Dissociative identity disorder (DID), previously known as multiple personality disorder (MPD),[7] is a mental disorder characterized by at least two distinct and relatively enduring personality states.
This is accompanied by memory gaps beyond what would be explained by ordinary forgetfulness. The personalities alternately show in a person's behavior; presentations, however, are variable.
Other problems which often occur in people with DID include borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), depression, substance use disorders, self-harm, or anxiety.
Some professionals believe the cause to be childhood trauma. In about 90% of cases, there is a history of abuse in childhood, while other cases are linked to experiences of war or health problems during childhood.
Treatment generally involves supportive care and counselling. The condition usually persists without treatment.
A large number of diverse experiences have been termed dissociative, ranging from normal failures in attention to the breakdowns in memory processes characterized by the dissociative disorders.
Thus it is unknown if there is a common root underlying all dissociative experiences, or if the range of mild to severe symptoms is a result of different etiologies and biological structures.
Other terms used in the literature, including personality, personality state, identity, ego state and amnesia, also have no agreed upon definitions. Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones.
Some terms have been proposed regarding dissociation. Psychiatrist Paulette Gillig draws a distinction between an "ego state" (behaviors and experiences possessing permeable boundaries with other such states but united by a common sense of self) and the term "alters" (each of which may have a separate autobiographical memory, independent initiative and a sense of ownership over individual behavior) commonly used in discussions of DID.
Ellert Nijenhuis and colleagues suggest a distinction between personalities responsible for day-to-day functioning (associated with blunted physiological responses and reduced emotional reactivity, referred to as the "apparently normal part of the personality" or ANP) and those emerging in survival situations (involving fight-or-flight responses, vivid traumatic memories and strong, painful emotions, the "emotional part of the personality" or EP).
Others have suggested dissociation can be separated into two distinct forms, detachment and compartmentalization, the latter of which, involving a failure to control normally controllable processes or actions, is most evident in DID. Efforts to psychometrically distinguish between normal and pathological dissociation have been made, but they have not been universally accepted.
In psychology, emotional detachment (sometimes referred to as emotional disconnection) is the inability to connect to others on an emotional level as well as a means of coping with anxiety by avoiding certain situations that trigger it. It refers to the evasion of emotional connections. It may be a temporary reaction to highly emotional circumstances or a chronic condition such as a depersonalization disorder.
Emotional detachment may not be as outwardly obvious as other psychiatric symptoms. People experiencing emotional detachment have a reduced ability to express emotion, to empathize with others or to form powerful emotional connections.
They are also at an increased risk for many anxiety and stress disorders. This can lead to difficulties in creating and maintaining personal relationships. The person may move elsewhere in their mind and appear preoccupied or "not entirely present", or they may seem fully present but exhibit purely intellectual behavior when emotional behavior would be appropriate.
They may have a hard time being a loving family member, or they may avoid activities, places, and people associated with past traumas. Their dissociation can lead to lack of attention and, hence, to memory problems and in extreme cases, amnesia.
Emotional detachment often arises due to psychological trauma in early years. For example, children who were raised in abusive or neglectful environments are more likely to experience emotional detachment as adults.
Compartmentalization is a subconscious psychological defense mechanism used to avoid cognitive dissonance, or the mental discomfort and anxiety caused by a person's having conflicting values, cognitions, emotions, beliefs, etc. within themselves.
Compartmentalization allows these conflicting ideas to co-exist by inhibiting direct or explicit acknowledgement and interaction between separate compartmentalized self-states.
The suggestion that DID was the result of childhood trauma increased the appeal of the diagnosis among health care providers, patients and the public as it validated the idea that child abuse had lifelong, serious effects. There is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption.
Proponents of the SCM note that the bizarre dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of DID who, through the process of eliciting, conversing with and identifying alters, shape or possibly create the diagnosis.
The characteristics of people diagnosed with DID (hypnotizability, suggestibility, frequent fantasization and mental absorption) contributed to these concerns and those regarding the validity of recovered memories of trauma.
It has also been found difficult to diagnose the disorder in the first place, due to there not being a universal agreement of the definition of dissociation.
The criteria require that an adult be recurrently controlled by two or more discrete identities or personality states, accompanied by memory lapses for important information that is not caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures.
People are often disinclined to seek treatment, especially since their symptoms may not be taken seriously; thus dissociative disorders have been referred to as "diseases of hiddenness".
The condition may be under-diagnosed due to skepticism and lack of awareness from mental health professionals, made difficult due to the lack of specific and reliable criteria for diagnosing DID as well as a lack of prevalence rates due to the failure to examine systematically selected and representative populations.
Due to overlapping symptoms, the differential diagnosis includes schizophrenia, normal and rapid-cycling bipolar disorder, epilepsy, borderline personality disorder, and autism spectrum disorder.
Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with dissociative disorder not otherwise specified rather than DID due to the lack of identities or personality states.
Dissociative disorder not otherwise specified (DDNOS) is a mental health diagnosis for pathological dissociation that matches the DSM-5 criteria for a dissociative disorder, but does not fit the full criteria for any of the specifically identified subtypes
Examples of DDNOS include chronic and recurrent syndromes of mixed dissociative symptoms, identity disturbance due to prolonged and intense coercive persuasion, disorders similar to dissociative identity disorder, acute dissociative reactions to stressful events, and dissociative trance.
DDNOS is the most common dissociative disorder and is diagnosed in 40% of dissociative disorder cases. It is often co-morbid with other mental illnesses such as complex posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, personality disorders, substance use disorders, and eating disorders.
Those with DID generally have adequate reality testing; they may have positive Schneiderian symptoms of schizophrenia but lack the negative symptoms. They perceive any voices heard as coming from inside their heads (patients with schizophrenia experience them as external).
DID must be distinguished from, or determined if comorbid with, a variety of disorders including mood disorders, psychosis, anxiety disorders, PTSD, personality disorders, cognitive disorders, neurological disorders, epilepsy, somatoform disorder, factitious disorder, malingering, other dissociative disorders, and trance states.
An additional aspect of the controversy of diagnosis is that there are many forms of dissociation and memory lapses, which can be common in both stressful and nonstressful situations and can be attributed to much less controversial diagnoses.
In contrast, genuine people with DID typically exhibit confusion, distress and shame regarding their symptoms and history.
A relationship between DID and borderline personality disorder has been posited, with various clinicians noting overlap between symptoms and behaviors and it has been suggested that some cases of DID may arise "from a substrate of borderline traits".
Reviews of DID patients and their medical records concluded that the majority of those diagnosed with DID would also meet the criteria for either borderline personality disorder or more generally borderline personality.
The DSM-II used the term Hysterical Neurosis, Dissociative Type. It described the possible occurrence of alterations in the patient's state of consciousness or identity, and included the symptoms of "amnesia, somnambulism, fugue, and multiple personality".
The name was changed for two reasons. First, the change emphasizes the main problem is not a multitude of personalities, but rather a lack of a single, unified identity and an emphasis on "the identities as centers of information processing".
Second, the term "personality" is used to refer to "characteristic patterns of thoughts, feelings, moods and behaviors of the whole individual", while for a patient with DID, the switches between identities and behavior patterns is the personality.
It is for this reason the DSM-IV-TR referred to "distinct identities or personality states" instead of personalities. The diagnostic criteria also changed to indicate that while the patient may name and personalize alters, they lack an independent, objective existence.
There is a general lack of consensus in the diagnosis and treatment of DID and research on treatment effectiveness focuses mainly on clinical approaches described in case studies.
The Dissociative Experiences Scale (DES) is a psychological self-assessment questionnaire that measures dissociative symptoms. It contains twenty-eight questions and returns an overall score as well as four sub-scale results.
The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a loss of reality as in psychosis.
Dissociation is commonly displayed on a continuum. In mild cases, dissociation can be regarded as a coping mechanism or defense mechanisms in seeking to master, minimize or tolerate stress – including boredom or conflict.
At the non-pathological end of the continuum, dissociation describes common events such as daydreaming. Further along the continuum are non-pathological altered states of consciousness.
More pathological dissociation involves dissociative disorders, including dissociative fugue and depersonalization disorder with or without alterations in personal identity or sense of self.
These alterations can include: a sense that self or the world is unreal (depersonalization and derealization); a loss of memory (amnesia); forgetting identity or assuming a new self (fugue); and separate streams of consciousness, identity and self (dissociative identity disorder, formerly termed multiple personality disorder) and complex post-traumatic stress disorder.
Dissociative disorders are sometimes triggered by trauma, but may be preceded only by stress, psychoactive substances, or no identifiable trigger at all.
Dissociative disorders are typically experienced as startling, autonomous intrusions into the person's usual ways of responding or functioning. Due to their unexpected and largely inexplicable nature, they tend to be quite unsettling.
Dissociation has been described as one of a constellation of symptoms experienced by some victims of multiple forms of childhood trauma, including physical, psychological, and sexual abuse. This is supported by studies which suggest that dissociation is correlated with a history of trauma.
Dissociation appears to have a high specificity and a low sensitivity to having a self-reported history of trauma, which means that dissociation is much more common among those who are traumatized, yet at the same time there are many people who have suffered from trauma but who do not show dissociative symptoms.
Symptoms of dissociation resulting from trauma may include depersonalization, psychological numbing, disengagement, or amnesia regarding the events of the abuse.
It has been hypothesized that dissociation may provide a temporarily effective defense mechanism in cases of severe trauma; however, in the long term, dissociation is associated with decreased psychological functioning and adjustment.
Other symptoms sometimes found along with dissociation in victims of traumatic abuse (often referred to as "sequelae to abuse") include anxiety, PTSD, low self-esteem, somatization, depression, chronic pain, interpersonal dysfunction, substance abuse, self-harm and suicidal ideation or actions.
Child abuse, especially chronic abuse starting at early ages, has been related to high levels of dissociative symptoms in a clinical sample, including amnesia for abuse memories. It has also been seen that girls who suffered abuse during their childhood had higher reported dissociation scores than did boys who reported dissociation during their childhood.
A non-clinical sample of adult women linked increased levels of dissociation to sexual abuse by a significantly older person prior to age 15, and dissociation has also been correlated with a history of childhood physical and sexual abuse. When sexual abuse is examined, the levels of dissociation were found to increase along with the severity of the abuse.
Carl Jung described pathological manifestations of dissociation as special or extreme cases of the normal operation of the psyche.
Attention to dissociation as a clinical feature has been growing in recent years as knowledge of post-traumatic stress disorder increased, due to interest in dissociative identity disorder, and as neuroimaging research and population studies show its relevance.
When receiving treatment, patients are assessed to discover their level of functioning. Some patients might be higher functioning than others. This is taken into account when creating a patient's potential treatment targets.
To start off treatment, time is dedicated to increasing a patient's mental level and adaptive actions in order to gain a balance in both their mental and behavioral action. Once this is achieved, the next goal is to work on removing or minimizing the phobia made by traumatic memories, which is causing the patient to dissociate.
The final step of treatment includes helping patients work through their grief in order to move forward and be able to engage in their own lives. This is done with the use of new coping skills attained through treatment.
Dissociatives are a class of hallucinogen which distort perceptions of sight and sound and produce feelings of detachment – dissociation – from the environment and self. This is done through reducing or blocking signals to the conscious mind from other parts of the brain.
Although many kinds of drugs are capable of such action, dissociatives are unique in that they do so in such a way that they produce hallucinogenic effects, which may include sensory deprivation, dissociation, hallucinations, and dream-like states or trances.
Many dissociatives have general depressant effects and can produce sedation, respiratory depression, analgesia, anesthesia, and ataxia, as well as cognitive and memory impairment and amnesia.
When dissecting complex mental tasks into their subcomponents, a researcher can establish a "single dissociation" between functions. This is done by demonstrating that a lesion to brain structure A disrupts function X but not function Y. Such a demonstration allows one to infer that function X and function Y are independent of each other in some way.
An example of "single dissociation" is a patient who cannot name an object when he or she can only see it, but can when he or she uses other senses like touching or smelling. Patient D.F. was unable to place a card in a slot, but could do so when told to place it "as if mailing a letter". From this the conclusion was drawn that judging orientation is one ability (which D.F. had lost) and visual control of an action another (which D.F. could still do).
Psychosis is an abnormal condition of the mind that results in difficulties determining what is real and what is not.
Symptoms may include false beliefs (delusions) and seeing or hearing things that others do not see or hear (hallucinations).[4] Other symptoms may include incoherent speech and behavior that is inappropriate for the situation.
There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities.
Acute psychosis is considered primary if it results from a psychiatric condition and secondary if it is caused by a medical condition.
A hallucination is defined as sensory perception in the absence of external stimuli. Hallucinations are different from illusions and perceptual distortions, which are the misperception of external stimuli.
Hallucinations may occur in any of the senses and take on almost any form. They may consist of simple sensations (such as lights, colors, sounds, tastes, or smells) or more detailed experiences (such as seeing and interacting with animals and people, hearing voices, and having complex tactile sensations). Hallucinations are generally characterized as being vivid and uncontrollable.
Auditory hallucinations, particularly experiences of hearing voices, are the most common and often prominent feature of psychosis.
During the early 20th century, auditory hallucinations were second to visual hallucinations in frequency, but they are now the most common manifestation of schizophrenia, although rates vary between cultures and regions. Auditory hallucinations are most commonly intelligible voices.
When voices are present, the average number has been estimated at three. Content, like frequency, differs significantly, especially across cultures and demographics. People who experience auditory hallucinations can frequently identify the loudness, location of origin, and may settle on identities for voices.
Western cultures are associated with auditory experiences concerning religious content, frequently related to sin. Hallucinations may command a person to do something potentially dangerous when combined with delusions.
A visceral hallucination, also called a cenesthetic hallucination, is characterized by visceral sensations in the absence of stimuli. Cenesthetic hallucinations may include sensations of burning, or re-arrangement of internal organs.
A delusion may involve diverse thematic content. The most common type is a persecutory delusion, in which a person believes that some entity is attempting to harm them.
Primary delusions are defined as arising suddenly and not being comprehensible in terms of normal mental processes, whereas secondary delusions are typically understood as being influenced by the person's background or current situation (e.g., ethnicity; also religious, superstitious, or political beliefs).
Disorganized speech, also called formal thought disorder, is disorganization of thinking that is inferred from speech. Characteristics of disorganized speech include rapidly switching topics, called derailment or loose association; switching to topics that are unrelated, called tangential thinking; incomprehensible speech, called word salad or incoherence.
Disorganized motor behavior includes repetitive, odd, or sometimes purposeless movement. Disorganized motor behavior rarely includes catatonia, and although it was a historically prominent symptom, it is rarely seen today. Whether this is due to historically used treatments or the lack thereof is unknown.
cat·a·to·ni·a
/ˌkadəˈtōnēə/
noun
- PSYCHIATRYabnormality of movement and behavior arising from a disturbed mental state (typically schizophrenia). It may involve repetitive or purposeless overactivity, or catalepsy, resistance to passive movement, and negativism.
- INFORMALa state of immobility and stupor."violent imagery and musical dissonance induce a state of catatonia"
Catatonia describes a profoundly agitated state in which the experience of reality is generally considered impaired. There are two primary manifestations of catatonic behavior.
The classic presentation is a person who does not move or interact with the world in any way while awake. This type of catatonia presents with waxy flexibility. Waxy flexibility is when someone physically moves part of a catatonic person's body and the person stays in the position even if it is bizarre and otherwise nonfunctional (such as moving a person's arm straight up in the air and the arm staying there).
The other type of catatonia is more of an outward presentation of the profoundly agitated state described above. It involves excessive and purposeless motor behaviour, as well as extreme mental preoccupation that prevents an intact experience of reality.
An example is someone walking very fast in circles to the exclusion of anything else with a level of mental preoccupation (meaning not focused on anything relevant to the situation) that was not typical of the person prior to the symptom onset.
In both types of catatonia there is generally no reaction to anything that happens outside of them. It is important to distinguish catatonic agitation from severe bipolar mania, although someone could have both.
Negative symptoms include reduced emotional expression, decreased motivation, and reduced spontaneous speech. Afflicted individuals lack interest and spontaneity, and have the inability to feel pleasure.
Childhood trauma has specifically been shown to be a predictor of adolescent and adult psychosis. Approximately 65% of individuals with psychotic symptoms have experienced childhood trauma (e.g., physical or sexual abuse, physical or emotional neglect).
Increased individual vulnerability toward psychosis may interact with traumatic experiences promoting an onset of future psychotic symptoms, particularly during sensitive developmental periods.
Importantly, the relationship between traumatic life events and psychotic symptoms appears to be dose-dependent in which multiple traumatic life events accumulate, compounding symptom expression and severity.
This suggests trauma prevention and early intervention may be an important target for decreasing the incidence of psychotic disorders and ameliorating its effects.
Psychotic symptoms may also be seen in:
- schizotypal personality disorder
- certain personality disorders at times of stress (including paranoid personality disorder, schizoid personality disorder, and borderline personality disorder)
- major depressive disorder in its severe form, although it is possible and more likely to have severe depression without psychosis
- bipolar disorder in the manic and mixed episodes of bipolar I disorder and depressive episodes of both bipolar I and bipolar II; however, it is possible to experience such states without psychotic symptoms.
- Sometimes in obsessive–compulsive disorder
- Dissociative disorders, due to many overlapping symptoms, careful differential diagnosis includes especially dissociative identity disorder.
Stress is known to contribute to and trigger psychotic states. A history of psychologically traumatic events, and the recent experience of a stressful event, can both contribute to the development of psychosis. Short-lived psychosis triggered by stress is known as brief reactive psychosis, and patients may spontaneously recover normal functioning within two weeks.[31] In some rare cases, individuals may remain in a state of full-blown psychosis for many years, or perhaps have attenuated psychotic symptoms (such as low intensity hallucinations) present at most times.
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