Dissociative Identity Personality Disorder (DIDP)

The Dissociative Identity Personality Disorder (DIDP) it's a disorder complex that has been very little studied and that represents a challenge for clinical professionals. The complexity lies in part in the difficulty of identifying it. For this reason, many cases are lost in anonymity.

Dissociative Identity Personality Disorder: What is it?

One of the first challenges that TIDP patients face in therapy is that they often receive incomplete or simply wrong diagnoses. Incomplete in the sense that they may be relevant with respect to any of the alter egos, while inadequate in the context of multiplicity.

Many people with Dissociative Identity Personality Disorder never go to a psychological or psychiatric consultation. And when they do, they are often misdiagnosed. This makes it impossible for them to get the help they need.

What is the TIDP?

Among the specialists of this disorder, is 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:

"In the last decade I have counseled and treated children and adults, especially women, who have Dissociative Identity Personality Disorder (DIDP). There is a very significant bias regarding the sex of the people who suffer from this condition. Male child victims of abuse are more prone to externalizing their trauma, even though both sexes employ 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 antipsychotic medication had little or no effect on them, that the voices they heard came from within rather than without, and that they did not have a disorder of thinking about time and place, except when they were in a trance state, despite all this, mental health professionals did not perceive flaws in the diagnosis. In view of professional confusion and social denial, some patients have managed to hide their multiplicity when accused of inventing it. In response to the key question concerning the small number of children with severe dissociated states, some patients confirmed negative responses to their childhood confessions that led them to hide the symptom. Those children were told that it would pass and that it was a phenomenon of imaginary friends "(2002 p. 5).

Dissociation

The purpose of the concept of dissociation: refers to process of encapsulating or separating the memory or emotion that is directly associated with the trauma from the I conscious. Dissociation is a creative way to keep something unacceptable out of sight. Dissociative Personality Identity Disorder is a way that the internal system creates to protect secrets and continually learns to adapt to the environment. It is a survival mechanism. Likewise, it favors and maintains the attachment with the abuser. Allow some conflicting emotions to be kept in separate compartments on a mental level.

More specifically, dissociation involves a wide variety of behaviors that represent lapses 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 involves suddenly finding yourself in a situation or having to face evidence of having performed actions that the person does not remember.
• The absorption it implies getting so involved in what is being done that the person forgets what is happening around them.
• The depersonalization it refers to experiencing events as if the individual were an observer, disconnected from the body or feelings.

Causes

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 an occurrence between 24 and 67% of sexual abuse in adult life, and between 60 and 81% of attempts at suicide.

Clearly, TIDP is an important aspect of the trauma-induced cluster of conditions. In the USA, in a sample of 100 patients with TIDP, it was found that 97% of them had experienced major trauma in childhood and almost half of them had witnessed the violent death of someone close to them. (Putman et al. 1986; cited by Sinason p. 11)

Until very recently, documenting childhood cases of TIDP has been extremely difficult. Although there are those who argue that this does not mean that they do not exist. The same occurs with adolescent cases and it is only adult TIDP cases that receive the support of the scientific community.

Richard Kluft believed that his efforts to find the natural history trace of the TIDP were unsuccessful. His attempts to find child cases were an "unmitigated fiasco." He described the case of an 8-year-old boy who seemed to manifest "a series of personality states developed ", after witnessing a situation in which someone almost drowned in water, and having suffered abuse physical. However, he noticed with other colleagues 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 an incipient multiple personality disorder in children; they raised the possibility of a broader spectrum of dissociative phenomenology that children could manifest.

Diagnostic criteria for TIDP

The DSM-V criteria specify that the TIDP manifests with:

• The presence of one or more distinct identities or personality states (each with its relatively stable perception patterns, in relation 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 widespread to be able to explained by ordinary forgetfulness and that it is not due to the direct effects of a substance (for ex. loss of consciousness or chaotic behavior during alcohol intoxication) or a general medical condition (eg. complex partial attacks).

Guidelines for diagnosis and treatment

Regardless of the diagnosis, if dissociation is present, it is important to explore what role it plays in the patient's life. Dissociation is a Defense mechanism.

It is important for the therapist to discriminate dissociation and to talk about defense mechanisms as parts of a process. The therapist can then accompany the patient in exploring the reasons why she may be using this mechanism as a defense. If the therapist addresses the issue of dissociation as early and there is some indication of it, the diagnosis will come more easily. Using the Dissociative Experiences Scale (DES) or Somatoform Dissociation Questionnaire (SDQ-20) can help determine the degree and role that dissociation plays in a person's life. (Haddock, D.B., 2001, p.72)

The International Society for the Study of Dissociation (ISSD) has developed general guidelines for the diagnosis and treatment of TIDP. It states that the basis for a diagnosis is a mental status examination that focuses on questions related to dissociative symptoms. ISSD recommends the use of instruments for dissociative review, such as DES, the interview program for Dissociative Disorders (DDIS) and the DSM-IV Structured Clinical Interview for Dissociative Disorders.

The DDIS, developed by Ross, is a highly structured interview that covers topics related to the TIDP diagnosis, as well as other psychological disorders. It is useful in terms of differential diagnosis and provides the therapist with the mean of the scores in each subsection, based on a sample of TIDP patients who answered the inventory. The SCID-D-R, developed by Marlene Steinberg, is another highly structured interview instrument used to diagnose dissociation.

An important aspect of Steinberg's work consists of the five core dissociative symptoms that have to be present to diagnose a person TIDP or TIDPNE (nonspecific). These symptoms are: dissociative amnesia, depersonalization, derealization, identity confusion, and identity alteration.

TIDP is experienced by the dissociator as confusion in identity (whereas the nondissociator typically experiences life in a more integrated way). The TIDP experience is comprised of the dissociator frequently feeling disconnected from the world around him, as if he is living in a dream at times. The SCID-D-R helps the clinician identify the specifics of this history.

Diagnosis

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

An initial interview that can last between 1 and 3 sessions.

A special emphasis on matters related to family of origin, as well as psychiatric and physical history. The therapist must pay attention to memory gaps or inconsistencies found in the patient's stories.

Direct observation

It is helpful to make notes regarding amnesia and avoidance that is occurring in the session. It is also necessary to appreciate changes in facial features or voice quality, in case it seems out of context to the situation or what is being treated at the time. Noticing 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 collect more information.

Record symptoms related to amnesia, depersonalization, derealization, identity confusion, and identity alteration before diagnosing TIDP or TIDPNE.

Differential diagnosis to rule out specific disorders

You can start by considering the previous diagnoses. That is, taking into account the number of diagnoses, how many times the patient has received treatment, objectives achieved in previous treatments. Previous diagnoses are considered but not used, unless they currently meet DSM criteria.

Then it is necessary to compare the DSM criteria with each disorder that has dissociation as part of its composition and diagnosing TIDP only after observing the change of alter egos.

Inquire for the presence of substance abuse and eating disorders. If dissociation is suspected, using a screening tool such as the CD or the ED can get a greater perspective regarding the role of the dissociation.

Confirmation of diagnosis

If the dissociation is confirmed, once again comparing the DSM criteria regarding possible diagnoses and the diagnosis of TIDP, only after observing the change of alter egos. Until then, the most appropriate diagnosis will be Nonspecific Dissociative Identity Disorder (NDIDP) or Post-Traumatic Stress Syndrome (EPS).

Bibliographic references:

• Bray Haddock, Deborah, 2001. The dissociative identity disorder. Sourcebook. McGrow-Hill Publishers, New York.
• Fombellida Velasco, L. and J.A. Sánchez Moro, 2003. Multiple personality: a rare case in forensic practice. Notebooks of Forensic Medicine. Sevilla Spain.
• Orengo García, F, 2000. Prevalence, diagnosis and therapeutic approach of dissociative identity disorder or multiple personality disorder. www.psiquiatria.com
• Rich, Robert, 2005. Got parts?: An insider's guide to managing life successfully with dissociative identity disorder. ATW and Loving Healing Press. USES.
• Sinason, Valerie, 2002. Attachment, trauma and multiplicity. Working with Dissociative Identity Disorder. Routledge, UK.