelligence (EI) got to do with it? Pers Individ Difference. 2008;44(8):1684– 95. https://doi.org/10.1016/j.paid.2008.01.018. 11. Elaine H, Pillemer JT, O’Brien MU, YCL L. The endurance of love: passionate and companionate love in newlywed and long-term marriages. Interpersona. 2008;2(1):35–64. https://doi.org/10.5964/ijpr. v2i1.17. 12. Fromm E. The art of loving. London; 1957. 13. Ross CA, Norton GR.  Differences between men and women with multiple personality disorder. Hosp Community Psychiatry. 1989;40(2):186–8. 14. LaJeunesse P.  Differences between men & women with multiple personality disorder. Centre for Suicide Prevention. 1989. https:// www.suicideinfo.ca/resource/siecno-­19890387/. Accessed 15 Jul 2022. 15. Adeosun, Fatiregun, Adeyemo. Social distance towards people with HIV-AIDS versus mental illness in a sample of adolescent secondary students in Lagos Nigeria. Interventions. https://publication. babcock.edu.ng/asset/docs/publications/MBBS/9533/2802.pdf. 16. Shpigelman CN, Roe D, Konopny-Decleve L, Eldan K. Disclosing mental illness during dating: an interpretative phenomenological analysis of the partners’ experience. Int J Ment Health Addict. 2019;17(6):1312–27. 17. Pietromonaco PR, Collins NL.  Interpersonal mechanisms linking close relationships to health. Am Psychol. 2017;72(6):531–42. 18. Benjamin LR, Benjamin R.  A group for partners and parents of MPD clients part III: marital types and dynamics. Dissociation. 1994;7(3):191–6. http://scholarsbank.uoregon.edu/xmlui/ handle/1794/1580 19. LADbible TV.  Two people with dissociative identity disorder talk | the gap | @LADbible TV, 2021. https://www.youtube.com/ watch?v=ZWxm-­xbln_I. Accessed 16 Jul 2022. 20. Spotlight 7news. All Of Me | Living with multiple personalities (dissociative identity disorder) | 7NEWS Spotlight. 2018. https:// www.youtube.com/watch?v=kqqyOVsMvHE. Accessed 16 Jul 2022. 21. DissociaDID.  ALTERS: Family/Friends/Dating? WHAT ARE WE!? Alter Dynamics |Dissociative Identity Disorder Reupload. 2022. https://www.youtube.com/watch?v=1EddBJqVL3U. Accessed 16 Jul 2022. 22. DissociaDID.  DATING with MULTIPLE PERSONALITIES!? Switch Caught On Camera Dissociative Identity Disorder REUPLOAD. 2022. https://www.youtube.com/ watch?v=ThasenxuL1s. Accessed 16 Jul 2022.

Dissociative Identity Disorder and Social Media

40

Reginald Deligent and Sean Klonaris

DID and Social Media Going down the Rabbit hole of the Internet by looking up the term “Dissociative Identity Disorder” (DID) will turn up all kinds of search results. These could include videos that seek to inspire, educate or even shock you with their no-holds-­barred perspectives on the condition. Within this range are posts that include mockery and even misinformation. DID is a unique mental health condition that is characterized by two or more distinct personality states and involves marked discontinuity in the sense of self. These peculiar characteristics attract the attention and curiosity of the public and media; sometimes to the detriment of those with the actual condition. The reality today is a mashup of TikTok, YouTube, Facebook, Reddit, and Instagram posts that often add to the confusion and at times seek to juice up viewers with a quick entertainment fix for monetary sake. But the spread in impact of the DID community is undeniable. Influencers like “The A System” on TikTok have gained over 1.1 Million followers and millions of video views [1]. These influencers are starting to understand the maxim: with great attention comes scrutiny and controversy. The hashtag for #DID has over 700 million views on TikTok. The videos and posts are often from a person claiming to have DID and sharing their experiences with multiple alters (or selves) on video. For example, there is a “Meet the System” format where social media creators introduce their different alters (each with a different personality) to the world [1]. There are also the popular “Catch my Switch on camera” videos where content hosts are literally showing their dissociative experiences while on camera. A viewer can see the R. Deligent (*) Department of Psychiatry, Aventura Hospital and Medical Center, Aventura, FL, USA S. Klonaris Clinical Mental Health Counseling, Nova Southeastern University, Fort Lauderdale, FL, USA

body make a quick transition, switching from alter to alter in real time. Some of these creators have been called out in the community as “fakers” or “posers”. “Posers” can use these types of videos to act out comedic personas or characters that can get laughs at the expense of the disorder and those who actually have it. Faking a mental health illness is serious but actually nothing new [1].

Faking Illnesses Online Social Media creators may be using mental health as a way to gain followers even if they do not have a disorder. Once they “label” themselves as having DID for example, they can gain followers and build up their media presence online from people who want to follow them to learn more. The very real mental illness called “Munchausen’s Syndrome” or “Factitious Disorder” are illness where individuals feign or deliberately induce symptoms of an illness to gain attention to themselves [2]. This led Marc Feldman, MD, in 2001 to coin a variation on the term, “Munchausen by Internet.” This is based on a situation where a monk documented online his experience of poverty and dealing with terminal cancer for which he could not afford treatment. After many years of sharing details of his disease online, viewers began to notice he was posting beyond the time he should have passed away from the disease. After several personal callouts, he admitted it was all a hoax [2]. DID has had its own social media influencers “posers” as well. YouTuber influencer Trisha Paytas uploaded a video called “Meet the Alters” where she claimed to have DID and discussed that she had given herself a self-diagnosis of DID [3]. There was a large backlash from family and friends who sought to correct the misinformation and stop the spread of the video that might hurt unknowing viewers. She withdrew the video and apologized [3]. Her case is not alone in that there are other attention-seeking social media users that use the label of the disorder as a way to poke the bear (their audience) and grab attention from their fanbase.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_40

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 elf-Diagnosing Audiences of Social Media S Content What if instead of getting diagnosed for mental illness symptoms by a Board Certified Psychiatrist, you relied on Dr. TikTok? [4] This platform in particular has exploded in popularity with a subculture community of people claiming multiple symptoms of many mental health disorders such as Tourette’s, Autism, and DID. In the DID videos, the video creators discuss what it is like living with the disorder and how to recognize it. The viewer may come away feeling he or she has the disease [4]. “Almost all of my 14-22 year olds that I work with right now, all of them have self-diagnosed something using TikTok;” said New York-based psychologist Rebecca Semel, PhD [5]. When a client says, “I saw this on TikTok; I’m waiting with bated breath. Where are we going with this?” [5]. DID is a serious mental disorder coming from a background of severe trauma. However many of us have dissociative experiences throughout life that don’t necessarily meet DID criteria [5]. Examples of everyday dissociative experiences that many can relate to are when one enters a trance on long trips on the highway or out-of-body experiences. The problem is people can start pathologizing these normal life experiences. When that happens, someone who is watching who has serious mental health concerns starts to think they have DID.  A viewer may convince themselves they have it and may show up in a Psychologist or Psychiatrist’s office seeking treatment for what they are “certain” they have. “All of a sudden all my adolescent patients come in thinking they have this disorder and they don’t,” says Naomi Torres-Mackie, Head of Research at the Mental Health Coalition. “A diagnosis should be made by an experienced mental health expert; plenty of TikTok creators post helpful information about mental health issues, but not all do .”—states Doreen Dodgen-Magee, Psy.D [5]. The other side of the issue is that self-diagnosis can actually be helpful to people if it drives them to seek out the mental health services they need. In this way, they may receive earlier treatment had they not been exposed to the YouTube or TikTok video content. The danger is that viewers may misdiagnose themselves and think they have symptoms that are more detrimental than they really are. The opposite may also be true in that viewers may trivialize serious mental health conditions. An interesting statistic is that DID is actually a relatively rare condition, affecting about .01–1% of the population. Despite this fact, more and more younger people are coming in with a diagnosis of mental health disorders that include DID in higher numbers than previously reported [6]. Younger viewers might self-diagnose after watching videos like that of a TikTok video featuring Gimena’s system. The video has gained a lot of

R. Deligent and S. Klonaris

traction in the DID community with over 5.5 million views from creator @sometimesgimen.a This video showcases Gimena’s system of 23 faces in various states of distress. She has made it her life purpose to help others who are struggling with the disorder and spread education online [6].

Dangerous Algorithms on Social Being “hooked” on social media takes on a new dimension when the content you are watching changes according to your particular interest. If social media networks are like a big candy store, the social media algorithm is like a candy shop owner who always knows your favorite sweet cotton candy treat and will serve it to you each time you come back again and again. Once it knows your top video subject interest, it will keep delivering it to you in different flavors and varieties every time. Imagine you start checking out some videos on DID on the platform one day, then when you return and go to your “For You Page” (which contains curated content just for you) You see it is full to the brim with new, fresh never-ending content related all things DID. This sends the viewer rapidly down a pipeline of DID content and related videos. “If you spend 15 minutes, 30 minutes, 60 minutes viewing people talk about these disorders over and over again, that can make it seem like the conditions are a lot more prevalent than they actually are in the world,” says psychologist Ethan Kross [7]. “This can lead a healthy person who has had dissociative episodes to believe they have full-blown DID and go to their psychologist with that concept in mind” [6]. Add on top of this always-available content; we all tend to have an “availability bias.” This is a cognitive bias when someone is creating judgments or decision-making based on immediate information readily available like social media, and not seeking out or noticing other information not as easy to access [7].

Self-Expression Outlet for Those with DID An individual with DID can use the digital domain of Social Media for self-expression and sharing. For example, a woman with DID uses the Quora online question forums in her own way for cathartic self-expression. Referring to her system, she states, “Quora we mostly use for producing - a way to satiate our need to be asked questions. In this way, we don’t feel bad talking about ourselves” Platforms like these give some breathing room to those with the disorder to share. “It has been healing for us, learning that it is okay to exist and take up space.” She admits that her system does face the occasional haters that she finds funny. “Every upvote, every comment, every share - makes me smile” [8].

40  Dissociative Identity Disorder and Social Media

Support and Community Online People with DID also use social media as a place to go verbalize and gain support from others who have the condition. “Living with Dissociative Identity Disorder” is an online Facebook group with 2,358 members (and growing) created by Patricia Louise Thomas. [2] The posts range from vlogs-­ style emotional thought expressions to facts about the disorder to educate those in the group. People here can connect with and build a support base for a very difficult condition. Self-proclaimed mental health professional advocate Max Selwood refers to expression on Social Media in this way: “TikTok is like a form of therapy. If I just speak about my mental health to as many people as possible, it feels less scary” [4].

Be Mindful of the Content You Consume It’s important to heed the warning to not take everything you see on the internet at face value. DID is under-represented and under-researched, so when one pulls up Google and searches for information related to DID, one must digest this information through the filter of healthy skepticism. “As any professional can attest, making a psychiatric diagnosis is a complicated process that often requires subtle distinctions. There is a big difference between experiencing symptoms and having a disorder” says Dr. Tholen, a retired cognitive psychologist. Getting a reliable and professional diagnosis is the key [9]. Some things to keep in mind when vetting TikTok, YouTube, or other videos. Make sure you are not relying on one platform or one type of media to gain your information. It also might be helpful to start asking yourself some basic questions about the video content: Has this video creator been paid by an entity that might affect their content? Does the speaker have credentials to back up their expertise on a condition? (informational videos) [7]. Is what they are sharing based on more than one person’s unique experience? How does their content compare with other well-respected sources and authorities on this topic? [4]. If a person has gone to the extreme and is spending a lot of time on social media watching content on DID or other mental health conditions, a tip might be to reduce the amount of time watching the platform in general and try to click “not interested” on content that comes up regarding mental health diagnoses. Anecdotally a person who started doing this for about a month, saw the mental health videos vanish entirely from her feed [4]. Despite the negatives of social media, it can give hope to viewers who can see and relate to the experiences of persons with DID thus allowing them to seek help without feeling

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shame. By observing and listening to true DID stories, they can become less vulnerable themselves.

Conclusion In this chapter, we have discussed DID and Social Media. The best strategy for a consumer is to make educated decisions about their mental health and the knowledge sources they use. The positives of this social media are undeniable: support, a powerful sense of belonging, and real-world stories from people who are actually suffering from DID.  As with any medium, there are those who will take advantage of the social media megaphone for profit. These include those who will fake illnesses just for attention. More customized and siloed information instantly curates content to our liking without regard to quality or truth. In the end, there is freedom in taking a deep breath before entering the social media digital landscape and deciding what you will consume and why. So next time you click the play button on YouTube or double tap the TikTok app to open; you can leave educated, wiser, and with a healthy skepticism of what you are about to consume.

References 1. Tavassoli S.  A perspective on TikTok’s mental health epidemic. 2022. confluence.gallatin.nyu.edu. Accessed June 25 Jun 2022. 2. Shepherd H. Is illness appropriation TikTok’s most troubling trend? 2021. id.vice.com/en_uk/article/pkb397/illness-­faking-­accusations-­ tiktok. Accessed 25 Jun 2022. 3. Harris M, Dodgson L.  A thriving YouTube community of people with multiple personality states went viral. Then controversies fractured it down the middle. 2022 . insider.com/did-­dissociative-­ idenitity-­disorder-­youutbe-­multiple-­personalities-­community-­real-­ fake-­2020-­8. Accessed 25 Jun 2022. 4. Pugie M.  Young people are using TikTok to diagnose themselves with serious mental health disorders. What’s behind this trend? 2022. health.com/emotional-­health. Accessed 1 Jun 2022. 5. Styx Lo. Dissociative identity disorder on TikTok: why more teens are self- diagnosing with DID because of social media. 2022. teenvogue.com/dissociative-­idneity-­disorder-­on-­tikTok. Accessed 25 Jun 2022. 6. Colombo C. Viral “Dissociative Identity Disorder” TikToker sparks questions about the internet’s effect on mental health. 2022. rollingstone.com. Accessed 25 Jun 2022. 7. Social media causing people to self-diagnose serious mental health conditions. Acadia Healthcare; 2022. intherooms.com/home/ iloverecovery. Accessed 25 Jun 2022. 8. Quora User. (n.d.). How do you make someone feel bad about themselves? I'm asking because it's constantly done to me, and I'd like to do it to the same people. Quora. quora.com/How-­do-­you-­ make-­someone-­feel-­ bad-­about-­themselves-­Im-­asking-­because-­its-­ constantly-­done-­to-­me-­and-­Id-­like-­to-­do-­it-­to-­the-­same-­people. Accessed 1 Jun 2023. 9. TikTok diagnosis videos leave some teens thinking they have rare disorders. 2021. newportcacademy.com/resources/press/tiktok-­ diagnosis. Accessed 25 June 2022.

Tips for Dissociative Identity Disorder Patients to Live a Good Life

41

Bilal Haider Malik and Ian Hunter Rutkofsky

Introduction Dissociative identity disorder (DID) patients exhibit problems in their memory, perception, sense of self, emotions and behaviours, detrimental to their mental functioning. The common symptoms of this disorder include detachment feelings where they feel foreign to their bodies, that is, they disconnect with their thoughts, actions or feelings [1]. Other patients experience amnesia and memory loss [2]. Experts believe that the condition results from traumatic, intense and repetitive childhood experiences such as emotional, physical

or sexual abuse. These patients tend to have an advantage over ordinary people because they can withstand tormenting experiences like disasters or accidents and other events that are difficult to bear [3]. All this is because they can disconnect their thoughts and feelings from the place and circumstances surrounding the overwhelming possibilities of danger or loss presented by the events [4]. DID can be diagnosed using psychotherapy or pharmacotherapy approaches involving counselling and use of medication, respectively, as shown in Tables 41.1 and 41.2.

Table 41.1  Diagnosis of DID Diagnosis of DID This strategy involves talking and counselling between a patient and a specialist Pharmacotherapy Involves use of medication to treat DID and stabilise comorbid conditions Psychotherapy

B. H. Malik (*) California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA I. H. Rutkofsky Amen Clinics, Washington DC, USA Convenient Psychiatry and Mental Health Services, Maryland, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_41

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260 Table 41.2  Psychotherapy and pharmacotherapy tips and course of action Psychotherapy

Treating DID entails a series of events, including multimodal and phases focused on prevalence of the illness and severe symptoms like anxiety, depression and mental restlessness. Experts conducting research on DID identity deduce that health centres that focus on treating the condition report diminishing number of patients with anxiety and depression. Still, reports reveal that persons in the later stages of the sessions have learnt to cope with trauma compared to patients in the early phases of treatment. The treatment is characterised by numerous levels to accommodate the different programmes and approaches that are critical to enforcing medication. For instance, the three phases employ different strategies to optimise results. Phase 1: This is the critical level of treatment because it focuses on safety measures. This phase recognises that DID patients are overwhelmed by negative thoughts, including suicide and violence, which is detrimental to them and the people around them. It also appreciates that the condition was developed in childhood and it is likely to advance into adulthood; hence, it is necessary to address the symptoms early because patients use it as a defence mechanism and indulge in alcohol and substance abuse, which accelerates the illness. Phase 2: This level of treatment seeks to develop self-acceptance that leads to growth and development of the patients. It focuses on helping the patients unleash their inner feelings of doubt, denial, shame and grief. Hence, the patient stabilises their mind and learns to face terrifying events with confidence. They are able to boost their memory and master the past events that led to the condition. Phase 3: Patients in this level of treatment breaks out of denial and learn to live with the condition. The prior stages help them realise that the past impedes future growth and development; hence, they focus on integrating their thoughts, emotions and feelings towards moving forward. Pharmacotherapy While medicines are not used to treat DID doctors prescribe them to reduce the symptoms that can lead to self-harm and other dangers because they serve as shock absorbers. This is because people with DID experience intense and frequent mood fluctuations, which distracts their normal functioning. However, the drugs are taken in low doses to reduce severe side effects that can result to anxiety. The drugs seek to manage the condition but they do not cure.

 ips for Dissociative Identity Disorder T Patients to Live a Good/Balanced/ Healthy Life Dissociative identity disorder is dangerous because patients demonstrate self-injurious behaviours and suicidal thoughts [5]. Still, the condition is frightening, and the patients prefer isolation. The following tips are helpful because they contribute towards helping the patients live a balanced life [6]. Figure 41.1 portrays some of the strategies deemed pertinent ensuring that DID patients experience quality life. For instance, provision of social support and promotion of physical exercises reduce the symptoms of DID.

Word List Recall Since early childhood events cause DID, older patients may have difficulties in remembering the precise details of such ordeals. Hence, caregivers should focus on helping these persons regain their memory. Patients can devise healthy lifestyle that involves exercising the mind. This will build and strengthen the brain muscles. For instance, they can create a list of words that they say aloud and try to remember events related to such words [7]. Constructing mental images of the objects and settings that interact with each other by dissociative disorder patients facilitates their motivation to self-­ awareness [8].

Pharmacotherapy While there is no specific medication to treat the condition, doctors prescribe antidepressants, antipsychotics and antianxiety drugs to treat symptoms like memory loss, anxiety and depression. Additionally, the medication assists with stabilisation and treatment of comorbid conditions [9].

Procedural Learning This process involves developing skills while performing different tasks. Thus, it helps people to learn how to do things in different contexts. It is helpful for dissociative identity disorder patients because they learn to coordinate tasks. Hence, they develop cognitive skills that will help them connect their emotions, behaviours and memory while interacting with other people [10]. Thus, this type of learning helps the DID patients concentrate on their tasks and allocate their attention.

Developing Positive Attitude Persons suffering from dissociative identity disorder should understand that they are normal human beings who grew up in difficult situations. Hence, they need to face the future with positivity and focus on positive things. This attitude will

41  Tips for Dissociative Identity Disorder Patients to Live a Good Life

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Fig. 41.1  Tips for DID patients

Tips for Dissociave disorder paents

Social support

Switching

Physical exercises

Social Psychotherapy

help them cope with the pain and events that present ­unpleasant outcomes like danger [10]. These persons should also learn to relax while keeping problems at perspective [11]. They should also be flexible to adapt as changes occur to improve their health and live better lives.

Social Support Support is essential to persons with DID as it gives them a sense of belonging. They are also able to participate in everyday activities, share equal rights and privileges with others. Hence, the people surrounding these patients should accommodate them and offer the help they need. Schools, workplaces and other social spheres should aim at creating awareness among community members [12]. The support will reduce stigma and help the patients to manage stress and anxiety if they get low grades or lose their jobs among other triggers of depression. Still, the support will help them open up to their loved ones as they stay connected through social activities.

Shareability Results Shareability school of thought holds that unshared experiences are sensory compared to shared events. Shareability depicts that shared events minimise confusion. Hence, persons suffering from DID should learn to share their childhood experiences. This will help people understand them and accord them appropriate help. It will also eliminate self-­ doubt and help them live a balanced life [13].

Pharmacotherapy

Switching Switching provides patients with dissociative disorders with a platform to understand brain functions like memory and amnesia. Thus, DID persons possessing the ability to shift their mental focus with ease can adapt this tip. This is because it involves shifting cognitive abilities and attention from one aspect to another [14]. Therefore, this tip is crucial because it will help the patients change their focus from negative memories and thoughts to positive things.

Learning About the Illness DID patients should learn to live with the condition instead of living in denial [15]. Hence, they should read about the illness from the Internet and visit hospitals that treat the disorder. All these will enlighten them on the triggers and what they need to live a balanced life. It will also give them insights to help them understand what they are going through, and family members will have an easy time catering to the patients [15]. Still, they are in a position to help other people suffering from the illness. The acquired skills will contribute to reducing the symptoms.

Enrolling in Support Groups Since isolation is the core of this identity disorder, the patients should join support groups to prevent feeling lonely and reduce paranoia. This is because the groups can be anon-

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ymously formed via online websites, physical or virtual meetings depending on the choice of the patient and their caregiver. Hence, they can consider their comfort levels, schedules and goals and choose a favourable group [16]. When people come together with a common interest, they share ideas and experiences to encourage each other. The patients can also get insights and offer wisdom on getting the proper treatment and therapy sessions. Groups are also vital because they offer the affected persons a platform to express their emotions and thoughts [17].

Physical Exercises Lenient physical activities like yoga are evident in boosting moods. Hence, it can help patients with trauma and other mental issues to increase their emotional regulation, among other benefits. Yoga would also help them understand and explore the different parts of their identity that have disconnected, and ultimately integrate them while developing unique coping mechanisms [20].

Balanced Diet

Psychotherapy Psychotherapy incorporates talking and counselling between a patient and a medical practitioner [18]. The health professional should have prior experience and training in dealing with people with trauma [18]. This will enable them to accommodate the patient and encourage them to discuss their mental condition. In the process, the patient will understand the cause of their illness and develop coping skills [19].

While there is no specific nutrition package for persons with DID, it is vital for caregivers and family members to prepare whole and unprocessed foods because food impacts mental health [20]. The nutrients will give the body and mind vital energy. Still, the patients should control and reduce their caffeine intake, particularly in the evenings and before bed. This is because caffeine contains substances that stimulate the brain and the entire body, which will increase anxiety and restlessness for these persons [21]. Summary of tips depicted in Fig. 41.2.

Tips for Dissociave disorder paents

Physical exercises & balanced diet Lenient physical activities like yoga are evident in boosting moods. Hence, it can help patients with trauma and other mental issues to increase their emotional regulation, among other benefits. Yoga would also help them understand and explore the different parts of their identity that have disconnected and ultimately integrate them while developing unique coping mechanisms. Staying active helps to counter the effects of antidepressant drugs and reduce the symptoms of anxiety and depression.

Fig. 41.2  Survival tips for DID patients

Psychotherapy Psychotherapy incorporates talking and counselling between a patient and a medical practitioner. The health professional should have prior experience and training in dealing with people with trauma. This will enable them to accommodate the patient and encourage them to discuss their mental condition. In the process, the patient will understand the cause of their illness and develop coping skills.

41  Tips for Dissociative Identity Disorder Patients to Live a Good Life

263

Getting Sufficient Sleep

Determine Priorities

Since DID patients lose awareness of their thoughts, emotions and self occasionally, ensuring they get enough sleep, such as 8 h a day, will help them in achieving sufficient rest. This is because their brain can rest and process new cells to replace those that have worn out [22]. Damaged tissues will also have enough time to repair. Hence, these patients should devise a sleep schedule and embrace sleep hygiene before bedtime. The schedule should be regular to enhance efficiency [23].

DID patients need to maintain a healthy mindset every day. Hence, the people surrounding them should not overwhelm these persons. Too much stress and information to process create anxiety and depression when they fail to meet expectations. Therefore, patients should prioritise their goals and avoid making decisions when they are not thinking clearly. They should focus on managing their time and energy and set reasonable targets. Caregivers should help them stay organised by creating a list of daily tasks and cutting back on obligations that exhaust their energy [30].

Meditation

Cognitive-Behavioural Therapy

DI.D patients are often anxious and depressed. On the other hand, meditation involves focusing mental energies on a subject to understand its causes and develop solutions. Therefore, these patients should meditate on their past experiences. This will help them develop coping techniques to withstand current and future overwhelming events in a conscious mind [24]. This tip will also help them learn to coordinate the mind and body, essential in connecting their thoughts, emotions and behaviours. The quiet time will also help them retain control of their lives as their mind becomes transformed [25].

DID patients experience a disconnection among their thoughts, behaviours and the body. Cognitive-behavioural therapy is a practical tip for helping them live a balanced life [31]. This is because the process involves a series of events that help the patients understand the connection among their emotions, behaviours and thoughts. They will learn to cope with suicidal thoughts and other injurious behaviours [32]. The patients will learn how to disconnect from negative thoughts through these sessions while finding an alternative to anxious thinking [33].

Consistent Physical Movements

Tracking Personal Life

DID patients should be discouraged from sitting for too long. Instead, they should move around; such activities include jogging, swimming, gardening and walking, among other aerobic exercises that will help them relax and reduce anxiety to substitute for other treatments [26]. All these will help them focus on their surroundings and reduce anxiety and depression from the distraction [27]. The patients will also minimise the risk of illnesses that come with physical weight gain [28].

To avoid disassociation with their behaviours, emotions and thoughts and live a happy life, DID patients should keep a journal to express their fear, anxiety, anger and pain that they explore every day [34]. This will help to understand their triggers, and they can discuss them with their support system, including the therapists. Writing down what they feel at that moment is equivalent to sharing the feelings with someone ready to listen which reduces anxiety [34].

Sticking to the Treatment Plans Caregivers and the people surrounding these patients should put measures to see they stick to the treatment programme. They should focus on completing the therapy sessions and prescribed medicine even if they feel better [29]. Terminating the treatment is detrimental as the symptoms can come back while developing withdrawal symptoms. Also, they should consult the health professionals when they experience intense side effects instead of changing the drugs [29].

Family Support Most Dissociative Identity Disorder (DID) patients claim that they have become better through family intervention. First, the family should tolerate the patient and understand them daily as they make progress [35]. Frequently asking about what the patient experiences are vital. However, they should not be expected to answer immediately since they cannot know what to tell [36]. While intimacy and touching will be difficult for the patient, the family should try since it helps to encourage the patient to talk.

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Career Support Colleagues can also aid in the betterment of the patient. First, they will help in accessing appropriate treatment [37]. Adequate treatment helps in producing better outcomes for dissociative identity disorder. Second, colleagues can learn about DID and how to help mitigate it. Educational opportunities regarding the disorder should be grasped [38]. It will provide a diverse understanding of the individuals living with the disorder. Third, at workplaces, individuals can help in promoting long-term and after-care recovery [39]. Friends can be connected with medical practitioners when the care begins in residential treatment. Since DID patients are not considered disable, they can face lack of provision of monitory benefits from the state but rules surrounding this keep on changing so its better to discuss with your family physician/ therapist/psychiatrist who can then sign post in the right direction. Also there are government and non-government organisations which can assist in signposting towards any help that patients can receive. Patients can be counselled on how they can practice their career effectively, and its important to speak with teachers/career counsellors/mentors and human resource department to identify areas which can be focussed during the career counselling sessions to achieve economic independence.

Religious Support DID patients can thrive well when introduced to churches, temples and mosques among other religious places for counselling proceedings. First, this will enable them to develop their confidence [40]. In most cases, DID patients lack the audacity to integrate with others due to their thoughts about different situations [41]. Religious inclusion will develop a different perspective about life and how they can cope with the disorder. Also, religious support will help the patient feel included in society [42]. As such, it will be easier to mitigate the issue at hand. In essence, the patient will thrive well in areas where individuals are accommodating.

Conclusion DID has proved to be a challenge in psychology, and the condition has triggered debates and controversies in the recent past. While there is no specific treatment and cause for the illness, this research paper has revealed that unresolved shame and guilt lead to the prevalence of the disorder. These emotions are associated with abuse and trauma from past experiences. DID is a mental illness that causes

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disruptions and disturbances within the inner thought. It is a psychiatric disorder where an individual experiences different personalities [43]. Different identities are a survival mechanism because people escape reality by shifting identity [44]. Health experts perceive DID as a separation between integrated, like emotions and memories. Other researchers have conceptualised it as a reaction to stigma, a neural connection, a coping technique and compartmentalisation of information processing [45]. Psychodynamic interpretation is the main conceptualisation that disconnection is a defence mechanism because patients escape anxiety, hence, it is perceived as a defence. Additionally, dissociation is depicted as a form of self-hypnosis [46]. Thus, the research defines DID as a disconnection from individual thoughts, self and the environment. DID develops from early childhood events like extreme abuse [47]. Lack of treatment continues to impede normal functioning as the individual grows old while developing alters [48]. Furthermore, signs of dissociative identity disorder are recognised when an individual feels more agitated and worried than usual. Patients who suffer (DID) experience dissociative amnesia [49]. All these means that one identity may not be aware of events when other identities are in control [50]. Since DID episodes are frequent, the patient will not remember what they have done or who they have spoken with, which is detrimental on their well-being and the entire society [51]. Therefore, society needs to devise coping mechanisms to help these persons reduce the risk of harming themselves or committing suicide [52]. Some tips include switching, enrolling in support groups, therapies, a balanced diet, sticking to the treatment plan, procedural learning and physical exercises, and other activities that will boost their moods and mental energy [53]. Acknowledgement  I am thankful to experts at UKWritings for their help in preparation of this manuscript.

References 1. Bowlby X.  Living with the reality of dissociative identity disorder: campaigning voices. Routledge; 2018. https://doi. org/10.4324/9780429476785. 2. Galton G, Sachs A, editors. Forensic aspects of dissociative identity disorder. Routledge; 2018. https://doi. org/10.4324/9780429474835-­11. 3. Becker T, Karriker W, Overkamp B, Rutz C.  The extreme abuse surveys: preliminary findings regarding dissociative identity disorder. In Forensic aspects of dissociative identity disorder. Routledge; 2018. p. 32–49. https://doi.org/10.4324/9780429474835-­4. 4. Bowlby X.  Living with the reality of dissociative identity disorder: campaigning voices. Routledge; 2018. https://doi. org/10.4324/9780429476785-­1.

41  Tips for Dissociative Identity Disorder Patients to Live a Good Life 5. Noble K. The art of Kim Noble. In: Living with the reality of dissociative identity disorder. Routledge; 2018. p.  5–11. https://doi. org/10.4324/9780429476785-­2. 6. Herman JL.  Review of Special issue: Guidelines for treating dissociative identity disorder in adults (3rd revision); Rebuilding shattered lives: Treating complex PTSD and dissociative disorders; and Understanding and treating dissociative identity disorder: A relational approach. Psychoanal Psychol. 2012;29(2):267–9. https:// doi.org/10.1037/a0027818. 7. Snyder BL. Views of women with dissociative identity disorder on intimate partner violence: a grounded theory approach. University of Missouri-Columbia; 2017. 8. Robertson N. Spiritual aspects of DID. In living with the reality of dissociative identity disorder. Routledge; 2018. p.  13–21. https:// doi.org/10.4324/9780429476785-­3. 9. Strochak RD. Not trauma alone: therapy for child abuse survivors in family and social context. 10. Hampton J. Neuroplasticity: neural networks, dissociative identity disorder, and A.I. Self-Publisher; 2019. 11. Dormoy M.  Guided imagery work with kids: essential practices to help them manage stress, reduce anxiety and build self-esteem. WW Norton & Company; 2016. 12. Bridger S. Living well is the best revenge. In: Living with the reality of dissociative identity disorder. Routledge; 2018. p. 93–103. 13. Winslow O. Reading, writing, and reeling. In: Living with the reality of dissociative identity disorder. Routledge; 2018. p.  23–33. https://doi.org/10.4324/9780429476785-­4. 14. MacKinnon RA, Michels R, Buckley PJ. The psychiatric interview in clinical practice. Washington, DC: American Psychiatric Pub; 2015. 15. Schofield L, Herschel-Shorland C.  Understanding dissociative identity disorder: a picture book and guidebook set. 16. Cureton R.  Medical aspects of recognising complex dissociative disorders. Living with the Reality of Dissociative Identity Disorder; 2018: 105–121. https://doi.org/10.4324/9780429476785-­11 17. Broad C.  Living with DID.  In: Living with the reality of dissociative identity disorder. Routledge; 2018. p.  67–79. https://doi. org/10.4324/9780429476785-­8. 18. Jafferany M, Khalid Z, McDonald KA, Shelley AJ. Psychological aspects of factitious disorder. Prim Care Companion CNS Disord. 2018;20(1):17nr02229. 19. Makover RB. Basics of psychotherapy: a practical guide to improving clinical success. American Psychiatric Pub; 2017. 20. Adler JM, Clark LA.  Incorporating narrative identity into structural approaches to personality and psychopathology. J Res Pers. 2019;82:103857. 21. Howell EF. Understanding and treating dissociative identity disorder: a relational approach. New York, NY: Routledge; 2011. 22. Spalletta G, Janiri D, Piras F, Sani G, editors. Childhood trauma in mental disorders: a comprehensive approach. Cham: Springer Nature; 2020. 23. Schimmenti A, Caretti V.  Linking the overwhelming with the unbearable: developmental trauma, dissociation, and the disconnected self. Psychoanal Psychol. 2016;33(1):106. 24. Health Central. Reversing your dissociative identity disorder: the 30-day journal for raw vegan plant-based detoxification and regeneration with information and tips; 2019. 25. Spring C. Personal and societal denial. In: Living with the reality of dissociative identity disorder. Routledge; 2018: 57–66. https://doi. org/10.4324/9780429476785-­7 26. White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health. 2016;1(1):21–31.

265 27. Van der Hart O, Witztum E.  Dissociative psychosis: clinical and theoretical aspects. Psychosis, Trauma and Dissociation: Evolving Perspectives on Severe Psychopathology; 2018:305–319. 28. Kerney. D.I.D, the gift of god: every day is another day, tips for D.I.D.: how to help those with did. Independently Published; 2021. 29. Scharfetter C.  Ego-fragmentation in schizophrenia: a severe dissociation of self-experience. Psychosis, trauma and dissociation: evolving perspectives on severe psychopathology; 2018:69–82. 30. Pandya SY, Clem MA, Silva LM, Woon FL.  Does mild cognitive impairment always lead to dementia? A review. J Neurol Sci. 2016;369:57–62. 31. Chefetz RA.  Issues in consultation for treatments with distressed activated abuser/protector self-states in dissociative identity disorder. J Trauma Dissociation. 2017;18(3):465–75. 32. Reinders AA, Veltman DJ. Dissociative identity disorder: out of the shadows at last? Br J Psychiatry. 2021;219(2):413–4. 33. Ringrose JL. Understanding and treating dissociative identity disorder (or multiple personality disorder). Routledge; 2018. https://doi. org/10.4324/9780429484483-­1 34. Niedzwiedz CL, Knifton L, Robb KA, Katikireddi SV, Smith DJ. Depression and anxiety among people living with and beyond cancer: a growing clinical and research priority. BMC Cancer. 2019;19(1):1–8. 35. Cureton R. Dissociative identity disorder. 36. Goldberg J. Dissociative identity disorder (multiple personality disorder). WebMD Medical Reference (May 31, 2014). 2014. 37. Zeligman M, Greene JH, Hundley G, Graham JM Jr, Spann S, Bickley E, Bloom Z.  Lived experiences of men with dissociative identity disorder. Adultspan J. 2017;16(2):65–79. 38. Ellis A, Gold SN, Yeturo S, Daly N, Soto T. Trauma-informed dialectical behavior therapy for dissociative identity disorder. Trauma. 2019;2:2–019. 39. Ducharme EL. Best practices in working with complex trauma and dissociative identity disorder. Pract Innov. 2017;2(3):150. 40. Dollahite DC, Marks LD, Dalton H. Why religion helps and harms families: a conceptual model of a system of dualities at the nexus of faith and family life. J Fam Theory Rev. 2018;10(1):219–41. 41. Bull DL, Ellason JW, Ross CA.  Exorcism revisited: positive outcomes with dissociative identity disorder. J Psychol Theol. 1998;26(2):188–96. 42. Brandt PY, Borras L.  Religion/Spirituality and Dissociative Disorders. Religion and spirituality in psychiatry. 2009: 145. 43. Roberts LW. undefined. American Psychiatric Pub; 2019. 44. Hurtado. 2 opposing emotions in 1 body: D.I.D., treatment and therapy: Dealing with did; 2021. 45. Bloem BR, Henderson EJ, Dorsey ER, Okun MS, Okubadejo N, Chan P, Andrejack J, Darweesh SK, Munneke M.  Integrated and patient-centred management of Parkinson’s disease: a network model for reshaping chronic neurological care. Lancet Neurol. 2020;19(7):623–34. 46. Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, Turan JM.  Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health. 2017;107(6):863–9. 47. Vora J, Tanwar S, Tyagi S, Kumar N, Rodrigues JJ.  FAAL: Fog computing-based patient monitoring system for ambient assisted living. In: 2017 IEEE 19th International Conference on e-health Networking, Applications and Services (Healthcom). IEEE 2017: 1–6. 48. Friedel RO.  Borderline personality disorder demystified, Revised Edition: An Essential Guide for Understanding and Living with BPD. Hachette UK; 2018.

266 49. Dindo L, Van Liew JR, Arch JJ. Acceptance and commitment therapy: a transdiagnostic behavioral intervention for mental health and medical conditions. Neurotherapeutics. 2017;14(3):546–53. 50. Goodman A, Fleming K, Markwick N, Morrison T, Lagimodiere L, Kerr T, Society WA. “They treated me like crap and I know it was because I was native”: the healthcare experiences of aboriginal peoples living in Vancouver’s inner city. Soc Sci Med. 2017;178:87–94. 51. Taft TH, Keefer L. A systematic review of disease-related stigmatization in patients living with inflammatory bowel disease. Clin Exp Gastroenterol. 2016;9:49.

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Tips for Family Members of DID Patients

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Aaiz Hussain, Lavi Singh, Shaheer Hussain, Amar Gill Singh, and Ian Hunter Rutkofsky

Introduction

Initial Thoughts on Diagnosis

It can be difficult to see a loved one experiencing the symptoms of dissociative identity disorder (DID). Oftentimes, family members and friends may find it challenging to find ways of providing support without inciting additional stress. The other chapters of this book have outlined how DID presents, the diagnostic measures taken, and the patient-care process. In this chapter, we outline the importance of family in helping patients with DID and tips for family members.

When a family member is diagnosed with a psychiatric disorder, more often than not, the family members involved may not know how to aid the patient, or even how to react. Relationships can suffer as a result of unfamiliarity or fear of the patient’s new onset medical condition. However, it is critical for family members and loved ones to be present and supportive. The importance of family caregivers’ involvement has been increasingly emphasized and family caregivers should be seen by clinicians as partners in the care of patients [1]. However, for patients with clinically diagnosed psychiatric disorders, family involvement is strongly recommended in clinical guidelines but usually suffers from poor implementation [2]. Common problems detected across studies indicate that families feel isolated, uninformed, lack a recognized role, and are not listened to or taken seriously when they attempt to implement family involvement [3]. While the stigma around mental health has been exponentially declining, it still remains in large portions of the US population. Historically, psychiatric conditions were never viewed through the same lens as conditions of other etiologies [4]. It is important to remember these conditions are not something to be ignored. Family members need to treat the patient’s condition with the same empathy and maturity as any other medical complication.

A. Hussain (*) Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA Corewell Health, William Beaumont University Hospital, Royal Oak, USA L. Singh Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA Wayne State University, College of Liberal Arts and Science, Detroit, USA S. Hussain Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA Midwestern University, College of Osteopathic Medicine, Downers Grove, USA A. G. Singh Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA Broward Health Medical Center, Fort Lauderdale, FL, USA I. H. Rutkofsky Amen Clinics, Washington DC, USA Convenient Psychiatry and Mental Health Services, Maryland, USA

Importance of Family Support When a patient is diagnosed with a psychiatric illness such as DID, many families may not know where to even begin. Reading this book and understanding the presentation of DID and the toll it may take on a DID patient is a big step. Family involvement in regard to psychiatric diagnoses can vary immensely, based on an array of factors. The involvement can range from a less intensive plan of the provision of general information on the mental health service and assess-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_42

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ments to more intensive involvement such as psychoeducation, consultation, and family interventional therapy. Families can encourage engagement with treatment plans, recognize, and respond to early warning signs of relapse, and assist in accessing services during periods of crisis. Family involvement can lead to better outcomes from psychological therapies and pharmacological treatments, fewer inpatient admissions, shorter inpatient stays, and better quality of life reports by patients [3].

Initial Support for the Patient’s Safety Many psychological disorders, including DID, are highly impacted by factors including family-related trauma and upbringing [5]. Families of DID patients should try to recognize any factors at home that may have influenced or exacerbated the patient’s condition. Dissociative disorders usually develop as a way to cope with trauma, most often in children subjected to long-term physical, sexual, or emotional abuse, or a home environment that is frightening or highly unpredictable [5]. Family members of patients, especially if the patient is a child, should contact social work, psychiatry, and/or family therapists if the patient is not in a stable and safe environment that will allow them to focus on recovery. Since DID can often develop as a result of abuse, it is important for family members to recognize when a person may be harmful to be in the presence of the patient. In a study conducted in a children’s sexual abuse clinic, patients were interviewed regarding in-home violent or abusive experiences among family members that had occurred at any time during their childhood. In this study, it was found that 58% of child sexual offenders, who were in-home males, also physically abused their adult female partner, half of in-home males, who were physically violent to children, also sexually abused them, and in 86% of homes with partner violence the children were also physically assaulted [6]. Given the high percentage of child abuse occurring from an adult in the same home as the child, it is important for family members of DID patients to recognize when a family member may have abused the patient during childhood/adolescence. This is extremely important to prevent exacerbations of DID symptoms, which can occur from stimuli that recall traumatic experiences including contact with past and current aggressors, and chronic and ongoing stress within the family, including abuse and violence [7].

What Can You Do and What to Expect? Oftentimes, the family members of the patients may feel that they would not be able to help out their recently diagnosed

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loved one if they are not medically trained. However, studies have found that strong family support is just as important as a trained psychiatrist treating the patient [2]. When dissociative identity disorder presents, it can be excessively difficult for a family member to understand what is truly going on. However, through family therapy and family education, a family member can not only understand the ailment but at the same time know how to adequately respond. While it might be assumed that dealing with a family member with DID would be similar to dealing with people with other psychiatric disorders, several differences should be paid attention to. It is important to be empathetic to a family member with DID, which is similar to advice for family members with other psychiatric disorders. However, the stark difference between DID from other psychiatric disorders and its main characteristic is that identity switches can occur abruptly, which can be startling. At one point, a family member with DID can be a loving brother but at another someone that you cannot recognize. This can lead to surprise and stress. However, the most important reaction to an identity switch is to remain calm and not become hostile or fearful, as this may further exacerbate an identity switch. Personality switches can further be brought on by triggers. Family members can recognize these triggers and try to remove them from the family members’ environment. These triggers are typically specific stimuli and can include smells, certain people, sounds, etc. [8]. However, if a trigger does happen at any time, it is important to remain calm and ideally talk to the patient corresponding to the identity they take on. So, for example, if a patient goes from being your brother to being a carpenter, talk to them as if they are a carpenter. Eventually, the patient’s identity should return and then you should talk to them as your brother. Family members of patients with DID should also ensure that they take care of themselves before trying to help their family members. Without having their own mental health stable, it may be difficult for them to give the emotional energy needed. Once the patient returns to their original identity, the patient can be introduced to the idea of seeking help. Since there might be denial and pushback, it is important to create a setting that is ideal for explaining to the patient why they may need help [7]. A secure environment and stabilization of symptoms should be sought, which could be in the patient’s home where they are surrounded by familiar objects that show them their true identity, for example, picture frames [9]. There should be adequate lighting, no loud sounds or noises, and other supporting family members, if possible. This will allow the patient to be relaxed and in a comfortable setting surrounded by loved ones. The patient should be told how much their family and friends care about them and that for that reason, they want them to get help. The patient can be told what happens with the patient pertaining to their

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identity switches but at the same time, the family member should remain factual, and not become emotional as this may trigger an identity switch. If a switch does happen in this circumstance, it is important to discontinue discussing the condition as this can lead to denial and worsening of the switch. Finally, the family member should NEVER ask the patient about trauma as a cause for their DID, as it can exacerbate the condition, especially since it would be brought up in an uncontrolled setting. Only a trained psychiatrist should delve into a patient’s past trauma. It can be suggested to the patient that their family is willing to help the patient find the right psychiatrist and take them to their appointments if necessary. Family involvement is a major aspect of both acute and chronic mental healthcare plans [2]. It can be easy to feel overwhelmed when being asked to participate in a family member’s psychiatric treatment, however, the family’s involvement can be the key to successfully treating the patient’s condition. Studies have shown clinical improvement and decreased instances of relapse as a result of close family care [2]. When approached by the psychiatric team, it is important to remain open-minded and ask questions about the specifics of your involvement, as involvement may vary depending on the patient’s systems and what the psychiatric team needs from the patient’s family. You might be referred to as the patient’s caregiver, as you would be an individual in a close relationship with the patient and supporting them with their mental health treatment [3]. While helping out and caring for a loved one is critical for the recovery process, it is important to take care of your physical and emotional health. The National Alliance on Mental Illness (NAMI) provides many support groups for patients and loved ones who are affected by mental health, such as NAMI Family-to-Family. Family-to-Family allows loved ones of people with mental illness to share experiences with one another and is an evidence-based program meant to improve the coping and problem-solving abilities of people close to a person with a mental health condition [10].

Role of Listening Patients with DID may benefit from being heard by their families and loved ones. Sometimes, the patient simply wants someone to hear their story, and this alone can be healing. Patients may want to spend time with a family member and talk about their issues without judgment or criticism. When listening, we may realize that the patient had certain unmet needs that we would not have figured out had we not listened to them. When taking on the role of support for a person with DID, it is important not to favor a specific alter or component of a patient’s identity over another. It is best to

maintain a non-judgmental perspective when listening to a patient, understanding that certain traits and personalities are a part of their collective identity. Family members who preserve a healthy, communicative relationship with a patient can learn to identify different personality states through effective listening over time. Being able to recognize the presence of a specific state can allow us to adjust how we might approach a patient, so as to not incite any psychological triggers. Moreover, it allows us to better understand how an individual’s personality states function within a patient’s identity system as a whole [11, 12].

Emergent Intervention Finally, a patient with DID may become suicidal, and as many as 70% of patients with DID attempt suicide [11]. If the patient is actively suicidal, 911 should be called and hospitalization would be necessary. If the patient is having passive thoughts, the patient can be directed towards the National Suicide Prevention Lifeline and once again to see a psychiatrist (see below). With continued ancillary support from the family, a patient with DID may be set towards the path to recovery. Additional resources can be found below.

Conclusion In conclusion, DID is very difficult for the patient and it can be for the family of the patient as well. A patient with DID may require a lot of support from the family in various ways and in some cases, the family may be the catalyst to getting the patient the treatment they may need. In this chapter, we outline the ways the family of a patient with DID can provide support and truly be a part of their treatment. A summary of DOs and DONTs can be seen below. DO Communicate—it is important to directly communicate with the patient and ensure them that you are there to help.

DON’T Pry—while communication is key, it is important not to pry any information that the patient does not want to discuss, especially past traumatic events. Empathize—it is essential for Ignore—ensure the patient does you to understand the severity of not feel lonely and feels the patient’s condition. You need comfortable approaching you. to empathize with the patient’s condition and understand the obstacles they face. Inform—keep in contact with Potential triggers—it is important the patient’s healthcare providers to avoid situations that may and update them on any new trigger the worsening of the findings such as changes in the patient’s mental condition. patient’s behavior.

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270 DO Call for help—many resources are available if the condition of the patient worsens anyway. Never hesitate to reach out in the case of an emergency.

DON’T Unstable environment—ensure that the environment the patient is in and the people whom the patient is interacting with do not make the person feel uncomfortable. If any family member has a history of abusing the patient they should not have access to communicate with the patient.

Self-care—assisting a loved one with a mental illness is a long road with many hardships. It is important to understand the significance of your own mental and physical health. Many resources are available for family members of mental health patients.

Resources 1. If your family member with DID is feeling suicidal, give them this number to call: 800–273-8255 (National Suicide Prevention Lifeline) OR https://suicidepreventionlifeline.org/chat/ (if the patient prefers chatting over text). 2. NAMI: a supportive program https://www.nami.org/ About-­M ental-­I llness/Mental-­H ealth-­C onditions/ Dissociative-­Disorders/Support (a) Peer-to-Peer Program: free eight-session program designed to allow individuals with mental health ­conditions such as DID to better understand themselves and express their experiences, emotions, etc. Incorporates a combination of activities, discussions, and informative videos. Over 30 NAMI locations are accessible across the country. (b) NAMI Connection Program: free support group style resource led by trained leaders with mental health conditions. Designed to allow you to hear the successes and challenges of others, while also providing the opportunity to share your own experiences; 90-min long meetings that meet weekly, biweekly, or monthly depending on location. (c) NAMI Family Support Group: free, peer-led support group for any adult with a loved one who has a mental health condition. This program is a great way to gain an insight from the challenges and successes of others facing similar experiences; 60–90-min meet-



ings that meet weekly, biweekly, or monthly depending on location. (d) NAMI Family-to-Family: 8-session educational program for family, significant others and friends of people with mental health conditions. Provides information and strategies for taking care of loved ones with mental health illness.

References 1. Jankovic J, Yeeles K, Katsakou C, et al. Family caregivers’ experiences of involuntary psychiatric hospital admissions of their relatives—a qualitative study. PLoS One. 2011;6(10):e25425. https:// doi.org/10.1371/journal.pone.0025425. 2. Dirik A, Sandhu S, Giacco D, et  al. Why involve families in acute mental healthcare? A collaborative conceptual review. BMJ Open. 2017;7(9):e017680. Published 2017 Sep 27. https://doi. org/10.1136/bmjopen-­2017-­017680. 3. Eassom E, Giacco D, Dirik A, Priebe S.  Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors. BMJ Open. 2014;4(10):e006108. Published 2014 Oct 3. https://doi. org/10.1136/bmjopen-­2014-­006108. 4. Parcesepe AM, Cabassa LJ.  Public stigma of mental illness in the United States: a systematic literature review. Admin Pol Ment Health. 2013;40(5):384–99. https://doi.org/10.1007/ s10488-­012-­0430-­z. 5. Şar V, Dorahy MJ, Krüger C.  Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychol Res Behav Manag. 2017;10:137–46. Published 2017 May 2. https://doi.org/10.2147/PRBM.S113743. 6. Kellogg ND, Menard SW.  Violence among family members of children and adolescents evaluated for sexual abuse. Child Abuse Negl. 2003;27(12):1367–76. https://doi.org/10.1016/j. chiabu.2003.10.008. 7. Rosenzweig MQ.  Breaking bad news: a guide for effective and empathetic communication. Nurse Pract. 2012;37(2):1–4. https:// doi.org/10.1097/01.NPR.0000408626.24599.9e. 8. Rehan MA, Kuppa A, Ahuja A, et al. A strange case of dissociative identity disorder: are there any triggers? Cureus. 2018;10(7):e2957. Published 2018 Jul 10. https://doi.org/10.7759/cureus.2957. 9. Okano K. Clinical handling of patients with dissociative disorders. Seishin Shinkeigaku Zasshi. 2015;117(6):399–412. 10. Helping a Loved One Cope with a Mental Illness. https://www.psychiatry.org/. http://www.psychiatry.org/patients-­families/helping-­a-­ loved-­one-­cope-­with-­a-­mental-­illness. Accessed 5 Jan 2022. 11. Spiegel D.  Expert Q&A: Dissociative disorders. Psychiatry.org  Expert Q&A: Dissociative Disorders. Published October 2020. https://psychiatry.org/patients-­families/dissociative-­d isorders/ expert-­q-­and-­a. Accessed 12 June 2022. 12. Dissociative identity disorder. Dissociative Identity Disorder. https://aamft.org/Consumer_Updates/Dissociative_Identity_ Disorder.aspx. Accessed 12 June 2022.

Neuroimaging and DID

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Steven Garcia, Skyler Coetzee, and Miguel Belaunzaran

Introduction The status of dissociative identity disorder (DID) as an empirically robust, post-traumatic developmental disorder is firmly based in neurobiological (as well as behavioral, cognitive, affective, and somatosensory) disintegration of a unitary, coherent personality structure resulting from complex trauma [1–5]. Higher rates of early life traumatization (i.e., physical abuse, sexual abuse or both) are observed in DID patients than in any other clinical population [6–9]. Accordingly, the study of dissociation and DID has historically been conducted within a dialogue between psychodynamically oriented clinicians and traumatologists [10–12]. Through this dialogue, a trauma-based model of DID has emerged as the predominant component in a complex, multifactorial etiology, alongside developmental, early attachment, cognitive and sociocultural factors [13–14]. The neurobiology of dissociation is a relatively recent addition to the conception of DID and one that currently requires further study with respect to dissociation as a transdiagnostic pattern of symptomatology as well as its unique manifestation in DID [15–18]. Dissociative symptoms present significantly across a wide range of disorders, but none more so than DID, borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD), for which a dissociative subtype (DPTSD) was introduced in DSM-V [17, 19]. In these and other conditions, dissociative symptoms and their severity are directly associated with histories of trauma [6, 20–22]. In addition, studies have reported comorbidity of both PTSD and BPD with DID at high rates, including 79% to 100% of DID patients with comorbid PTSD and 30–80% with comorbid BPD [13, 19, 23–26]. Thus deeper understanding of the neurobiology of trauma-based dissociation across diagnoses and in DID specifically is essential to establish a sound empirical evidence base for DID diagnosis and treatment [27, 28].

S. Garcia (*) · S. Coetzee · M. Belaunzaran Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA

 rauma-Based Dissociation: Hyperarousal vs. T Hypoarousal Two psychophysiologic responses to traumatic stress have been consistently distinguished: hyperarousal and hypoarousal [11, 29–34]. Hyperarousal, referred to by Van der Kolk [34] as “primary dissociation”, is associated with “fight or flight” threat responses, including tachycardia, increased skin conductance, hypervigilance, irritability, increased startle response, elevated anxiety as well as re-­ experiencing symptoms, such as intrusive thoughts and flashbacks (Lanius et al., 2006) [34, 35]. In studies by Frewen and Lanius [30], hyperarousal responses were found in 70% of PTSD patients [30]. In contrast, hypoarousal “secondary dissociation” in the terminology of Van der Kolk [34] or “peritraumatic dissociation” is a depersonalized, avoidant state without anxious symptoms or sympathetic threat responses which may also include derealization, alexithymia, amnesia, analgesia, bradycardia, syncope, or catatonia [34, 36, 37]. Though hypoarousal responses predominate in dissociative disorders, they may also be prominent in other trauma-related psychopathologies and have been historically under-recognized in these conditions [31, 32, 38, 39]. Hypoarousal may be broadly distinguished into responses of subjective detachment from the emotionally overwhelming aspects of trauma (e.g., depersonalization, derealization, alexithymia, isolation of affect, or affective dysregulation) and separation or compartmentalization of traumatic experiences from consciousness (e.g., “out-of-body” experiences, amnesia) [40, 41]. Hyperarousal and hypoarousal responses broadly distinguish two prototypical subsystems of dissociative personality structure which present most markedly in DID: alternate identities fixated in re-experiencing of traumatic memories (i.e., the emotional part of the personality (EP)) and those which, through avoidance and varying degrees of amnesia, take functional command of the patient’s daily life (i.e., the apparently normal part of the personality (ANP)) [42, 43].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_43

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Though hyperarousal and hypoarousal responses are markedly distinct, they typically present clinically in interaction with each other, such that post-traumatic dissociative symptomatology often constitutes combinations of these response patterns [11]. An functional magnetic resonance imaging (fMRI) and prospective questionnaire study of peritraumatic dissociation during recall of trauma in acutely traumatized patients found a significant positive correlation between peritraumatic dissociation and greater activation of right occipital lobe regions (i.e., the right medial lingual and fusiform gyri) associated with vivid autobiographical memory (AM) recall of affective-laden memories [44–47]. In addition, responses to a prospective questionnaire isolated peritraumatic dissociation as the only significant predictor of the development of PTSD 3  months following the initial trauma. These findings suggest a direct influence of peritraumatic dissociation in the development of hyperarousal responses, specifically re-experiencing symptoms (i.e., intrusive thoughts, intrusive memories and flashbacks). A significant correlation was also found between childhood trauma and dissociative symptoms as well as symptom severity, consistent with studies indicating a direct association between childhood trauma and persistent dissociation [48, 49]. Nevertheless, numerous symptom-­provocation studies using both audiovisual and script-driven imagery paradigms indicate distinct patterns of neural activity associated with hyperarousal and hypoarousal responses. Many of these studies have focused on traumatized patients with hyperarousal responses to symptom-provocation, some of which only included patients for whom traumatic cues elicited both physiologic reactivity (e.g., elevated heart rate) and subjective distress [50–54]. However, other studies assigned patients to separate “hyperarousal” and “hypoarousal” groups depending on their reactivity during imaging [55, 56].

 issociation and Post-traumatic Stress D Disorder Hyperarousal responses in PTSD patients have been previously associated with altered activation patterns of the medial prefrontal cortex (mPFC), anterior cingulate cortex (ACC), and thalamus compared to healthy controls [36, 50–52, 54, 57]. In an fMRI functional connectivity (FC) study of hyperarousal in PTSD patients in response to recall of traumatic material with the right anterior cingulate gyrus as the reference voxel, Lanius et al. [56] found coactivation in the right caudate, right posterior cingulate gyrus, right parietal lobe and right occipital lobe among the PTSD group [56]. This connectivity pattern is suggestive of nonverbal memory retrieval, consistent with predominant sensorimotor processing of traumatic memories [58–60]. The right-lateralized connectivity pattern in these patients is also consistent with

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previous studies demonstrating right brain dominance in activation during hyperarousal responses due to traumatic memory recall [39, 53, 55, 61, 62]. Similarly, a transcranial magnetic stimulation study by Spitzer et  al. [63] found a negative correlation between dissociation and left hemispheric excitability as well as left-to-right transcallosal conduction time, indicating an association between dissociation and a lack of right hemispheric integration [63]. In an fMRI FC study comparing hypoarousal in dissociative PTSD patients and hyperarousal in PTSD patients having flashbacks in a script-driven imagery paradigm, Lanius et al. [64] found a right-hemispheric pattern of activation in frontal regions and the insula of dissociative PTSD patients compared with a left-hemispheric pattern of activation in frontal regions of controls, suggesting greater negative affective valence of traumatic memory in dissociated PTSD patients [64]. This interpretation is consistent with their subjective reports, including hypoarousal responses to the effect of “escaping from” the emotions elicited by recall of traumatic material. These dissociative PTSD patients reported altered perception of internal bodily states, intermittent ability to ignore pain, difficulty identifying, and describing emotions (i.e., alexithymia), as well as feeling “removed” from their traumatic experience upon recall [64]. Together with greater insula activation than controls, these findings suggest a significant role for the insula in the development of dissociative symptomatology (i.e., altered perception of bodily sensation and emotion) which coheres with literature implicating the insula in these responses [65–67]. In a study of the hypoarousal responses elicited by script-­ driven recall of traumatic material in dissociative PTSD patients, Lanius et al. [55] found a greater right hemispheric activation than controls in the right mPFC, right medial and inferior frontal gyrus, anterior cingulate gyrus, superior and middle temporal gyri, parietal lobe, and occipital lobe [55]. These findings contrast with patterns of activation characterizing hyperarousal in PTSD patients using the same script-­ driven imagery paradigm, characterized by significantly lower activation of the mPFC, ACC, and thalamus compared to healthy controls [51]. In addition, the findings in dissociative PTSD patients of Lanius et al. [55] bear similarities with the increased metabolic activity in parietal areas and the left occipital cortex found in depersonalization disorder (since renamed depersonalization/derealization disorder in DSM-­ V) patients [19, 55]. However, decreased metabolic activity has been demonstrated in the right superior and middle temporal gyri of these patients, suggesting only partial commonality in brain regions mediating hypoarousal responses of different dissociative disorders [55, 68]. The findings of Lanius et  al. [55] also complement those of Gündel et  al. [69], which demonstrated a positive correlation between alexithymia and right anterior cingulate gyrus surface area [55, 69]. In light of literature suggesting a strong positive

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correlation between alexithymia and dissociation, the right anterior cingulate gyrus may thus play a role in the affective inhibition characteristic of hypoarousal responses [70, 71].

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and severe dissociative symptoms, neither trauma-related symptoms nor the severity of traumatic experiences were related to postcentral gyrus volume in these patients. In addition, significantly smaller (9% less) right precuneus volumes were found in BPD patients compared to controls and greater Dissociation and Borderline Personality right precuneus volume was significantly correlated with Disorder greater severity of depersonalization. The latter finding is consistent with previous ones of increased precuneus activaComparable rates of traumatization and dissociation have tion correlated with both depersonalization disorder and been reported in BPD as in DID and PTSD [17, 72–75]. trauma-based dissociation in PTSD patients with histories of Accordingly, rates of comorbidity between these disorders childhood abuse, further implicating alterations of the precuare also very high, with recent studies reporting 25–30% of neus in the hypoarousal responses of dissociative states [55, BPD patients with comorbid PTSD and 10–37% of patients 64, 68]. with comorbid DID [24, 25, 74, 76–81]. There is also a sigIn an innovative fMRI study of BPD patients utilizing nificant diagnostic overlap among BPD, PTSD, and DID, yet script-driven induction of dissociation and an emotional studies of dissociation in BPD remain relatively lacking [74, working memory task (EWMT), Krause-Utz et al. [97] found 82, 83]. Various dissociative symptoms (e.g., numbing, anal- patients in acute dissociation demonstrated working memory gesia, depersonalization, and derealization) have been (WM) deficits and decreased amygdala activation bilaterally reported in up to 80% of BPD patients, the termination of under all conditions compared to undissociated BPD patients which has been reported among the primary motives for non-­ [97]. Dissociated BPD patients also exhibited decreased left suicidal self-injury in these patients [75, 84–86]. In BPD, posterior cingulate, cuneus, and lingual gyrus activation with both hyperarousal and hypoarousal responses coincide and exposure to negative distractors (i.e., scenes of interpersonal interact with various features of the condition including violence) during the EWMT compared to undissociated affective dysregulation, an unstable sense of self and inter- patients. This significantly decreased amygdala activity in personal dysfunction [86, 87]. dissociated BPD patients compared to undissociated BPD The neurobiological study of dissociation in BPD has patients together with no significantly different amygdala proceeded through investigations of fronto-limbic dysfunc- activation between dissociated BPD patients and controls tion involving the mPFC, orbitofrontal cortex (OFC), insula, offers support for a previously proposed role of dissociation ACC, amygdala, and hippocampus (HPC) which has been in emotional modulation via inhibition of amygdala reactivthought to play an important role in the affective dysregula- ity [75, 98–101]. Significantly decreased activation of the tion, social dysfunction, and identity disturbances character- left cuneus, precuneus, and posterior cingulate with negative istic of BPD patients [84, 88–90]. In a recent meta-analysis, distractors was also found in dissociated BPD patients comSchulze et al. [91] found amygdalar hyperactivation in both pared to undissociated BPD patients, default mode network BPD and PTSD patients compared to MDD patients and (DMN) structures thought to be involved in self-referential controls [91]. In addition, BPD patients demonstrated greater processing, such as AM memory, envisioning the future, activation of the mPFC, left middle temporal gyrus, left pos- mentalization, and moral decision-making [102–108]. The terior cingulate gyrus, left amygdala, and left HPC as well as hypoactivation of these structures when exposed to scenes of hypoactivation of the left precentral and postcentral gyri. interpersonal violence (i.e., negative distractors) suggests However, models of fronto-limbic imbalance involving lim- alterations in self-referential processing in response to negabic hyperactivation coupled with hypoactivation of frontal tively valenced stimuli may also contribute to dissociation in regions (e.g., mPFC, dorsolateral prefrontal (dlPFC), OFC) BPD [93]. lack specificity and have not been consistently replicated These dissociated BPD patients also demonstrated with respect to impulsivity in BPD patients, though dlPFC decreased amygdala FC with the fusiform gyrus compared to and OFC hypoactivation may correlate with reactive aggres- undissociated BPD patients and controls. The fusiform gyrus sion in subsets of patients [92–95]. has been implicated in the processing of aversive social stimWith respect to structural anomalies in BPD patients with uli (e.g., facial threat appraisal) and previous studies have childhood trauma and dissociative comorbidities, an MRI implicated increased amygdala FC with the fusiform gyrus study by Irle et al. [96] found significantly greater left post- in fear conditioning of visual stimuli [109–111]. Decreased central gyrus volumes in BPD patients with comorbid dis- amygdala FC with the fusiform gyrus in dissociated BPD sociative disorders (i.e., DID or dissociative amnesia (DA)) patients, but not undissociated BPD patients, may thus sugthan BPD patients without these comorbidities (11% greater) gest that disintegration between these regions contributes to or healthy controls (13% greater) [96]. While these findings dissociative hypoarousal responses. In addition, increased suggest an association between greater postcentral gyrus size amygdala FC with the left inferior parietal lobule, right mid-

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dle occipital gyrus, right superior and middle temporal gyri, and left claustrum was also found in dissociated BPD patients. Greater amygdala FC with the inferior parietal lobule may mediate emotional reactivity and self-referential processing in dissociative states given its suggested role in memory and affective regulation [112, 113]. Alterations in the superior temporal gyrus have previously been associated with dissociative symptomatology (e.g., derealization and depersonalization) in depersonalization disorder and PTSD patients and decreased gray matter volume as well as increased middle and superior temporal gyri activation have been correlated with greater dissociative symptoms in BPD patients [64, 68, 114, 115]. Consistent with two previous studies demonstrating cognitive disturbances and lower pain sensitivity following script-driven imagery induced dissociation in BPD patients, greater left inferior frontal gyrus activity was also found in both dissociated and undissociated BPD patients compared to controls [114, 116]. Given the lack of specificity of this finding for dissociation and no significant difference in WM between undissociated BPD patients and controls, greater inferior frontal gyrus activation may indicate the dissociated patients’ attempts at interference inhibition when performing the EWMT [93, 97]. +++

ume and resolution of post-traumatic dissociative symptoms. Higher hippocampal volumes have been found in recovered DID patients compared to DID patients with florid symptoms as well as in PTSD patients after significant treatment response following paroxetine treatment, coinciding with improvements in verbal declarative memory and altered reactivity to a stress challenge paradigm [129–131]. In a recent series of meta-analyses investigating neural correlates of retrieval and re-experiencing of traumatic AM in PTSD patients and controls, Thome et  al. [132] found asymmetrical activation of the AM network between groups [132]. The AM network includes the medial and lateral prefrontal cortices, HPC and parahippocampal cortices, posterior parietal and posteromedial cortices, as well visual processing regions [47, 133, 134]. Comparatively, PTSD patients demonstrated greater posteromedial cortical activation whereas greater medial prefrontal cortical activation was found in controls. Given that the medial prefrontal cortices and the posteromedial cortices are thought to mediate the retrieval and re-experiencing processes of AM, respectively, these findings suggest reduced prefrontal cortical activation and greater posteromedial cortical activation may underlie the hyperarousal response of re-experiencing traumatic AM memories rather than their more controlled retrieval [132].

Trauma-Based Dissociation and Memory

MRI Studies of Dissociative Identity Disorder

The primarily sensorimotor and affective processing of traumatic memories, rather than encoding in declarative memory, in the presentation of trauma-based, dissociative disorders (DD) has broad implications for the neurobiological study of DID [33, 117–120]. Given its relatively high distribution of glucocorticoid receptors, the HPC is especially susceptible to damage due to chronic activation of the hypothalamic-­ pituitary-adrenal (HPA) axis [121, 122]. Deficits in declarative memory of traumatic experiences may thus be a consequence of hippocampal damage resulting from HPA axis dysfunction which coincides with the hyperarousal of complex trauma [32, 118, 123, 124]. Accordingly, decreased hippocampal volume has been consistently associated with traumatic stress and dissociative disorders [34, 37, 123, 125]. Hippocampal volume has also been found to be negatively correlated with the severity of post-traumatic and dissociative symptomatology. In one study of patients with DID as well as dissociative disorder not otherwise specified (DDNOS), DID patients with florid symptoms had 25% lower hippocampal volume than healthy controls compared to DDNOS patients who had 13% less hippocampal volume [126]. This correlation has also been demonstrated in MRI studies of female PTSD patients with histories of early childhood sexual abuse [127, 128]. In addition, studies have also indicated a positive correlation between hippocampal vol-

Structural MRI Findings Some of the most striking neuroimaging findings in DID have been in recent MRI studies clarifying structural anomalies in DID patients of unprecedented power and specificity. Reinders et al. [135] utilized T1- weighted anatomical MRI to study 32 female patients with DID and 43 control patients without DID.  The study found no difference in amygdala volume between patients with DID and control patients without DID [135]. However, Reinders et al. [28] proposed that certain biomarkers could potentially be applied to structural imaging to identify patterns associated with DID and facilitate diagnosis [28]. The authors utilized linear binary Gaussian process classifiers, a form of pattern recognition software, to analyze imaging from 32 female patients with DID and 43 control patients and distinguished between DID patients and controls with a sensitivity of 72% and specificity of 74%. While similar to those of previous studies, imaging findings that suggested DID were not as obvious as those suggesting healthy controls. However, they included patterns within the gray matter of the left medial parietal lobule, left superior frontal gyrus, and bilateral cerebellum. As for patterns within the white matter suggesting DID, the left inferior fronto-occipital fasciculus, left inferior and superior longitudinal fasciculus, right corticospinal tract, bilateral

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cingulate, bilateral insula, bilateral frontal regions (inferior, medial, and superior), left parietal regions, putamen, right temporal regions (inferior and middle), and bilateral cerebellum were identified. Given the role of memory in dissociative amnesia, the HPC is a region of interest in studying neuroanatomical correlates in DID. A study by Dimitrova et al. [136] was conducted utilizing T1-weighted anatomical MRI comparing 32 female patients with DID and 43 control patients without DID [136]. Lower hippocampal volumes were found in patients with DID when compared with control patients without DID. These reduced volumes were noted in multiple regions, including the HPC bilaterally, bilateral cornu ammonis (CA) 1, right CA4, right granule cell molecular layer of the dentate gyrus (GC-ML-DG), as well as the left presubiculum. Reduced bilateral hippocampal CA1 subfield volume was associated with dissociative amnesia. No other dissociative symptoms correlated uniquely or significantly with this measure. Emotional neglect correlated negatively with volumes of the bilateral global HPC, bilateral CA1, CA4 and GC-ML-DG, and right CA3. From these findings, the authors suggest a biomarker for dissociative amnesia, CA1. They further posit that an interplay between dissociative amnesia and traumatization leads to reduced hippocampal volumes in patients with DID. The nonspecific finding of smaller hippocampal volumes has been associated with numerous dissociative and trauma-­ related disorders, including PTSD, DID, MDD with history of early abuse, and BPD with history of early abuse [137]. A meta-analysis conducted by Blihar et al. [138] included two previous studies by Chalavi et  al. [139] and a study by Vermetten et  al. [137] [137–139]. Their analysis of hippocampal and amygdala volumes found similar results to those previously discussed. Patients with comorbid DID and PTSD had smaller HPC bilaterally, and patients with DID had smaller left HPC with a trend for a smaller right HPC as compared to PTSD patients. No significant difference between patients with comorbid PTSD and DID and controls was found. Comparison of the amygdalae between patients with DID and patients with PTSD was not possible in their analysis due to lack of data. In the aforementioned study by Vermetten et  al. [137], both hippocampal and amygdala volumes were found to be smaller in patients with DID than in control patients without DID.  They reported 19.2% reduced hippocampal volumes and 31.6% reduced amygdalar volumes in female patients with DID as compared with control participants. The hippocampal:amygdala volume ratio was also found to be significantly different between patients with DID and control patients without DID [137]. Chalavi et al. [139], whose findings were included in the Blihar study described above, studied 17 females with DID and 16 females with PTSD.  They compared these groups

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with 28 healthy controls. They found global hippocampal volume to be decreased in both the DID and PTSD patients when compared with control patients. This was particularly significant in patients with PTSD-DID and PTSD with childhood trauma history. The group of patients with PTSD-DID also showed abnormal morphology and significantly reduced CA2–3, CA4-DG, and presubiculum volumes. Hippocampal volume was found to be negatively associated with severity of childhood trauma and dissociative symptoms [139]. In a separate study, Chalavi et al. [140] studied cortical and subcortical gray matter volumes and found reduced volumes in patients with PTSD-DID (n = 17) and PTSD (n = 16) compared with control patients (n  =  32). This finding was global as well as regionally found in the frontal, temporal, and insular cortices. PTSD-DID patients also showed differences in size of the HPC, putamen, and pallidum when compared with PTSD-only patients and healthy controls. Patients with PTSD-DID had smaller HPC than healthy controls, larger pallidum compared to healthy controls and PTSD only, and larger putamen compared with PTSD only. Hippocampal volume was once again negatively correlated with severity of lifetime trauma. Dissociative and depersonalization symptom severity was positively correlated with putamen and pallidum volume and negatively correlated with inferior parietal cortical volume [140]. In a systematic review, Lotfinia et al. [16] analyzed resting state fMRI, task-related fMRI, diffusion tensor imaging, and voxel-based morphology studies in patients with primary dissociative disorders, borderline personality disorder, and PTSD. They found that neural patterns associated with dissociation were not limited to distinct regions, rather they are more closely related to and vary depending upon patient symptoms. While these patterns were not distinctly regionalized, they were noted especially in the frontal and temporal regions. In addition, similar neural activation was found between patients with DID and patients with dissociative PTSD.  Neither group showed such similar overlap with patients with depersonalization/derealization disorder [16]. A study by Ehling et  al. [141] yielded several findings related to hippocampal, parahippocampal gyrus, and amygdalar volumes in female patients with DID as compared with control patients. Patients with DID showed reduced hippocampal, parahippocampal, and amygdala volumes as compared with control patients. These volumes were also inversely related to severity of both psychoform and somatoform dissociative symptoms. Furthermore, the authors found a negative correlation between hippocampal volume and the following variables: cumulative reported potential trauma, dissociation (both somatoform and psychoform), post-­ traumatic stress symptomatology, and general psychopathology. Parahippocampal gyrus volumes were also found to be negatively associated with some of the same measures: dissociation (both psychoform and somatoform), and post-­

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traumatic stress symptomatology. Both hippocampal and parahippocampal gyrus volumes were strongly related with reported trauma. These volumes also showed a stronger association with dissociative symptoms (both psychoform and somatoform) than they did with general psychopathology. Interestingly, patients who had recovered from DID demonstrated a greater hippocampal volume than patients with immanent DID [141].

Functional MRI Findings The profound functional deficits in DID, especially pertaining to memory and affective regulation, have recently been examined in fMRI studies of comparable power and specificity to the previously discussed structural MRI studies. In a study paradigm incorporating fMRI and an n-back working memory task (WMT), Vissia et al. [142] studied the EPs and ANPs of DID patients in comparison to DID-simulating controls as well as a separate control group of PTSD patients and healthy controls in matched pairs. Main working memory (MWM) activation of the prefrontal parietal network (PPN) was observed in the left ventrolateral prefrontal cortex (vlPFC) and frontal pole in all neutral states (i.e., ANPs of DID patients, neutral states of DID simulators and healthy controls) as well as in the simulated EPs of DID simulators but not in the EPs of DID and PTSD patients. These findings validate the authors’ hypothesis that the WM neural activation patterns of DID patients cannot be simulated by DID simulators, coinciding with a comparative lack of parietal region recruitment in EPs of DID patients. The differential PPN activation patterns between EPs and ANPs in this study also corroborate previously proposed neurofunctional biomarkers of pathological dissociation, especially in the dlPFC [18, 142]. In addition, the EPs of DID patients made greater omission errors during the WMT than simulated EPs and while both EPs and simulated EPs had slower reaction times, EPs in DID patients performed the slowest. Also in accordance with hypotheses of the study authors, both WMT performance and PPN activation in DID exhibited state-­dependence with ANPs demonstrating superior WMT performance in addition to greater PPN activation than EPs, complementing previously mentioned findings of WMT deficits in dissociated BPD patients [97, 116]. Similar PPN activity for MWM in the EPs of DID patients and PTSD patients may be indicative of similar cognitive disturbances in the EPs of these populations. However, the findings of this study were not entirely consistent due to greater MWM-related right insula activation in simulated EPs than ANPs of the DID simulators. Further validating the trauma model of DID and the Theory of Structural Dissociation of the Personality (TSDP)

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from which the concepts of EP and ANP are derived, an fMRI perfusion study clarified distinct perfusion patterns between the EPs and ANPs of DID patients at rest compared to simulated EPs and ANPs in DID simulators as well as healthy controls [143]. Resting-state comparisons of DID patients and DID simulators demonstrated greater perfusion in several DMN structures in DID patients, including the dorsomedial prefrontal cortex (dmPFC), angular gyrus, middle temporal gyrus, and precuneus [107, 108]. In contrast, greater perfusion of the occipital fusiform and middle frontal gyri was found in DID simulators. This disparity in DMN activation may indicate greater self-referential processing in DID patients at rest compared to DID simulators [102, 103, 106]. In comparisons of EPs and ANPs of DID patients, EPs had greater perfusion of the dmPFC, primary somatosensory cortex and motor-related regions, whereas greater bilateral thalamus perfusion was found in ANPs. These findings are consistent with clinical descriptions of EPs and ANPs in TSDP, particularly the fixity of re-experiencing symptoms in the EP given the primarily sensorimotor and affective processing of dissociated trauma discussed previously [11, 42, 43]. Increased dmPFC perfusion in EPs also complements previous findings of greater dmPFC activity in EPs of DID patients exposed to potentially threatening stimuli in a backward masking paradigm [144]. DID simulators also differed in their perfusion patterns in accordance with their reported approaches to achieve simulation of EPs and ANPs: trying to feel as another person does and imagining oneself as another person. Simulated ANPs demonstrated a greater perfusion in occipital areas compared to simulated EPs while instructed to close their eyes during the simulation task, indicating that the DID simulators likely employed visual mental imagery to simulate ANPs [145, 146]. In contrast, greater perfusion of the OFC, pars triangularis of the inferior frontal gyrus, frontal operculum, and anterior insula was found in simulated EPs compared to simulated ANPs. Given the suggested roles of these structures in mediating social cognition and empathy, these findings are indicative of empathic engagement on the part of DID simulators in order to simulate EPs [147–150]. When compared to healthy controls, greater left temporal lobe perfusion was found in DID patients, consistent with previous studies implicating altered temporal lobe activity in dissociative processes, including developing and switching between dissociative states [151, 152]. Healthy controls demonstrated greater perfusion of the mPFC, HPC, and posterior parietal regions than DID patients, regions involved in episodic envisioning of the past and future, implying these controls under resting instruction allowed their minds to wander, remember, and imagining episodic events [153–156].

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PET Studies of Dissociative Identity Disorder Due to the capacity of positron emission tomography (PET) to quantitatively characterize the physiologic function of tissue in terms of blood flow, neurotransmitters, metabolic rate, and uptake of radiolabeled agents, PET studies have been essential in identifying brain regions with differential activation in DID patients [157, 158]. In the landmark symptom-­ provocation PET study “One brain, two selves”, which functionally operationalized EPs and ANPs of DID patients for the first time, distinct patterns of regional cerebral blood flow (rCBF) were found for each of these dissociative subsystems.158 These differing patterns are consistent with TSDP, which attempts to explain the division of personality noted in patients with trauma-related conditions. As previously discussed, this division of personality may devolve into sub-components of the whole which are characterized by specific psychobiological profiles (i.e., hyperarousal vs. hypoarousal responses). Given the “apparently normal” capacity of ANPs compared to EPs to assume tasks of daily living that maintain a higher degree of functional status and inhibit access to trauma-related memories, more normalized responses would be expected of ANPs. In contrast, EPs maintain fixation on traumatic experiences, with a greater involvement of defensive systems that constrict functional behavior [42, 43, 159]. Compared to ANPs, Reinders et  al. [160] found EPs focused on traumatic memories and defensive operations demonstrated increased rCBF in the amygdala, insula, somatosensory regions including the right lateral fissure as well as the left cerebellum. In addition, these EPs demonstrated increased heart rate, higher blood systolic and diastolic pressure, and higher subjective ratings of emotional sensorimotor experiences when exposed to a trauma-related memory script compared to ANPs, providing further empirical validation of the EP and ANP of DID patients [160]. In a PET study comparing the hyperarousal and hypoarousal responses of DID and PTSD patients, 11 DID patients and matched DID simulators completed an autobiographical script-driven imagery paradigm in hypo-aroused and hyper-aroused states [161]. In response to a trauma-­ related text, DID patients in a hypo-aroused state demonstrated activation of the posterior association areas, parahippocampal and cingulate gyri, left lingual gyrus as well as the right temporal and fusiform gyri. In contrast, DID patients in a hyper-aroused state activated the caudate nucleus, left amygdala, and left insula while processing the trauma-related text. These findings support the study authors’ contention that hypoarousal and hyperarousal in DID, as in PTSD, appear to each be mediated by disparate brain activation patterns to the effect that hypoarousal overmodulates affective regulation, whereas hyperarousal undermodulates.

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The authors also present this study as further validation of TSDP, delineating the hypo-aroused and hyper-aroused states as analogous to the ANP and EP, respectively.

EEG Studies of Dissociative Identity Disorder Though a comparatively underutilized modality in the study of DID, electroencephalography (EEG) findings have contributed to the empirical validation of DID as a clinical diagnosis and of the alternate identities of DID specifically. In a quantitative EEG (QEEG) study using both “within-subject” and “between-subject” controls, Lapointe et al. [162] found that the EEG recordings of two alternate identities in a single DID patient differed more so from each other than they did from two EEG recordings of a single, healthy control [162]. Since the variability in EEG between different people is greater than the variability in a single person at different times, this finding is consistent with alternate identities in DID being more so “different people” than they are different conscious states of the same person. However, the EEG recordings of the alternate identities in a single DID patient were also more similar to each other than the recordings of two different controls, suggesting that though distinct changes in EEG data were observed between alternate identities, these data still retained a degree of specificity to the individual DID patient. In addition, the intrapersonal variability which provided the basis for comparison between recordings of alternate identities was predominantly differing beta activity in the prefrontal and temporal lobes. These brain regions contain previously mentioned DMN structures thought to be involved self-referential thinking and possibly altered in the setting of dissociative symptomatology [102, 103, 105–108]. In a QEEG study which assessed the cortical connectivity of DID patients via average alpha coherence, Hopper et al. [163] employed five gender and age-matched professional actors as healthy controls and thus compared 15 alternative identities in five DID patients to 15 “alternative identities” simulated by controls [163]. The alpha coherence of these simulations by the controls did not differ significantly from the DID alternative identities. However, alpha coherence was significantly decreased in alternate identities of the DID patients compared to their “host” identities (referred to by Van der Hart et al. [46] as the ANP), whereas no significant differences were found between ANPs and controls. The decreased alpha coherence in alternative identities compared to simulations was distributed across frontal, temporal, central, parietal cortical regions, complementing the aforementioned findings of Lapointe et al. [162], and further implicating disintegration of these regions in DID [162, 163].

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In addition to clarifying distinct patterns of activity between different alternate identities in DID, EEG has also been used to assess integration via change in resting-state brain FC in response to phase-oriented treatment. An advantage of assessing FC with EEG rather than fMRI as in previously discussed studies is the capacity for data acquisition at significantly higher time resolutions, in addition to greater convenience of application, lower expense and aversiveness to participants [164]. In a controlled EEG FC and clinical questionnaire study, Schlumpf et al. [164] examined FC of ANPs in patients with complex DD (i.e., DID and DDNOS; n = 17) and complex PTSD (cPTSD; n = 19) before and after 8  weeks of treatment in both eyes-open and eyes-closed resting-­states following an emotional regulation task. Prior to treatment, patients in both resting conditions demonstrated brain networks involving the DMN, PFC, and ACC with significantly decreased FC in the alpha and theta frequency band compared to controls. Following treatment, this hypoconnectivity normalized with patients exhibiting similar FC to controls in all but the eyes-open alpha frequency band network in addition to significant symptom improvement and enhanced capacity for adaptive emotional regulation.

Conclusion Though still a disputed diagnosis among some clinicians and researchers, it is hoped that the discerning reader will take the findings presented in this chapter as repudiation of any controversy regarding the empirical basis and diagnostic validity of DID. However, DID and other trauma-based dissociative psychopathologies remain a diagnostic and therapeutic challenge, making further study essential to improve outcomes for this underserved and highly vulnerable patient population. Recent advances in the neurobiological study of DID with the innovative use of various neuroimaging modalities offer the opportunity for further clarification of still nonspecific imaging findings in DID patients. Given the significant transdiagnostic prevalence of dissociative symptomatology and high comorbidity of DID with PTSD, BPD, and other conditions, neuroimaging studies will prove a vital tool in reevaluating current understanding and treatment approaches to this disorder. Future applications of these studies may include further comparison with other psychiatric patient populations and investigating the neural correlates of successful DID treatment.

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Gender Differences in Dissociative Identity Disorder

44

Ansha Panachikkal Abubacker

Introduction Dissociative identity disorder, a severe form of dissociative disorder earlier called multiple personality disorder is a complex and chronic psychological condition characterized by a discontinuity in autobiographical memory, thoughts, and sense of identity. This particular mental condition has a strong association with trauma that has been faced by the patients in their childhood [1]. On an average, 75% of them have suffered from childhood sexual abuse, 55% from emotional abuse, and 65% from physical abuse. Around 60% are victims of childhood [2]. The biological development of the brain in both men and women is not the same, as does the way they react to different stresses. Moreover, sex differences are a vital determinant of vulnerability to psychosocial stress. Cultural variability in different communities also affects behavioral development and may influence gender differences in dissociative identity disorder [3]. This chapter focuses on the gender differences in dissociative identity disorders and their major causes.

 emale Population and Dissociative Identity F Disorder Females affected with dissociative identity disorder are proved to be more symptomatic than males. According to a study conducted on 177 cases to know more about gender differences in dissociative disorder post-traumatic stress disorder symptoms, sleep problems, somatization, and anxiety symptoms are more prevalent in the female population than in males. Increasing age significantly shows a rise in symptoms like auditory hallucinations, suicidal thoughts, self-­ harm, and dissociative amnesia. An equal proportion of the male and female population suffers from the condition in early childhood but later in adolescence, a slight rise is seen A. Panachikkal Abubacker (*) Kerala University of Health Sciences, Thrissur, Kerala, India

in females with dissociative disorder. Physical, emotional, and sexual abuse in early childhood stands as the prime cause affecting behavioral development resulting in dissociative disorders including severe identity disorder in the later part of life [4]. Another study conducted in central Turkey to find out the prevalence of dissociative disorder in the general population with the Dissociative Disorders Interview Schedule among 628 women belonging to 500 households with a mean age of 34 years showed 18.3% of participants diagnosed with dissociative disorder and 1.1% had dissociative identity disorder [5]. In an epidemiological study conducted on 2153 participants who have completed the Dissociative Experience Scale, no significant sex differences in dissociative identity disorders were found. Even though there still exists hypothetical gender differences that even suggest a 9–1 predominance in the female population as they were found to be more symptomatic, this does not contribute to the diagnostic categories [6].

 ale Population and Dissociative Identity M Disorder The male population with dissociative identity disorder is found to have suffered from sexual and emotional abuse in their childhood. Post-traumatic Stress Disorder and Dissociative Identity disorder goes hand in hand. A study conducted on 44 patients with Dissociative Identity Disorder and 22 patients with Dissociative Disorders Not Otherwise Specified showed post-traumatic stress disorder as the most prevalent comorbidity. Around 85% of men who contracted sexual abuse in their childhood were reported to have appeared with dissociative identity disorder with fear and rage [7]. Another study by Allegia and Mishna showed that 26% of men in the general population and 36% of men from clinical settings had a history of sexual abuse. These men were reported to have been part of interpersonal vio-

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lence, homicides, and other criminal offenses. High rates of criminal cases are a challenge to finding the right treatment for the disorder in men as they are a threat to the society [8]. Studies done by Lowenstein and Putnam and Gentile et al. shows that the majority of people with this disorder are women. However, their earlier studies in 1990 showed that the disorder was more common in men [9]. Multiple personalities shown by men themselves show gender alters with women. Rosik concludes that more than 60% of men show opposite gender alters. Cultural thoughts and social stigma of men being more strong and ill-free inhibit them to seek early treatment. This can result in consequences like men engaging in criminal activities and causing self-harm [10].

 ransgender Population and Dissociative T Identity Disorder Being in a community that leads a stressful life with a feeling of being locked inside another gender which unmatches their identity, they are prone to have mental issues from childhood. Considering the mental trauma in childhood to be the greatest risk of gender identity disorder, transgender males and females have an equal chance of getting this condition. Fewer data are available for the specific population suffering from gender identity disorders. A study performed by Burnes et  al. on 14 transgenders have described the stressors like sexual abuse, verbal abuse, and interpersonal violence faced by the community contributing to mental health issues including dissociative disorders [11].

Conclusion The female population showed a higher prevalence in gender identity disorder compared to male population. More data are needed to comment about the transgender population.

Epidemiological factors like sexual and physical abuses were present as a common factor in the overall population with gender identity disorder.

References 1. Rifkin A, et al. Dissociative identity disorder in psychiatric inpatients. Am J Psychiatr. 1998;155(6):844–5. 2. Brand BL, Lanius R, Vermetten E, Loewenstein RJ. Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. J Trauma Dissociation. 2012;13:9–31. 3. Rodewald F, Wilhelm-Göling C, Emrich HM, Reddemann L, Gast U. Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. J Nerv Ment Dis. 2011;199(2):122–31. https://doi.org/10.1097/ NMD.0b013e318208314e. PMID: 21278542. 4. Putnam FW, Hornstein N, Peterson G. Clinical phenomenology of child and adolescent dissociative disorders: gender and age effects. Child Adolesc Psychiatric Clin. 1996;5(2):351–60. https://doi. org/10.1016/S1056-­4993(18)30370-­. 5. Sar V, Akyüz G, Doğan O.  Prevalence of dissociative disorders among women in the general population. Psychiatry Res. 2007;149(1–3):169–76. https://doi.org/10.1016/j.psychres.2006.01.005. Epub 2006 Dec 8 6. Spitzer C, Klauer T, Grabe HJ, Lucht M, Stieglitz RD, Schneider W, Freyberger HJ.  Gender differences in dissociation. A dimensional approach. Psychopathology. 2003;36(2):65–70. https://doi. org/10.1159/000070360. 7. Zeligman M, et  al. Lived experiences of men with a dissociative identity disorder. Adultspan J. 2017;16(2):65–79. 8. Allagia R, Mishna F. Self-psychology and male child sexual abuse: healing relational betrayal. Clin Soc Work J. 2014;42:41–8. 9. Loewenstein RJ, Putnam FW.  The clinical phenomenology of males with MPD: a report of cases. Dissociation. 1990;3:135–43. 10. Rosik CH. Opposite-gender identity states in dissociative identity disorder: psychodynamic insights into a subset of same-sex behavior and attractions. J Psychol Christianity. 2012;31:278–84. 11. Burnes TR, Dexter MM, Richmond K, et  al. The experiences of transgender survivors of trauma who undergo social and medical transition. Traumatology. 2016;22(1):75.

A Psychiatrist’s Perspective on DID

45

Sindhura Kompella, Felicia Gallucci, and Joseph Ikekwere

Introduction

Dissociative Identity Disorder (DID)

Dissociative identity disorder (DID) is quite rare and a fascinating illness to most clinicians since patients may have more than two alternate personalities and present with different affect and characteristics all within oneself. Upon initial diagnosis, the average number of personalities in DID is 2–4. The average number of personalities in someone with DID is 13–15 over the entire course of treatment. It is unusual, but there have been cases in which more than 100 personalities have been reported. The splitting nature of the illness can be fascinating since these personalities or alter-egos can present at different times, and patients do not recall each episode and instead report having “blackouts” of memories. It is also challenging for clinicians to diagnose since the diagnosis is mostly found as a rule out diagnosis after medical, substance use history, and other psychiatric comorbidities are assessed. Patients also commonly present with comorbidities of other psychiatric conditions and clinicians need to be wary of the illness presentation and treatment options to have appropriate treatment plans. The loss of memory, according to one study shows that the inter-identity amnesia should be considered more of a meta-memory problem than an inability to retrieve information since patients have access to memory representations. Consequently, it is an important aspect to understand, especially in considering therapeutic interventions such as identify self with others, hypnosis, or integrating memories across their various identities with the help of trauma-focused cognitive behavioral therapy [1].

DID is important to understand and diagnose since illness can be rare, and diagnosis is often overlooked. Though current dissociative identity disorder facts now show that the prevalence of the disorder is beginning to rise compared to less than 100 diagnosed cases by 1944, perhaps due to greater understanding and better knowledge and understanding of the condition along with fewer cases of misdiagnosis. Patients with DID present with multiple comorbidities. It is hard for clinicians to distinguish the complexity of the illness if they are not vigilant, which can lead to an increase in hospitalization and worse treatment outcomes for the patients. A study done on 230 patients in an inner-city hospital outpatient service shows that borderline personality disorder and trauma history were prevalent in the DID patient population. This group was studied to better understand suicidality rate and self-injurious behaviors. It was evident through the study that the number of patients who commit suicide in this population group is often overlooked. More importantly, the presence of DID itself was strongly associated with all measures of suicidality and self-harm after confounding variables were eliminated. Moreover, logistic regression analysis of the study shows that multiple suicide attempts status was significantly associated with dissociative diagnosis. This has serious implications if DID is misdiagnosed for other psychiatric illnesses that may not have similar outcomes in the general population group [2].

DID in Child vs. Adult S. Kompella (*) · F. Gallucci Department of Psychiatry, University of Miami, Miller School of Medicine, Miami, FL, USA J. Ikekwere Department of Psychiatry, University of Illinois, Chicago, IL, USA Southwest Psychiatric Services, Orland Park, IL, USA

Many studies have shown that DID in childhood-onset is uncommon. However a study done on ~70 adolescent patients with dissociative disorder were observed to have no difference in gender distribution in dissociative vs. non-­dissociative groups. They also noted that separation anxiety disorder was very common in this population group. More importantly,

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about 90% of patients had an additional psychiatric disorder. The diagnosis of DID in adolescents has been shown to be effective through clinical interviews using Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), but the self-report questionnaires such as Adolescent Dissociative Experiences Scale have been shown to be promising. These tools relate dissociative symptoms with dysfunctional relationships and childhood trauma in most cases. Hence, we can see that both in adult and childhood-­onset, DID patients have similar etiology. It is also important for clinicians to screen for trauma early since it can have further implications on how DID may initiate into adulthood or become more severe in presentation with age [3]. Another small study conducted in Japan by Bozkurt et al. shows that adolescent patients with DID have comorbid mood disorders, substance use disorders, and trauma. The most common psychiatric comorbidities included depression, posttraumatic  stress disorder (PTSD) and anxiety disorders. It also shows that about 50% of patients with DID had comorbid conditions; hence clinicians should be vigilant with the illness so misdiagnosis is limited and appropriate treatment options are undertaken promptly in this population group [4]. Some symptoms that are seen per the literature review include behavioral features such as staring, mood swings, forgetfulness, fear or anger, and extensive reaction to stimuli, somatic complaints during testing such as physical pain in response to imagery studies, as mentioned in Silberg’s study. Some of these symptoms may be preliminary in patients, and therefore, it can be difficult to diagnose a child with DID vs. an adult since they may be less communicative. However, being vigilant for some of these characteristics may help guide clinicians to consider this illness among the complexities of other psychiatric illnesses [5].

Risk Factors Individuals who are victims of past violence and mistreatment are at elevated risk of developing DID. Children who have experienced significant repeated trauma and have a high hypnotic potential combined with poor parental support and difficulties with attachment [6]. High correlation between DID and trauma with up to 90 percent in cases is found across the high correlation countries [7]. Other risk factors include severe abuse, recurrent neglect, natural disasters, and past trauma in childhood. It is believed that dissociative symptoms originate to help a person deal with distressing and traumatic memories.

Diagnosis The clinical interview, which is structured, is the best way to diagnose patients with DID. Current DSM-5 criteria for diagnosis of DID is as follows: (a) Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption of marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual. (b) Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. (c) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (d) . The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. (e) The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Source: From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. Some questions to consider include the following as indicated in Table 45.1. Table 45.1  Interview questions for dissociative identity disorder Open-ended Forgetful events Objects missing/present Different handwriting Voices The other person Collateral history

Memory problems? You behave differently in different circumstances You either miss certain events or places or they are present at odd times You find you write differently at different times and cannot recall the handwriting at times You may hear auditory hallucinations You may feel like another person altogether or “not you” Family or friends may tell you about various events that you may be forgetful about or did not know has occurred

45  A Psychiatrist’s Perspective on DID

Treatment DID recovery is long-term, multistaged and consists mainly of talk therapy, hypnotherapy, and other psychotherapeutic treatment interventions. Treatment consists largely of psychotherapy modalities rather than pharmacological interventions prescribed to treat specific symptoms. A trauma-based therapy approach with modifications to include the alternate dissociative states (or “alters”) has been employed. Empirical evidence has demonstrated that a triphasic trauma-based model is beneficial in DID with improvements in symptomatology and functioning [8]. This model has three stages of treatment focus: (1) safety, stabilization, and symptom reduction, (2) processing and mastering trauma memories, and (3) reintegration of identity [9]. The goal of treatment, at best, is to consolidate the dissociative states whereby the patient does not subjectively experience separate identities. However, clinical reports have demonstrated that this outcome is challenging to achieve. Alternatively, a more realistic treatment goal focuses on integration, cross-communication and adaptive functioning between the alters, which optimizes social, emotional and cognitive functioning in the individual [6]. It is important to view the person as one entity when working with DID patients. Together, the multiple alters form the individual and are a part of their identity as a whole. As such, it is equally important for the person to be held responsible for the behavior of any of the alters despite amnesia. This distinction assists in developing and strengthening the integrative functioning between the alters [10].

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ing one treatment modality before another. Some baseline level of stability is required for DID patients to begin the triphasic trauma-based model. Therefore, it may be more appropriate to treat one of the comorbid conditions first before considering DID treatment [10].

Differentials Some differential diagnoses as discussed already in Chap. 17 include but not limited to schizophrenia, schizoaffective disorder, possible borderline or histrionic personality disorder due to changes in affect and personality, and Bipolar disorder (especially Bipolar II disorder), Asperger syndrome or even Munchausen syndrome in some cases. Important to consider any substance abuse, including Lysergic acid Diethylamide, mescaline, or peyote. Additionally, other differentials include medical conditions which can present similarly such as epilepsy and traumatic brain injuries [11, 12].

Conclusion DID is quite rare and hard to diagnose due to the nature of the illness and how the presentation can be complex since it can co-occur with PTSD-like symptoms. Therefore, it is important for clinicians to understand symptom presentation and severity, so misdiagnosis is limited and appropriate treatment options are rendered to the population groups.

References Other Treatment Considerations Duration and frequency of treatment are individualized. Due to the complexity and comorbidities associated with DID, the duration of treatment tends to be long term with years of therapy, rather than other psychotherapy modalities that last for weeks or months. There are no guidelines on the frequency of sessions. This determination becomes dependent on patient motivation, stability, therapist expertise, and insurance compensation, to name a few contributing factors. The role of pharmacotherapy in the treatment of DID has been established to treat comorbid conditions. No particular medication has been studied to be effective for the treatment of DID alone. Similarly, other psychotherapeutic interventions can be used to treat the comorbid conditions, such as Dialectical Behavioral Therapy (DBT) or substance abuse treatment for patients with Borderline personality disorder or substance use disorders, respectively. Being mindful of the complexity of the patient and severity of symptoms may lead to prioritiz-

1. Marsh RJ, Dorahy MJ, Butler C, Middleton W, de Jong PJ, Kemp S, Huntjens R.  Inter-identity amnesia for neutral episodic self-referential and autobiographical memory in dissociative identity disorder: an assessment of recall and recognition. PLoS One. 2021;16(2):e0245849. https://doi.org/10.1371/journal. pone.0245849. 2. Foote B, Smolin Y, Neft DI, Lipschitz D.  Dissociative disorders and suicidality in psychiatric outpatients. J Nerv Ment Dis. 2008;196(1):29–36. 3. Sar V, Önder C, Kilincaslan A, Zoroglu SS, Alyanak B. Dissociative identity disorder among adolescents: prevalence in a university psychiatric outpatient unit. J Trauma Dissociation. 2014;15(4):402–19. 4. Bozkurt H, Duzman Mutluer T, Kose C, Zoroglu S.  High psychiatric comorbidity in adolescents with dissociative disorders. Psychiatry Clin Neurosci. 2015;69(6):369–74. 5. Silberg JL.  Dissociative symptomatology in children and adolescents as displayed on psychological testing. J Pers Assess. 1998;71(3):421–39. 6. Fink G, editor. Stress consequences: mental, neuropsychological and socioeconomic. New York: Academic Press; 2010. 7. Reinders AS, Nijenhuis ER, Quak J, Korf J, Haaksma J, Paans AM, et  al. Psychobiological characteristics of dissociative identity disorder: a symptom provocation study. Biol Psychiatry. 2006;60(7):730–40.

288 8. Brand BL, Loewenstein RJ, Spiegel D.  Dispelling myths about dissociative identity disorder treatment: an empirically based approach. Psychiatry. 2014;77(2):169–89. 9. Brand BL, Myrick AC, Loewenstein RJ, Classen CC, Lanius R, McNary SW, et al. A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychol Trauma Theory Res Pract Policy. 2012;4(5):490.

S. Kompella et al. 10. Chu JA.  Guidelines for treating dissociative identity disorder in adults (2005)–International Society for Study of Dissociation. J Trauma Dissociation. 2005;6(4):69–149. 11. Rathbun JM, Rustagi PK.  Differential diagnosis of schizophrenia and multiple personality disorder. Am J Psychiatr. 1990;147:375–5. 12. Shibayama M.  Differential diagnosis between dissociative disorders and schizophrenia. Seishin Shinkeigaku Zasshi. 2011;113(9):906–11.

Biography and Interview of a Patient with DID

46

Ian Hunter Rutkofsky, Hassaan Tohid, and Shirley Davis

Introduction

Part 1: Biography

We are honored to present the following two-part chapter, Biography (Part 1) and Interview (Part 2) of the life of Shirley Davis. The contents of the following chapter contain sensitive material and actual life events. Shirley’s Biography and Interview will focus on her trauma and experience living with Dissociative Identity Disorder (DID). Shirley’s case of DID is an example of how severe the disorder can be, with over 100 personalities. She is now far into her therapy and treatment and is well in the process of personal fusion. Shirley Davis is a freelance writer and author of several books on DID. Her books include the following:

The extreme trauma I experienced began at birth and carried on until I was 15 when I finally told on my grandpa. Grandpa had not only tortured me but had also sold me to his friends for sex, making a six-pack of beer or cash. When I told on grandpa, he immediately denied what he had done and that whole side of my family disowned me. Life went on and thanks to dissociative identity disorder, I could carry on for many years having ‘forgotten’ what happened. However, I always knew something was different. I could have other children accuse me of things I did not remember doing and wake up in strange places. These “differences” car 1. “Dissociative Identity Disorder In A Nutshell: A First-­ ried into adulthood, but I did not know what to think of them, Hand Account.” so I assumed everyone encountered what I was experiencing. 2. “A Compilation of the Research On the Topic of As an adult, the switching and not remembering what I Dissociative Identity Disorder.” said or did was becoming a liability. I often scratched my 3. “The Tears Will Cease: Recovering from Dissociative head and wondered why people called me by different names Identity Disorder.” when I met them at the store. 4. “Becoming: the Wonder of Integration.” To be clear, I remembered some of what grandpa and his 5. “Surviving the Treatment and Realities of Dissociative friends had done to me, but I did not know the extent of the Identity Disorder.” horror they had brought me. It was not until I was 29 that the 6. “Child Alters.” memories of what happened, depression and anxiety, caught 7. “The Last Comprehensive Resource Book About up to me. Dissociative Identity Disorder You Will Ever Need.” I had memories spontaneously return when I was 29 years 8. “The Storm in Your Brain Called Complex Post-­Traumatic old. I had gone to bed for the night and turned off the light. Stress Disorder.” Suddenly, I was transported back in time to when I was a small child who was being brutally sodomized. I shook off the vision I had just had and sat up the rest of the night, terrified that if I turned the light back off, it would come again. After that night, I would experience the resurfacing of memories anywhere and at any time. I thought I had gone crazy. I. H. Rutkofsky (*) I had been seeing a drug and alcohol counselor to support Amen Clinics, Washington DC, USA my brother, who was an alcoholic, and told her what I had Convenient Psychiatry and Mental Health Services, been experiencing. She took a deep breath and told me she Maryland, USA could not help me, but she knew someone who could. She H. Tohid · S. Davis handed me a business card with the name Paula McNitt on it. California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA I made the appointment that very day. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_46

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I remember the first day I met Paula. It was in November 1989, and it terrified me to meet her. I had a horrible time not floating away from her in a dissociated state. I did not know it was called dissociation then. I just knew I wanted desperately to get her help to make the craziness in my mind stop. I saw Paula once a week for 4 months before she finally gave me the diagnosis of what they then called multiple personality disorder. I was floored. I had heard of the disorder because I had once seen Sybil, but me? At first I dismissed her diagnosis and thought seriously about not going back, but I did and I am glad I did not quit her because we began a partnership that would see me through to final fusion. The work of overcoming the horrendous damage done to my mind by my abusers was arduous. I would get so exhausted working on the chaos that is DID that I would become suicidal and need to go into the hospital for a while. This happened over 30 times in the course of 5 years in treatment. One by one, we dissected the memories that were surfacing, and slowly, I started to heal. Along the way, I became more self-aware and could focus on who I was as a person. At first, I hated who I was and snubbed Paula when she would tell me I was a worthwhile person. It would take many years of treatment for me to finally understand that I am my own best ally and that I am indeed worthwhile. In 1998, I had been seeing Paula for 9 years when, because of bankruptcy, the clinic she worked for told me I could not make payment arrangements. They also told me I could never see Paula again. They did not allow me to even say goodbye, and I found out later, they did not tell Paula why I was not seeing her either. It was as though the umbilical cord had been cut too soon, as Paula was the only mother I really ever knew because my birth mother was neglectful. I began to figuratively bleed to death as my mental health deteriorated. I searched for a therapist to take the place of Paula, hoping to find a psychologist like her, but had no luck. I spiraled down in my mental and physical health until my brother insisted I check myself into a long-term psychiatric facility. I do not remember entering the facility or the first 2 years I was there. I do not know who in my DID system was in control, but I was told I acted like a juvenile, so I strongly suspect it was one of my teenagers. When I came to myself again, I was told by the facility that DID did not exist and that I was to never talk about it to anyone, including staff, other residents, and especially the counselor they were assigning me for treatment. During my time in the facility, I began to grow. I learned on my own the value of having one’s freedom because I had none. I learned that life is too short to allow me to live in chaos. However, I lingered in that facility for 7 years until the facility changed my counselor. Dawn, my new therapist, had experience in the treatment of dissociative identity disorder and we worked together

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towards my healing and eventual freedom from the facility. Because I had been told never to speak to my counselor about DID, we often met outdoors out of earshot of the powers that be. I had promised my mother I would remain in the facility, and she wanted me to stay forever. However, in June 2011, my mother died, and I was suddenly freed from her influence. I went to her funeral on Saturday and on Monday I told Dawn I was ready to leave. I moved into a group home in September 2011 and loved the relative freedom I had when compared to the long-term facility. I shopped at the store with a personal shopper and felt shocked at the prices of things. I needed to learn to live outside of an institution again, not knowing anything about what had changed since I entered the facility. Then, in June 2012, my brother invited me to move in with him and his new wife. I accepted and in July first moved in with them. I had lost Paula for nearly 14 years previously and saw a therapist with our local mental health clinic. All I could talk about was Paula in every session and finally my new therapist asked why I did not go see Paula again. I told her about the bankruptcy and what they had told me, but she insisted I try, anyway. The very next day, I called the business department of the clinic and found out they had gone not-for-profit and had a program that would not only pay off my old bill but allow me to see Paula again at no cost to me. So, I excitedly made a new appointment with Paula and begin seeing her again. That first visit with Paula was like a homecoming. All the children in my DID system shouted for joy and filled my mind with so much noise I could barely hear what Paula was saying to me. We were finally home. Paula and I worked together until her retirement in 2016. By then, I had grown in strength and self-understanding to the point we both knew I would be alright. Fusion had begun and continues to this day. Today, I live a quiet life. I still see a therapist once a month for maintenance and to keep track of the severe depression, I can experience with the changing of the seasons. I have not seen Paula since 2016, and sometimes I feel grieved that I will most likely never see her again. But life goes on and I am doing fine.

Part 2: Interview 1. Do we have your permission to ask these questions to you? For the book chapter and publish them with you being a coauthor? Yes, you do. 2. Hi how are you?

46  Biography and Interview of a Patient with DID

I am doing just fine. I am living a quiet life in Springfield, Illinois. 3. Please tell us more about yourself? I am an author, speaker, and aunt to two beautiful boys. My books and writing are available online. I enjoy writing very much and write for CPTSD Foundation as their chief writer. 4. What do you do for a living? And your educational background? I write for a living and have been on SSDI (social security disability income) since 1995 because of my inability to work with having both physical and emotional problems. However, I am also a writer’s coach, teaching others how to write well. I earned an Associate Degree in Psychology in 2015 from Lake Land College in Mattoon, Illinois. I am only a few classes away from earning my bachelor’s degree also in psychology. My writing ability came from my great aunt, who was also a prolific writer. 5. Why do you think you have DID? I know I have DID, as I was diagnosed with it in 1990. The symptoms are unmistakable as I experience time loss, identity confusion, and the emergence of alters. 6. If you were officially diagnosed, what year was it? And who diagnosed you? A psychiatrist or a psychologist? No need to mention the name of your doctor. A psychologist officially diagnosed in 1990 with dissociative identity disorder. 7. How old are you now? 61 Years old. 8. When was the first time you had a DID episode? If you mean switching, I noticed when I was 9 or 10 years old. 9. How did you know it was a DID episode? I have always noticed things were not quite right, but I did not know it was DID until I was diagnosed and talked to a psychologist about my experiences. 10. Tell us about your DID? I am poly fragmented, meaning; I have over 100 identity states. I have worked hard over the past 31 years while in therapy and have come to final fusion where all my alters are cooperating and going in the same direction. At one time, I would switch and do or say things I did not remember, a few of them illegal. Now I am pretty much at peace and the chaos mostly has ended. 11. Why did you seek a psychiatrist/treatment? I was having horrendous flashbacks and did not understand what they were. I thought I had become psychotic and was frightened, so I sought help from a therapist.

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12. How many personalities do you have when you have a DID episode? Usually only one or two will come out at the same time. Sometimes I am conscious with one or two and we all front. 13. Every case of DID can be different. Do you think your DID case differs from others? Absolutely. My experiences and alters differ from other DID systems. However, there are similarities between them, too, such as switching and losing time. 14. Is your DID case different from the ones we see on TV/movies? Oh, hell yes! TV and the movies portray people with DID as monsters who are dangerous and need to be locked up or avoided. I am not a monster like in Split. I cannot run at superhuman speeds, climb walls, nor do I eat people. The movies and TV have done more damage to people like me living with DID than anything else. 15. Do you have any triggers that bring out a DID episode? I have several triggers. Certain odors like men’s cologne and beer mixed, and even certain music. 16. How long does this new personality last? Alters form all throughout the lifespan of a person like me, living with DID. They stay for life as they are all me and I am them. They are not strangers or demons. When an alter emerges to take over the body, the episode can last minutes to years. 17. How many personalities do you have overall at different times ever since your first episode? Over 100. 18. Who told you about your first episode? No one. I just became aware of episodes of switching and understood what they were when I was diagnosed. I had things happen to me all my life I could not explain. People would call me by different names in public and I was told I did or said things I could not remember doing or saying. 19. Are all personalities of different gender and age? Yes. I have a wide range of ages, both sexes, and all sexually orientations. 20. Did you ever feel you are possessed by a demon? No. Never. I have been tossed out of two churches because I would not allow them to perform an exorcism. Like I said, alters are not demons, they are parts of myself stuck in trauma-time. 21. When other personalities are active, do you remember that your other personalities are in power or controlling you? Now I do, but at one time I did not. I would switch, do, or say something, then when I switched back. Sometimes I would be totally ignorant of what happened or even that the episode had happened at all.

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22. Did treatment help? Yes. Most definitely. 23. Any medications you took to treat DID? There are no drugs to treat DID. There are only medications to treat the depression and anxiety that accompany it. 24. Tell us about your childhood? Do you think you had some childhood trauma? My childhood was full of trauma. I was abused and neglected from a very young age and forced to fend for myself to look for food. My dad was in the Navy and onboard a ship out to sea for at least 7 months at a time, and my mother was addicted to alcohol and prescription medications. I was severely neglected. I was also exposed to trauma from my grandfather, who was brutal in his attacks. It was not only sexual abuse he committed against me, but he also sold me to his friends for sex and used torture to control me. My childhood was a living hell. 25. How do you describe your parents? Great, okay, or bad? My mother was a prescription drug addict and an alcoholic who was neglectful and abusive. My father was in the Navy and away for months at a time onboard ship. Neither tried to stop the abuse that was happening to me from another family member. They were terrible parents. 26. Any history of substance use? In question 25, I outlined my mother’s addictions. My father was a binge drinker, and I became sober 4  years ago from a 40  year addiction to prescription medications. 27. Do you want to get rid of DID? Or do you consider it an integral part of your personality? I am actively pursuing final fusion, which does not mean what it sounds. My alters and I are as close as we can get to being a “singleton” (someone who does not have DID). We are conscious and coaware, working together most of the time now. 28. Do you remember all the personalities? Or do others tell you? I remembered (discovered) all my personalities myself. 29. After coming back to your original personality, which is Shirley Davis, do you remember being someone else for the time being? Not always. Sometimes I am aware because I can see the evidence such as money has been spent or new clothes bought. One time I had an air conditioner delivered to me in an alters name. 30. How long is each episode? Usually, a few hours but some can last years.

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31. On average after how many days do you get the episode of DID? I am not able to count them. Sorry. 32. What is the longest time you spent without an episode? Two years. I lost two years of my life and awoke in a psychiatric ward. 33. Any post episode symptoms? Exhaustion and confusion. Plus, I have to mop up if someone has done or said something that is harmful. 34. Any pre-episode symptoms? Not really. I know something triggers them, but I am not always knowledgeable as to what those triggers are. 35. Any comorbid conditions? Psychiatric conditions. Yes. I have an anxiety disorder and major depression. 36. Anything you feel is the reason for your DID? Extreme childhood trauma is the cause of DID. I was tortured and otherwise abused by a family member and his friends from birth to age 15. I was also a victim of narcissistic abuse from my mother. 37. Do you want to get rid of these multiple personalities? I wish to integrate, but there is no getting rid of DID as it is a lifelong condition. 38. Has it affected your overall health? Yes. My addictions which were fed by DID cause me to end up not only grossly obese but also in a wheelchair after a stroke. 39. Relationships? Parents, siblings and spouse. Romantic relationships are affected? All my relationships are affected. I was married once for 8 years but divorced him because I could not handle the pressure of both treating DID and marriage. Since then (2000), I have had absolutely no relationships. I have no friends except those I visit via online chat rooms. I isolate myself. 40. Career? And financial situation. I write for a living, but it does not pay well. However, I enjoy it very much. I am on disability so I do not make enormous amounts of money to live on each month. However, my financial situation is improving since I have complete control over my money now. 41. What would have been different had you not been a DID patient? I would have my PhD in psychology by now and be working for NASA because I would have gotten into school early and worked hard to obtain that career. At one time, my goal was to help get people to Mars by analyzing which personality types would get along well on a long space flight.

46  Biography and Interview of a Patient with DID

42. Do you consider yourself as a patient? No. I am not a survivor any longer either. I am a thriver. 43. What advice will you give to a DID person? There is tons of advice I would give a person living with DID. For one, never give up. The chaos will pass as you heal. Two, make certain your therapist believes in not only your diagnosis, but also in your healing from DID. Three, healing takes a long time. As my therapist told me, it takes longer than what you want but not as long as you fear. And finally (for the sake of room I would not say more), be patient with yourself and your alters. DID does not develop overnight and it would not heal overnight. 44. What advice will you give to a DID patient’s family? Read all you can on the diagnosis to further understand the struggles your family member is going through. Remember, DID and its accompanying symptoms are not your fault, but you cannot fix someone else. It cannot be done so do not try. Just be there for them and support them with your love. 45. What do you think of the stigma related to DID? The stigma attached to DID is unfounded and unnecessary. We have enough to deal with without being discriminated against. 46. Since you are open about your DID, do you think it was a good decision to be open about it? Being open about DID is not for everyone. I am out there on the internet, but I seldom disclose to people I do not know well as I do not want them to be afraid of me because of the way the media portrays us in the movies and television. 47. Have you been discriminated against because of DID? Yes. I have had doctors treat me badly because I have DID and also when I lived in a psychiatric facility I was not allowed to speak about DID to anyone, not even the therapist they assigned me. They did not believe DID was real and instead thought I was just a manipulative person. 48. These personalities can change anytime, anywhere? Or is there a particular time of the day? Or any activity? Switches can take place anytime and anywhere. There does not seem to be a particular time of day when switching becomes worse, at least in my DID system. 49. Is it possible that you are walking or driving a car and suddenly change your personality? Or does it happen only when you are resting or eating? Etc.

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What I am doing does not affect whether or not I switch personalities. All I need is an appropriate trigger. If I were to change into a different alter while driving it would be okay because we have a rule that forbids child alters from driving. If a switch occurs during normal activities such as eating, there is no harm done. When was the last time you were under the episode? I have them daily, so the answer to your question is yesterday (it is early morning here right now). I still switch but they are not as frightening or destructive as the episodes I had when I first entered therapy. Anything you would like to add? Dissociative identity disorder is not a death sentence when one is diagnosed with it. Instead, DID was a blessing when I was a child because I was trapped and helpless. DID was the only way for me to escape either dying by suicide (which I attempted at age 7) or going totally insane. Overall, do you consider yourself a happy person? Yes. Today I am a happy and contented person. Did you ever think why me? How did you handle this question? A million times per day in the beginning and middle stages of healing. I handled it by saying, “Why not me?” After all, I am not the only person who has DID and perhaps I could handle the hassle of it better than other people. Did your therapist help? Enormously. If it were not for Paula, I would not be alive today. Did religious and spiritual support help? Absolutely not. Any message to the readers in the end? Those, like me, who live with DID are only people. We are not monsters, special, or crazy. We are totally normal for the circumstances we grew up under. What do you want others to know about DID? DID is a survival mechanism that helped me to survive circumstances that were desperate and abusive. I wish people would read the truth about DID and not depend on movies or television shows to teach them about what it is like to have the disorder. Shirley, you have been active with your Blog and books about DID, how can others find your blog and would you like others to know about your books? My Amazon.com publishers page is here: https:// w w w . a m a z o n . c o m / S h i r l e y -­J -­D a v i s / e / B01MSKQ76I?ref=sr_ntt_srch_ lnk_1&qid=1638632647&sr=8-­1 My blog can be found at: https://www.learnaboutdid. com/ My books contain no triggering material, just facts from a person who has lived experience.

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59. Has blogging and writing about DID been therapeutic for you? Yes, it has. I have enjoyed receiving comments from those who have read my material about how much I have helped them. That means the world to me. I feel empowered by my writing and hope that others can read my material and gain self-knowledge. 60. Do you ever wake up or dream in another personality? I sleepwalk as other personalities, so I guess the answer to this question is yes? 61. Does your diet change or do you find it difficult to follow a strict diet plan while in other personalities? I am diabetic and have problems with my child alters wanting and getting candy and other sugary foods. 62. How about the professional world, at work, does DID ever interfere with your ability to perform at work? I am on permanent disability because I do not do well with the stress or pressure of working. Too much stress will cause me to become exhausted and that raises the possibility of me becoming suicidal. It is just not worth it. 63. Do you remember the whole episode of DID vividly every time or just sometimes or never? Is it like a blackout? I sometimes get inklings and visions of what occurred while I was dissociated but mainly I have amnesia for the event. 64. I know a patient who used to fight her multiple personalities and used to get back to her real personality after continuing struggle. Does that happen to you? (If it is a blackout, then she of course will answer NO). No. At least not anymore.

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65. Where have you ever misdiagnosed initially? I was very fortunate and found a therapist right away who correctly diagnosed me with DID.  On average, it takes around 11 years for people to receive the correct diagnosis. 66. Do you have any other psychiatric comorbidities? Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). 67. Do you have any medical comorbidities? I live in a wheelchair, I have diabetes, I have had breast cancer, and many other ailments that experiencing adverse childhood experiences have contributed to. 68. Do you have any family history of psychiatric? My mother had Major Depressive Disorder and attempted suicide twice before completing it in 2011. 69. What do you think about Cases reported where physiologic changes differ within different personalities? Such examples being one personality having an allergy such as hives to a food. I have never had this experience, so I really do not want to comment on it.

Conclusion We hope that the Biography (Part 1) and Interview (Part 2) in the chapter has brought a pithy summary of some important questions. These questions aim to answer real-life circumstances and open up key replies to many inquiries about DID.  Given the time Shirley Davis provided us to answer these personal questions, we are confident that the interview delivers another look into the window of the life of a DID patient.

Comorbid Conditions in Dissociative Identity Disorder Patients: What to Look for?

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Hassaan Tohid

Introduction It is rightly said that “problems never come alone.” The same could be considered true for Dissociative Identity Disorder (DID); it also comes with some comorbid conditions in many cases. In fact, according to a study, on average, individuals with DID can have up to five comorbid conditions [1]. While not all patients will have comorbid conditions, clinicians should be aware that there is always a possibility of a hidden condition alongside DID. As discussed previously in this book, DID is a mental disorder characterized by the presence of two or more personality states or identities. Nonetheless, I believe this book would have been incomplete without a chapter on the comorbidities associated with this disorder. This chapter is my attempt to address certain conditions that clinicians should consider while treating patients with DID to improve the well-being of the patients.

Some Common Comorbid Conditions of DID The following are some comorbid conditions that clinicians should consider while treating patients with Dissociative Identity Disorder (DID): 1. Post-Traumatic Stress Disorder (PTSD) This book has already addressed that DID is associated with childhood trauma. Therefore, it is reasonable to expect Post-Traumatic Stress Disorder (PTSD) to be one of the comorbidities associated with DID.  Studies have revealed that the most common comorbid condition with DID is PTSD [1]. However, a study with 25 patients showed that the most common psychiatric diagnoses were Major Depression, present in all 25 patients, followed by PTSD in 22 patients, anxiety disorders in 21 H. Tohid (*) California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA

patients, and attention-deficit hyperactivity disorder (ADHD) in 15 patients [2]. Although this study had a small sample size of 25 patients, it is evident that PTSD is prevalent in the majority of DID cases. In a study conducted by Frauke Rodewald et al., it was suggested that the comorbidity profiles of patients with Dissociative Identity Disorder (DID) and Dissociative Disorders not otherwise specified (DDNOS) were quite similar to those with Post-Traumatic Stress Disorder (PTSD), with a high prevalence of anxiety, somatoform disorders, and depression. However, the profiles differed from those of patients with anxiety disorders and major depression [1]. These findings confirmed the relationship between PTSD, DID, and DDNOS. Considering that finding PTSD in DID patients is not surprising, clinicians should ask these patients specific questions. For example, if they experience recurrent nightmares or memories of past traumatic events, if they have flashbacks, if they avoid certain people, places, or activities associated with the traumatic events, or if they exhibit hypervigilance or symptoms such as heightened sensitivity, difficulty concentrating, and sleep disturbances. Asking these questions can help therapists better understand the patient’s condition. 2. Depression It is natural to assume that individuals who have experienced serious trauma in their past would be at risk of developing major depression at some point in their lives. Additionally, the challenges faced by many individuals with Dissociative Identity Disorder (DID) due to their diagnosis can also increase their risk of developing depression. Bozkurt et  al. discussed the prevalence of depression as the second most common comorbid condition associated with DID. Although their study focused on adolescent patients, it provides insight that individuals with DID, regardless of age, can have depression as a comorbid condition [2]. Furthermore, Ellason et al. suggested that 82% of adult DID patients had at least one comorbid Axis-I disorder with a mean number of comor-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_47

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bid disorders being 7.3 [3]. This data indicates that age does not play a significant role in the presence of comorbid conditions such as depression. A knowledgeable clinician should always inquire about symptoms related to depression during the ­assessment. DID patients may exhibit symptoms such as sadness, anhedonia, and other commonly associated depressive symptoms. Therefore, it is crucial to ask questions pertaining to these symptoms for an accurate diagnosis. Moreover, it is well known that individuals with major depression are at risk of suicide, so it is essential not to overlook inquiries about suicide risk to ensure patient safety. 3. Anxiety Disorders Some individuals with Dissociative Identity Disorder (DID) may also present with anxiety disorders such as Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, and Panic Disorder [2, 4, 5]. The stress associated with DID symptoms can sometimes contribute to the development of these anxiety disorders. Therefore, it is important not to overlook questions related to anxiety. Clinicians should inquire about symptoms such as constant worry, fear, and difficulties with concentration. 4. Substance Use Disorders It is possible for some individuals with DID to turn to illicit drugs as a way to cope with the stress of their life affected by DID or as a result of painful traumatic experiences [6]. Therefore, questions related to substance use disorders should never be ignored. It is essential to consider the possibility that the patient may have been using drugs or alcohol for an extended period and may require rehabilitation. Since substance use disorder significantly impacts various aspects of life, including health, relationships, career, and finances, it is imperative that if the patient is severely affected by substance use and the clinician is not specialized in treating substance use disorders, the patient should be referred to a clinician who specializes in treating drug and alcohol addiction. 5. Borderline Personality Disorder (BPD) Dissociative Identity Disorder (DID) patients are prone to being affected by Borderline Personality Disorder as well. Several studies have shown the prevalence of Borderline Personality Disorder in DID patients. A skilled clinician is aware of this and does not overlook the importance of screening for Borderline Personality Disorder when treating DID patients. If the clinician feels that they lack the expertise and skills necessary to address Borderline Personality Disorder, they should refer the patient to a clinician who is well-trained and equipped to treat this condition [7].

H. Tohid

Other Psychiatric Disorders DID patients may or may not present with other psychiatric disorders such as schizophrenia, bipolar disorder, and Attention-Deficit Hyperactivity Disorder (ADHD) [2, 8]. However, these disorders are not as common as the ones mentioned above. A competent therapist always keeps this in mind and asks questions with a comprehensive perspective. If a patient has a comorbid condition that the clinician lacks experience in treating, it is recommended to refer the patient to someone who is well-trained and experienced in dealing with such cases, or to pursue further training and knowledge about the specific disorder.

Conclusion It is important to note that these comorbidities can vary, and not every individual with Dissociative Identity Disorder (DID) will experience all of them. Proper diagnosis and personalized treatment plans are essential for effectively managing both DID and any accompanying conditions.

References 1. Rodewald F, Wilhelm-Göling C, Emrich HM, Reddemann L, Gast U. Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. J Nerv Ment Dis. 2011;199(2):122–31. https://doi.org/10.1097/ NMD.0b013e318208314e. 2. Bozkurt H, Duzman Mutluer T, Kose C, Zoroglu S. High psychiatric comorbidity in adolescents with dissociative disorders. Psychiatry Clin Neurosci. 2015;69(6):369–74. https://doi.org/10.1111/ pcn.12256. Epub 2014 Dec 29 3. Ellason JW, Ross CA, Fuchs DL. Lifetime axis I and II comorbidity and child-hood trauma history in dissociative identity disorder. Psychiatry. 1996;59:255–66. 4. Boon S, Draijer N. Multiple personality disorder in The Netherlands: a study on reliability and validity of the diagnosis. Lisse: Swets & Zeitlinger Publishers; 1993. 5. Bliss EL. A symptom profile of patients with multiple personalities, including MMPI results. J Nerv Ment Dis. 1984;172:197–202. 6. McDowell DM, Levin FR, Nunes EV. Dissociative identity disorder and substance abuse: the forgotten relationship. J Psychoactive Drugs. 1999;31(1):71–83. https://doi.org/10.1080/02791072.1999. 10471728. 7. Ross CA, Ferrell L, Schroeder E.  Co-occurrence of dissociative identity disorder and borderline personality disorder. J Trauma Dissociation. 2014;15(1):79–90. https://doi.org/10.1080/15299732 .2013.834861. 8. Foote B, Park J. Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues. Curr Psychiatry Rep. 2008;10(3):217–22. https://doi.org/10.1007/s11920-­008-­0036-­z.

Dissociative Identity Disorder: The Editor’s Perspective

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Hassaan Tohid and Ian Hunter Rutkofsky

Introduction By now, having diligently read through the preceding chapters of this book, you should have acquired a deeper understanding of what Dissociative Identity Disorder (DID) entails. Without delving into intricate details, we acknowledge that DID is a personality disorder recognized by the Diagnostic and Statistical Manual (DSM) [1], which poses a challenge not only to patients but also to their families [2]. It is difficult to fathom what it would be like to live with a disorder in which one lacks control over their own personality, and where they can switch between not just two but potentially hundreds or even thousands of different personalities. DID is not as uncommon as some believe, with a prevalence rate of approximately 1.5. Many individuals with DID have experienced some form of traumatic event in their past, and as a result, may exhibit symptoms of the disorder later in life.

based knowledge, endorsed by scientific research, the DSM, and the majority of clinicians and psychiatrists globally.

The Impact of Denial

Denying the existence of DID implies rejection of the hard work, efforts, and experience of numerous talented scientists and researchers who have conducted extensive research. Furthermore, denying it disrespects the genuine suffering of individuals with DID. Facebook, for instance, hosts several groups for patients with various types of illnesses [3]. DID is no different. There are various Facebook groups where patients and their families discuss the issues, problems, and challenges associated with DID. Those who still doubt the legitimacy of this disorder should speak with those who have experienced its symptoms. It is easy to dismiss something without speaking to those who have endured it. We must demonstrate empathy and put ourIs Dissociative Identity Disorder Real? selves in the shoes of others to comprehend their position. Rejecting DID outright without speaking to the thousands Despite the fact that numerous psychiatrists deny the legiti- of individuals who have suffered from this disorder will macy of Dissociative Identity Disorder (DID), we have pro- only perpetuate our ignorance. vided evidence-based research and knowledge in this book Denying the existence of Dissociative Identity Disorder that clearly indicates it is a genuine disorder recognized by (DID) poses yet another challenge, which is the impact on most mental health clinicians, psychologists, and psychia- the treatment of patients. If medical professionals themselves trists worldwide. The DSM, as discussed earlier, also recog- reject the validity of this disorder, how can we provide the nizes it as a disorder. Therefore, those who reject the necessary care for those suffering from this serious condilegitimacy of this disorder should read opposing perspectives tion? DID is often accompanied by other comorbid condiand acknowledge that those of us who believe in the legiti- tions, and denying its existence deprives many patients of the macy of DID are supported by scientific facts and evidence-­ care and treatment they deserve. Clinicians carry a great responsibility to their patients, and the principles of beneficence and non-maleficence require them to act in the best H. Tohid interest of their patients and avoid causing harm. By denying California Institute of Behavioral Neurosciences and Psychology, Fairfield, CA, USA the legitimacy of DID, we ultimately harm those who suffer from this serious disorder. I. H. Rutkofsky Amen Clinics, Washington DC, USA There are generally two types of denials regarding DID.  Some doctors deny the existence of the disorder, Convenient Psychiatry and Mental Health Services, Maryland, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4_48

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although this is a small minority. Others deny it for religious reasons, which is common in many parts of the world. They consider DID as a form of demonic possession. The consequences of both types of denials are the same: a large number of DID patients are denied treatment, which is ultimately detrimental to their well-being. We firmly believe that our book will not only benefit clinicians but also help educate people who are unaware of the reality of DID as a disorder. Our work aims to raise ­awareness and promote understanding of this condition, which can ultimately improve the lives of those who suffer from it.

H. Tohid and I. H. Rutkofsky

References 1. Diagnostic and statistical manual of mental disorders: DSM-5. 5th edition, American Psychiatric Association. DSM-V; 2013. https:// doi.org/10.1176/appi.books.9780890425596.dsm02. 2. Kitamura N. Seishin Shinkeigaku Zasshi. 2011;113(9):918–26. 3. Chung JE.  Social networking in online support groups for health: how online social networking benefits patients. J Health Commun. 2014;19(6):639–59. https://doi.org/10.1080/10810730.2012.757396.

Index

A Abuser introject, 16 Acute dissociative reactions, 30, 90 Acute stress disorder, 81, 90 Adaptationism, 216 Additive genetic influences, 133 Adenylyl cyclase8 (ADCY8) gene, 134 Adjunctive therapy, 4 Adolescent Dissociative Experiences Scale (A-DES), 102 Adversities, 186 Alter personality, 186 Altered sensory perceptions, 127 American Academy of Psychiatry and Law (AAPL), 238 American Criminal Justice System, 234 American Medico-Psychological Association, 8 American population, 175 American Psychological Association, 73 Amnesia, 243 Amygdala, 80, 138 Animal hypnosis, 127 Anterior cingulate cortex (ACC), 138 Anterograde amnesia, 111 Anticonvulsants, 209 Antidepressants, 208 Anti-posttraumatic stress disorder (PTSD) drug, 129 Antipsychotics, 208 Antisocial personality disorders, 10 Anxiety, 61, 67, 73–75, 81, 296 Anxiolytics, 209 APBB2 genes, 134 Assessment instruments, 239 Asymmetric amnesia, 119 Attachment figures, 236 Attachment problems, 179 Attachment styles, 236 Attachment theory, 165, 166 Attention Deficit Hyperactivity Disorder (ADHD), 296 Auditory hallucinations, 94 Authoritative parenting style, 165 Autism, 61 Automatic regrettable memories, 130 B Badiou, Alain, 188 Baker, Charley, 245 Balanced diet, 262 Battered Child Syndrome, 235 Beck Anxiety Inventory (BAI), 62 Beck Depression Inventory (BDI-II), 62 B-endorphins, 35 Beta-blockers, 209 Bilateral stimulation, 62, 63

Biographic memory episodes, 12 Biography, 289, 290 Biopsychosocial model, 96 Bipolar disorder (BPD), 15, 296 Bipolar disorder type 2 (BP-2), 161 Bodily self-detachment, 187 Borderline personality disorder (BPD), 88, 102, 123, 155, 160, 184, 218, 273, 274, 296 clinical presentations, 110, 111 diagnosis, 111 differentials, 112 epidemiology, 109, 110 etiology/risk factors, 110 prognosis, 110 treatment options, 112 Brandmarked therapy methods, 179 C Canadian Journal of Psychiatry, 145 Cardiovascular effects, 35 Career support, 264 Caregiver and individual attachment, 165 Ceruloplasmin, 35 Charcot, Jean-Martin, 21 Chase, Truddi, 246 Child and adolescent, DID diagnosis, 102 differential diagnoses, 102 management, 103 Child Dissociative Checklist (CDC), 102 Child management techniques, 167 Childhood abuse, 143, 148 Childhood experience questionnaire (CEQ), 176 Childhood experiences, 251 Childhood memories, 234 Childhood-onset post-traumatic stress disorder (PTSD), 137 Childhood sexual abuse, 187 Childhood trauma, 16, 133, 137, 148, 149, 187, 188 Children’s Dissociative Experience Scale, 102 Christianity, 172 Chronic and recurrent syndromes, 30 Chronic traumatization, 179 Clinical improvement, 269 Clinician-administered tools, 154, 155 Clonidine, 209 Cognitive analytic therapy, 213 Cognitive behavioral therapy (CBT), 4, 61, 89, 91, 213, 224, 263 Cognitive complexity, 69 Cognitive distortions, 179 Cognitive-emotional, 187 Cognitive-evaluative, 34 Cognitive insight, 186

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 H. Tohid, I. H. Rutkofsky (eds.), Dissociative Identity Disorder, https://doi.org/10.1007/978-3-031-39854-4

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300 Cognitive skill, 102 Cognitive therapy, 25 Common psychiatric disorders, 208 Communication, 61 Communication skills, 61 Community based studies, 87 Comorbid conditions, 292 Comorbidity, 110 Companionate love, 250 Complex Dissociative Disorders (CDD), 177 Complex posttraumatic stress disorder (C-PTSD), 88, 123 Concrete infanticidal attachment, 237 Conscious awareness, 21 Conversion disorder (CD), 156, 161 Convicted child abusers, 247 Coping strategies, 61 Correlation inconsistencies, 36 Corticolimbic hypothesis, 37 Cortico-limbic system, 137 Cortisol secretion, 134 Countertransference, 216 Court of Law, 236 Criminal activity, 57, 237 Criminal responsibility, 235 Cross-cultural variation, 42 Cultural beliefs, 94 Cultural Formulation Interview (CFI), 42 Culturally competent, 41 Culture bound syndromes, 42, 43 Cumulative traumatization, 187 Cyclic-nucleotide-gated potassium channel 1 pacemakers, 130 D Decision-making capacity, 240 Deconstructive encouragement, 191 Defendants, 239 Defense syndrome, 147 Dehydronorketamine, 34 Delusional phenomena, 90 Delusions, 94 Depersonalization, 22, 111 Depersonalization/derealization disorder (DPDRD), 3, 159 course, 30 diagnosis and clinical features, 29 differential diagnosis of, 30 epidemiology, 29 etiology, 29 treatment, 30 Depression, 295, 296 clinical correlations and implications of, 68 dissociative identity disorder (DID) diagnostic and therapeutic considerations, 70 neurophysiology and neurocircuitry, 68, 69 symptomatology and pathogenesis, 69, 70 lability and suicidal ideation, 67 social and emotional functioning, 67 and trauma-related disorders, 68 Derealization, 111 Detachment, 187, 237 Diagnostic and Statistical Manual (DSM), 67, 159, 297 diagnostic criteria, 8–10 diagnostic issues, 10, 11 evolution of, 8 Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5), 22, 23, 31, 42, 44, 73, 77, 87, 119, 141, 153, 207 Diagnostic instruments, 236

Index Dialectical behavioral therapy, 89, 225 Dialectical discourse, 190 Dialectical dynamic therapy (DDT), 190 Dialectical thinking, 188, 190 Diet change, 294 Different personalities, 247 Diffuse tensor imaging (DTI), 137 Dipeptidyl-peptidase 6 (DPP6) gene, 134 Discrete Behavioral States Model (DBSM), 81 Disillusionment, 181 Disorganized attachment, 236 Disorganized speech, 94 Disrupted-in-schizophrenia-1 (DISC1), 95 Dissociated traumatic memories, 222 Dissociation, 7, 42, 218, 237 vs. dissociative disorder, 77, 78 Dissociative amnesia (DA), 3, 22 diagnosis and clinical features, 26 differential diagnosis, 27 epidemiology, 26 etiology, 26 Dissociative anesthesia, 156 Dissociative disorders, 237, 268 Dissociative Disorders Interview Schedule (DDIS), 68, 70, 82 Dissociative Disorders Not Otherwise Specified (DDNOS) diagnoses, 86, 87 Dissociative effect, 130 Dissociative episodes, 234 Dissociative events, 23 Dissociative Experience Scale (DES), 69, 176, 186, 203 Dissociative Experiences Scale-Taxon (DES-T), 68, 82 Dissociative fugue, 111 diagnosis and clinical features, 28 differential diagnosis, 28 epidemiology, 28 etiology, 28 treatment, 29 Dissociative identity disorder (DID), 2, 23, 24, 101, 289, 291–294, 297 accurate diagnosis of, 179 adults vs. children prognosis, 201 in animals freeze response in, 128, 129 mammalian brain, 129, 130 pathological dissociation approach, 127 trauma and distress, 130, 131 and anti-depression, 36 anxiety, 74, 75 vs. bipolar, 115 and borderline personality disorder, 273, 274 brain network, 138, 139 causes of, 141, 142 challenges in diagnosis, 156 changes to, 86 characteristic features of, 85 childhood trauma, 149 in child vs. adult, 285, 286 clinical features, 24 clinical presentation, 101, 102, 116 clinical surface, 182 clinical trials, 175–177 treatment options, 177 cognitive behavioral therapy, 224 comorbidity, 49, 50, 295, 296 competency and, 240 confusion of roles, 219 consciousness, 143 coping after resolution, 180

Index core dissociative dimensions, 182 cortico-limbic disconnect model, 138 court cases involving, 241 crime, infanticidal attachment, 236 cultural presentations of, 171 culture-bound presentations, 169 dating in people with, 251 diagnosis of, 24, 116, 235, 259, 286, 287 diagnostic criteria, 8–10, 86, 153 diagnostic tools, 154–156 differential diagnosis, 25, 116, 287 early markers for, 148 EEG studies of, 277, 278 electroconvulsive therapy, 227 emergent intervention, 269 environmental stressors, 148 epidemiology, 24, 80, 87, 105, 115 etiology, 24, 81, 87, 115, 116 etiopathology of, 137 evidence-based treatment guidelines, 213 experimental pharmacological treatments, 209 eye movement and desensitization reprocessing, 224, 225 factors and causes, 119, 120 family history of psychiatric, 294 family involvement, 269 family support, 267, 268 family therapy, 226, 227 fantasy model (FM), 147 female population, 283 forensic aspects of, 237 functional dissociation of self, 182 functional MRI findings, 276 future direction of research, 178 future directions in diagnosis, 156 future of treatment, 210 general principles, 180, 181 glutamate’s role in neurotransmission, 139 group therapy, 200, 215, 216 history of, 124, 125, 153, 154 early history, 1 and hypnosis, 2 sybil, 2 20th century, 1 in Hollywood and movies, 57–59 hyperarousal vs. hypoarousal, 271, 272 hypnosis, 224 identificatory processes, 191–193 impact of denial, 297–298 impact of social media on, 3 identity, 143 incidence and prevalence, 49 individualized treatment plans, 200 initial thoughts to diagnosis, 267 inpatient treatment, 214, 215 internal moderator, 183 interpersonal stressors, 148 layers of treatment, 181–183 legal statues, 234 longitudinal cohort studies, 197 in male patients diagnosis of, 106 locations of presentation, 105, 106 risk factors for, 105 sociocognitive model, 106 symptomatology at presentation, 106 trauma model, 106 treatment of, 106

301 male population, 283, 284 malingering, 240, 241 medical management, 177, 178 memory, 143 miscellaneous/non-physiological presentations of, 162 and mood disorders, 161 multi-modal approach, 200 myths, 15–19 natural self and emotions, 183 neuroanatomical changes, 137 neurobiologic correlation, 150, 151 neuroimaging, 137 neurophysiology, 80 non-dissociative psychiatric disorders, 160 and other dissociative disorders, 159, 160 outpatient treatment, 214 partial hospitalization program (PHP), 215 patient’s safety, 268 perception, 144 personality disorders, 160, 161 PET studies of, 277 pharmacological and psychiatric combined therapy, 200 pharmacological monotherapy, 199, 200 pharmacological treatment of, 208, 209 phase oriented treatment model, 221–223 phases of, 191 positive aspects, living with, 204, 205 possession, 172 posttraumatic stress disorder, 272, 273 predictors of clinical course, 200 presentations of, 159 prevalence, 4, 73 development and course of, 10 and diagnosis, 4 primary structural dissociation, 122 primary treatment of, 213 prognosis of, 116 proposed etiology of, 142 and psychiatric comorbidities, 198, 199 psycho-biology of, 124 psychotherapy and pharmacotherapy tips, 260 and psychotic disorders, 161 ratification of aquisitions, 193 and religion, 169, 170 religious and spiritual support, 293 vs. repression, 217 revictimization, perpetration, and self-destructive behavior, 219, 220 risk factors, 50, 115, 116, 145, 146, 286 ritual abuse and satanic abuse, 170, 171 role of listening, 269 schneiderian symptoms, 149 secondary structural dissociation, 122 sensorimotor therapy, 226 separateness vs. wholeness, 220, 221 social media characteristics, 255 dangerous algorithms on, 256 faking illnesses online, 255, 256 influencers, 255 self-diagnosing audiences of, 256 self-expression outlet, 256 support and community online, 257 sociocognitive /non-trauma-related model, 149 spirituality, in mental health, 169, 170 structural dissociation, 122 structural MRI findings, 274–276

302 Dissociative identity disorder (DID) (cont.) tertiary structural dissociation, 124, 125 transgender population, 284 trauma and open communication, 121 trauma-based dissociation and memory, 274 trauma focused psychotherapy, 223, 224 trauma model (TM), 147 traumatic memories, 220 traumatic (symptomatic) self, 182 treatment, 83, 287, 292 goals and modalities, 213–216 and management, 4 options, 117 outcomes, 209, 210 in 21st century, 2, 3 types of, 3 Dissociative personalities, 18 Dissociative psychosis, 186 Dissociative seizure, 161 Dissociative symptoms, 22, 179 Dissociative trance, 91 Dissociative Trance Disorder Interview Schedule (DTDIS), 91 Distorted cognitions, 130 Distressing dreams, 130 Dopamine, 35 E Early childhood abuse, 151 Economic planning, 166 Ego state therapy, 226 Electroconvulsive therapy (ECT), 25, 37, 227 Emotion dysregulation, 110 Emotional and psychological stress, 203 Emotional distress, 94 Emotional dysregulation, 204 Emotional operating systems, 218 Emotional pain, 73, 188 Emotional regulation, 61 Emotional stabilization, 61 Empathy, 61 Empathy-based relationship, 188 Enactment, 150 Environment, 133 Environmental influences, 176 Environmental stressors, 148 Ethnicity, 41 Evolution, 127 Evolutionary adaptedness, 127 Experiences Scale Score, 176 Explicit memory, 23 Expressive and occupational therapies, 26 External reality, 188 Extreme stress, 129 Extrinsic factors, 250 Eye movement desensitization and reprocessing (EMDR), 26, 62, 177, 213 F False memory syndrome, 31 Family members, 166, 167, 200, 269 Family support, 263 Family therapy, 26, 200, 226, 227 Fantasy model (FM), 82, 147, 149

Index Fear and trauma, 237 Fear of freedom, 193 Fight Club, 58 Financial situation, 292 Forensic psychiatrist, 234, 239, 240 Forensic report, 239 4-D model, 81 Freud, Sigmund, 21 Frye test, 235 Functional dissociation, 184 Functional impairment, 83 Functional magnetic resonance imaging (fMRI), 138 Fusions, 180 G Gamma-aminobutyric acid (GABA), 34, 139 Ganser syndrome, 31, 42 Gender differences, in love, 250 Generalized anxiety disorder (GAD), 296 Global Assessment of Functioning (GAF), 177 Glutamate receptors, 142 Glutamatergic systems, 129 Glycerophospholipid metabolism, 129 Grossly disorganized behaviors/catatonia, 94 Group therapy, 26, 200, 215, 216 H Hallucinations, 36, 94, 102 Healing process, 247 High-functioning individuals, 11 Hilgard's model, 21 Hinduism, 171 Hippocampal-pituitary-adrenal (HPA) axis functioning, 69 Hippocampus, 138 Hippokrates, 190 Host personality, 188 Hyperarousal vs. hypoarousal, 271, 272 Hypnagogic hallucinations, 150 Hypnosis, 2, 25, 89, 91, 213, 224 Hypnotherapy, 4 Hysteria, 1, 154 Hysterical psychosis, 186 I Identifiable characteristics, 246 Identificatory operations, 190 Identity alteration, 185 Illness, 261 Implicit memory, 23, 176 Impulsivity, 111 Individual psychosocial maturation, 188 Individual recovery, 167 Infanticidal attachment, 237 Infatuation, 250 Informed consent, 217 Initial emotional expression, 166 Intelligent functional entity, 245 Intensive psychological distress, 130 Interleukin-6 (IL-6), 134 Internal homicide, 186 Internal reality, 187 Internally detached individual, 184–187

Index International Society for the Study of Trauma and Dissociation (ISSTD), 82, 177, 201, 213, 226 Interpersonal conflicts, 166, 167 Interpersonal relationship dynamics in people with mental illness, 251 review of, 249 romantic relationship dynamics, 249, 250 Interpersonal stressors, 148 Intimate partner violence (IPV), 219 Intrinsic functional connectivity MRI (fcMRI), 177 Introjective identification, 187 Invisible disability, 251 J Janet, Pierre, 21 Juvenile trauma, 130 K Ketamine, 139 adverse effects, 35, 36 contraindications and cautions, 36 DID, 37 controversy, 37, 38 pathophysiology, 37 dissociation and other CNS adverse effects, 36 history, 33 indications, 33, 34 mechanism of action, 34, 35 pharmacokinetics, dosage, and administration, 34 Ketamine exposure, 129 Ketamine-induced dissociation, 38 Kinetic movements, 171 L Levinger, George, 249 Linear thinking, 186 Literary Doubles, 54 Love, types of, 250 M Magnetic resonance imaging (MRI), 137 Major depressive disorder (MDD), 33, 69, 81, 198 Major psychiatric disorders, 41 Malingering, 236, 238 Medial prefrontal cortex (MPFC), 176 Medical community, 19, 246 Medical comorbidities, 294 Medical option, 18 Medication regimen, 207 Meditation, 263 Memory, 143, 274 gaps, 246 lapses, 102 researchers, 234 Mental abnormality, 129 Mental content, 183 Mental disorders, 166 Mental health, 247 Mental health issues, 203 Mental health professionals, 234 Mental healthcare, 245 Mental illness, 169

303 dating in people with, 250 Mentalization, 187 Meta-memory problem, 285 Michigan Alcoholism Screening Test (MAST), 62 Mindfulness, 61, 62 M'Naghten Rule, 234 Modalities, 61, 62 Monsters Inside: The 24 Faces of Billy Milligan, 59 Mood disorders, 161 Mood stabilization, 208 Mother-deprived animals, 131 Motivational systems, 218 Motor expressions, 127 Multidimensional Inventory of Dissociation (MID), 62, 82, 102, 155, 203 Multimodal management approach, 67 Multiple childhood traumas, 247 Multiple identity enactment, 150 Multiple personality disorder, 53–55, 234, 245, 246, 292 μ-opioid receptor, 35 N Naltrexone, 209 National Alliance on Mental Illness (NAMI), 269 National Epidemiological Survey on Alcohol and Related Conditions (NESARC), 109 National Institute on Alcohol Abuse and Alcoholism (NIAAA), 109 Natural self, 183 N-dealkylation, 34 Negative emotions, 185 Network structure theory, 95 Neural-circuit dynamics, 129 Neuregulin-1 (NRG1), 95 Neurological symptoms, 180 Neuroplasticity, 61 Neuropsychiatric manifestations, 208 Neurosis, 8 Neurotransmission, 150 NMDA-type glutamate receptor antagonists, 129 N-methyl-d-aspartate (NMDA) antagonists, 128 N-methyl-D-Aspartate (NMDA) receptor, 34, 36, 139 Non-epileptic seizures (NES), 156 Nonprofessional groups, 216 Nonverbal experiences, 61 O Obsessive-compulsive disorder (OCD), 15, 93 Ongoing abuse interferes, 189 Open-ended style, 239 Orbitofrontal hypothesis, 37 Organic mental disorders, 41 Original identity, 268 Other specified dissociative disorder (OSDD), 3, 17, 30, 31, 87 chronic and recurrent syndromes, 88 OSDD-I chronic and recurrent syndromes, 85 OSDD-II identity disturbance, 85 OSDD-III acute dissociative reactions, 86 type I, 89 type II, 89 type III, 89–91 type IV, 91, 92 Overadjustment, 189 Overprotection/overcontrol, 187

304 P Panic attacks, 65 Panic disorder, 296 PANSS questionnaire, 94 Paradigm shift, 190 Paradoxical intervention and psychoeducation, 91 Paranoid psychosis, 186 Parieto-occipitotemporal cortex, 139 Partial hospitalization program (PHP), 215 Patient Health Questionnaire-9 (PHQ-9), 68 Patient’s childhood, 236 Patient’s functioning, 221 Patient’s personalities, 208 Performance anxiety, 247 Peritraumatic dissociation, 90 Permanent disability, 294 Person’s well-being, 249 Personal information, 141 Personal life, 263 Personality disorders, 16, 160, 161 Personality-oriented therapy, 216 Personality switches, 268 Pharmacological monotherapy, 199, 200 Pharmacotherapy, 73, 260 Phase-oriented treatment model, 222 Physical contact, 216 Physical exercises, 262 Physical movements, 263 Physician-patient confidentiality, 238 Physiological stress, 130 Polymorphous clinical phenotype, 187 Positive attitude, 260 Positive psychology, 62 Positron emission tomography (PET), 137, 143 Possession, 171 Possession trance, 31 Post episode symptoms, 292 Post-traumatic constellation, 190 Posttraumatic model (TM), 22 Post-traumatic stress disorder (PTSD), 34, 81, 147, 160, 161, 189, 272, 273, 295 case studies, 62–64 clinical interviews, assessment, 62 dissociative subtype of, 82 modalities, 61, 62 Post-traumatic symptoms, 179 Pre-episode symptoms, 292 Prefrontal cortex (PFC), 138, 139 Prenatal infections, 95 Primary depression, 69 Primary dissociation, 219 Procedural learning, 260 Projective identification, 187 Prolonged exposure (P.E.) therapy, 177 Psychiatric comorbidities, 213, 285, 294 Psychiatric disorders, 159 Psychic equivalence, 186 Psychoanalytic theory, 21 Psychodynamic interpretation, 264 Psychodynamic psychotherapy, 201, 213 Psychodynamic therapy, 8, 91, 213 Psychoeducation, 61, 62, 66 Psychogenic Amnesia and Psychogenic Fugue, 2 Psychogenic movement disorders (PMD), 161 Psychogenic nonepileptic seizures (PNES), 101, 161 Psychogenic seizures, 180

Index Psychological detachment, 189 Psychological expressions, 41 Psychological mechanisms, 133 Psychological self, 183 Psychopathological symptoms, 127 Psychopharmacological interventions, 25 Psychopharmacological treatments, 98 Psychosocial education, 62 Psychosocial stressors, 93 Psychotherapeutic process, 61 Psychotherapy, 4, 25, 73, 190, 201, 262 Psychotic disorders, 161 Purine metabolism, 129 R Race, 41 Recovered memories, 170 Regional cerebral blood flow (rCBF), 139 Relaxation and art therapy exercises, 61 Religious rituals, 167 Religious support, 264 Repression, 21, 217, 236 Retrospective cohort study, 68 Retrospective studies, 50 Romantic relationships, 292 Rudimentary memory systems, 23 S Safe alternative strategies, 167 Schema therapy, 201 Schizophrenia, 16, 129, 296 clinical case presentation, 97 diagnosis, 97, 98 diagnostic criteria, 94 vs. DID, 93 differential diagnosis, 98 epidemiology DID and, 94 etiology and risk factors, 94, 95 pathophysiology, 95 prognosis, 96, 97 treatment, 98 Schwartz, Arielle, 61 Scientific experimentation, 127 Scientific research, 18 Secondary dissociation, 219 Self-care techniques, 61 Self-conception, 101, 145 Self-conscious, 189 Self-control, 187 Self-deception, 179 Self-diagnosis, 256 Self-harm behavior, 222 Self-identity, 189 Self-injurious behaviours, 98, 260 Self mutilating behaviour, 198 Self-mutilation, 187 Self-report tools, 155, 156 Self-soothing, 61 Self-system, 183 Semel, Rebecca, 256 Sensorimotor intervention, 226 Sensorimotor psychotherapy, 226 Sensorimotor therapy, 226 Sensory-discriminative, 34

Index Sensory feedback, 61 Sensory feelings, 61 Sensory loss, 156 Several childhood traumas, 66 Sexual abuse, 185, 246 Sexual relationships, 216 Sexual violence, 133 Shareability school of thought, 261 Single nucleotide polymorphisms (SNPs), 134 Sleep disturbances, 23, 150 Sleep model (SM), 23 Sleep-related experiences (SREs), 23 Social anxiety disorder, 296 Social responsibilities, 249 Social-skills training, 227 Social support, 261 Sociocognitive model (SCM), 22, 50, 150 Sociocultural influence, 150 Sociological self, 182 Somatic symptoms, 102 Somnambulism, 234 Specialized physiotherapy, 91 Specific dissociative disorders, 159 Spirituality, 169 Split, 58, 218 Standard international assessments, 42 Standardized Mini Mental State Exam (SMMSE), 62 State mental health laws, 233 Stevenson, Robert Louis, 54 Strategic internationalism, 216 Structural dissociation of personality, 218 Structural family therapy, 167 Structured Clinical Interview for DSM-IV Dissociative Disorders-­ Revised (SCIDD), 69–70, 82 Structured Interview of Reported Symptoms (SIRS), 106 Subjective units of distress (SUD), 225 Substance use, 292 Substance use disorders, 296 Sufficient sleep, 263 Suggestive psychotherapy, 150 Suicidal thoughts, 260 Suicidality and self-mutilation, 180 Support groups, 167, 261 Supportive therapy, 213, 224 Switching, 261 Sybil, 58 T Tactical integrationism, 216 10th revision of the International Classification of Diseases (ICD-10), 78–79, 153

305 Tertiary dissociation, 219 Therapeutic alliance, 216 Therapeutic movements, 191 Therapy session, 18 Thigpen, Corbett H., 245 Thomas, Louise, 257 Tomlinson, Kendal, 245 Transference, 216 Trauma-focused therapy, 224 Trauma, 191 and fantasy model, 150 history, 96 ICD-10 Criteria, 78, 79 ICD-11, 79, 80 impacts of, 83 Trauma model (TM), 147 Trauma-related altered states of consciousness (TRASC), 81 Trauma spectrum disorders, 68 Trauma therapy, 179, 189 Traumatic events, 203 Traumatic Memory Inventory (TMI), 176 Traumatic Stress Inventory, 102 Traumatic stressors, 245 Treatment-based commitments, 235 Treatment of Patients with Dissociative Disorders Study (TOP DD), 198, 221 Treatment plans, 263 Treatment providers, 166 Treatment-resistant depression (TRD), 69 Turkish psychiatrists, 42 Turkish society, 189 21-item Beck Depression Inventory (BID), 68 U Unipolar depression, 161 Unspecified Dissociative Disorder (UDD), 3, 87 Untreated pernicious anemia, 246 V Verbal abuse, 149 Verbal emotional abuse, 187 Vocalizations, 61 Volumetric measurements, 138 W Walker, Herschel, 247 World Health Organization (WHO), 38, 78, 83