the Dissociative Personality Disorder (PIDD) it is a complex disorder that has been studied very little and poses a challenge to clinical professionals. Part of the complexity lies in the difficulty of identifying it. This is why many cases are lost in anonymity.
Dissociative personality disorder: what is it?
One of the first challenges that TIDP patients face in therapy is that they often receive incomplete or simply misdiagnosed diagnoses. Incomplete in the sense that they may be relevant to one of the alter egos, while they are inadequate in the context of multiplicity.
Many people with dissociative personality disorder never show up for a psychological or psychiatric consultation. And, when they do, they are often misdiagnosed. This prevents them from getting the help they need.
What is TIDP?
Among the specialists in this disorder are Valerie Sinason, Psychoanalyst and director of the Clinic for Dissociation Studies. She is the editor of the book “Attachment Trauma and Multiplicity” and in the introduction to it, she comments:
“Over the past decade, I have counseled and treated children and adults, especially women, who suffer from Dissociative Personality Disorder (DID). There is a very important bias concerning the sex of the people who suffer from it. Male child victims of abuse are more likely to externalize their trauma, although both sexes use externalizing responses.Most of the children and adults I have evaluated have been misdiagnosed as schizophrenic, borderline , with an antisocial or psychotic disorder … despite the fact that the antipsychotic drugs had little or no effect on them, the voices they heard were from within and not from the outside, and ‘they had no thought disturbance over time and site except when in transit, despite all this, mental health professionals did not perceive any errors in the diagnosis, reckoning Given professional confusion and social denial, some patients have achieved or cultivate their multiplicity when accused of inventing. In response to the key question regarding the small number of children with severe dissociated states, some patients confirmed negative responses to their childhood confessions that led them to mask symptoms. These children were told that this would happen to them and that it was a phenomenon of imaginary friends ”(2002 p. 5).
The purpose of the concept of dissociation: refers to the process of encapsulation or separation of memory or emotion directly associated with the trauma of the conscious self. Dissociation is a creative way to keep something unacceptable out of sight. Dissociative Personality Disorder is a way that the internal system creates to protect secrets and is continually learning to adapt to the environment. It is a survival mechanism. It also promotes and maintains tilt with the aggressor. It allows, on the mental level, to keep certain conflicting emotions in separate compartments.
More precisely, dissociation it involves a wide variety of behaviors that represent failures in the cognitive and psychological process. The three main types of dissociative behavior that have been recognized are: amnesia, absorption and depersonalization.
- the dissociative amnesia it is about being suddenly in a situation or having to face proof of having performed actions that the person does not remember.
- the absorption it’s about getting so involved in what’s going on that the person forgets what’s going on around them.
- the depersonalization it is about experiencing events as if the individual were an observer, disconnected from the body or from feelings.
North et al. (1983; cited by Sinason p. 10) found that this condition was not only linked to a high percentage of child sexual abuse, but also to a 24-67% occurrence of sexual abuse in life. . Adult, and between 60 and 81% of suicide attempts.
It is clear that TIDP is an important aspect of grouping together conditions produced by trauma. In the United States, in a sample of 100 patients with PIDD, it was found that 97% of them had suffered significant trauma in childhood and nearly half of them had witnessed the violent death of a loved one. (Putman et al. 1986; cited by Sinason p. 11)
Until very recently, it was very difficult to document cases of PIDD in children. Although there are those who argue that it doesn’t mean they don’t exist. The same is true for adolescent cases and only adult cases of TIDP receive support from the scientific community.
Richard Kluft said his efforts to trace the natural history of TIDP had failed. His attempts to find cases of children were an “absolute fiasco”. He described the case of an 8-year-old boy who appeared to exhibit “a series of developed personality states” after witnessing a situation in which someone nearly drowned in water and suffered physical violence. However, he and other colleagues realized that his field of vision was too narrow. He noted that Gagan and MacMahon (1984, cited by Bentovim, A. p. 21) described a notion of incipient multiple personality disorder in children; the possibility of a broader spectrum of dissociative phenomenology that children might exhibit has been raised.
TIDP diagnostic criteria
the DSM-V criteria specify that the TIDP manifests as:
- The presence of one or more different identities or personality states (each with their own relatively stable patterns of perception, relating to and thinking about the environment and the self.
- At least two of these identities or personality states repeatedly assume control of the person’s behavior.
- The inability to remember important personal information that is too prevalent to be explained by ordinary forgetting and that is not due to the direct effects of a substance (for example, loss of consciousness or chaotic behavior during intoxication alcoholic) or a general medical condition (eg complex partial attacks).
Guidelines for diagnosis and treatment
Whatever the diagnosis, in the event of dissociation, it is important to explore the role it plays in the patient’s life. Dissociation is a defense mechanism.
It is important for the therapist to discriminate between dissociation and to talk about defense mechanisms as part of a process. The therapist can then accompany the patient in exploring the reasons why he can use this mechanism as a defense. If the therapist addresses the issue of dissociation as soon as there is any indication of it, the diagnosis will come more easily. Using the Dissociative Experience Scale (DES) or the Somatomorphic Dissociation Questionnaire (SDQ-20) can help determine the degree and role that dissociation plays in a person’s life. (Haddock, DB, 2001, p. 72)
The International Society for the Study of Dissociation (ISSD) has developed general guidelines for the diagnosis and treatment of TIDP. He states that the basis of a diagnosis is a mental status examination that focuses on issues related to dissociative symptoms. The ISSD recommends the use of dissociative review tools, such as DES, Dissociative Disorders Maintenance Program (DDIS), and DSM-IV Structured Dissociative Disorder Clinical Interview.
The DDIS, developed by Ross, is a very structured interview that covers topics related to the diagnosis TIDP, as well as other psychological disorders. It is useful in terms of differential diagnosis and provides the therapist with the average scores for each subsection, based on a sample of TIDP patients who responded to the inventory. The SCID-DR, developed by Marlene Steinberg, is another very structured interview instrument used to diagnose dissociation.
An important aspect of Steinberg’s work is the five central dissociative symptoms that must be present to diagnose a person with TIDP or TIDPNE (non-specific). These symptoms are: dissociative amnesia, depersonalization, unrealization, identity confusion, and identity alteration.
TIDP is experienced by the dissociative as identity confusion (whereas the non-dissociator generally lives life in a more integrated way). The TIDP experience is that the dissociator often feels disconnected from the world around him, as if he is sometimes living in a dream. The SCID-DR helps the clinical professional to identify specific aspects of this history.
In any case, the basic components of the therapist related to the diagnostic process include, but are not limited to, the following:
A comprehensive history
A first interview which can last between 1 and 3 sessions.
Special emphasis on questions relating to the family of origin, as well as psychiatric and physical history. The therapist should pay attention to memory gaps or inconsistencies found in the patient’s accounts.
It is helpful to take notes regarding the amnesia and avoidance that occurs during the session. You should also appreciate the changes in facial features or voice quality, in case it seems out of context to the situation or what you are dealing with right now. Notice an extreme state of sleep or confusion that interferes with the patient’s ability to follow the therapist during the session (Bray Haddock, Deborah, 2001; pp. 74-77).
Review of dissociative experiences
If dissociation is suspected, a review tool such as DES, DDIS, SDQ-20 or SCID-R could be used to gather more information.
Note symptoms related to amnesia, depersonalization, unrealization, identity confusion, and identity alteration before diagnosing TIDP or TIDPNE.
Differential diagnosis to rule out specific disorders
You can start by considering the above diagnoses. That is to say, taking into account the number of diagnoses, the number of times the patient has received treatment, and the objectives achieved during previous treatments. The above diagnostics are considered even if not used, unless they currently meet DSM criteria.
It is then necessary to compare the DSM criteria with each disorder whose dissociation is part of its composition and to diagnose TIDP only after observation of alter ego alterations.
Look for the presence of drug addiction and eating disorders. If it is suspected that there may be dissociation, using a review tool such as CD or ED, a greater perspective can be obtained regarding the function of the dissociation process.
Confirmation of diagnosis
If dissociation is confirmed, DSM criteria are re-compared against possible diagnoses and diagnosis of TIDP, only after observing relief from alter egos. Until then, the most appropriate diagnosis will be dissociative nonspecific personality identity disorder (PIDDI) or post-traumatic stress disorder (PSE).
- Bray Haddock, Deborah, 2001. Dissociative Identity Disorder. Source book. McGrow-Hill Publishers, New York.
- Fombellida Velasco, L. and JA Sánchez Moro, 2003. Multiple personality: a strange case in forensic practice. Notebooks of forensic medicine. Seville, Spain.
- Orengo García, F, 2000. Prevalence, diagnosis and therapeutic approach of dissociative identity disorder or multiple personality disorder. www.psiquiatria.com
- Rich, Robert, 2005. Have Parts ?: A Guide to Successfully Managing Life with Dissociative Identity Disorder. ATW and Loving Healing Press. UNITED STATES.
- Sinason, Valerie, 2002. Attachment, trauma and multiplicity. Working with Dissociative Identity Disorder. Routledge, UK.