Term Paper on "Dissociative Identity Disorder (Did)"

Term Paper 12 pages (4094 words) Sources: 12 Style: APA

[EXCERPT] . . . .

, 2013). Why DID in particular and DDs in general failed to get attention is not really clear, but it may be related to the modern attitude surrounding DDs. The reception to this disease, or any of the group of dissociative diseases, has oftentimes been marked by sufficient skepticism to prevent a full study of DID.

As a result, what is known of modern DID is sometimes disputed, even by experts in the field. First, many psychologists and psychiatrists disagree that DID exists. Even among those who acknowledge DID as a disease; there is significant disagreement about the etiology and causation of the disease, which has treatment implications. For example, there are two primary schools of thought regarding the etiology of DID. Many believe that DID is linked to childhood trauma, while others suggest that it is based on patients being prone to fantasy (Reinders et al., 2012). Moreover, those who believe that DID is related to fantasy may even go so far as suggesting that it is not actually a disorder. While the etiology of DID is not fully understood, it is believed that "severe and chronic dissociative symptoms tend to develop in the context of severe and chronic childhood traumatization, which includes profound attachment disruptions" (Schlumpf et al., 2013). This fact is backed up by studies that have found that psychiatric patients with DD are almost three times as likely to report childhood abuse than psychiatric patients without DD (Yu et al., 2010). What this evidence suggests is that DID is probably more likely linked to childhood trauma than the result of fantasy, though both theories will be explored.

Previously, it was believed that DID was linked to patients being fantasy prone. In fact, the sociocognitive model (SCM), which is also referred to as the fantasy model, suggests that DID is caused by patients who are highly prone to fantasies, role-playing, and suggestibility (Schlumpf et al., 2012). The fantasy view of DID suggests that DID is a syndrome that "consists of rule-governed and goal-directed experiences and displays of multiple role enactments that have been created, legitimized, and maintained by social reinforcement" (Lilienfeld et al., 1999). This does not mean that the patients are consciously acting or role playing, but it does suggest social modeling as an element of the disease. Through this social modeling, patients enact elements of DID that they have incorporated through media. In other words, advocates of the SCM believe that people with DID have a disorder, but they do not believe that they have fragmented personalities with multiple identities.

However, recent research belies the fantasy model; even highly fantasy prone mentally healthy women are not able to enact the brain patterns suggested in the ANP and EP of patients with DID. However, "DD patients have dissociative part-dependent biopsychosocial reactions to masked neutral and angry faces. As EP, they are overactivated, and as ANP underactivated" (Schlumpf, 2013). "According to the Theory of Structural Dissociation of the Personality (TSDP), DID is a severe form of posttraumatic stress disorder (PTSD) encompassing different types of dissociative parts of the personality" (Schlumpf et al., 2013). Furthermore, the "Theory of Structural Dissociation of the Personality (TSDP) proposes that dissociative identity disorder (DID) patients are fixed in traumatic memories as 'Emotional Parts' (EP), but mentally avoid these as "Apparently Normal Parts" of the personality (ANP)" (Schlumpf et al., 2013). Brain images of patients who have presented with DID vary sufficiently from patients without DID when experiencing or acting out EP and ANP events to support the theory of differential brain functioning in the two groups, which suggests that there is something biological in result, if not in origin, to a DID diagnosis.

While there does appear to be physiological proof that DID is an actual mental illness, it can be difficult for a person without a DD to understand how DID can impact a patient's life. It may be easiest to think of people with DID as having adapted to be very avoidant when unpleasant things occur. There is some support for "the notion that persons with DID consciously redefine their perceptions of the environment when this environment starts to become unpleasant and intrusive. In this process the individual seems to change point-of-view on demand and is able to alter his or her experience in the situation by rerouting the perception of the stimuli observed" (Dale, 2008). However, the reality is that life is threatening and a process that begins as an adaptive way to dissociate during childhood trauma, particularly childhood sexual abuse, can transform into a problem that keeps the person from being fully integrated. As a result, people with DID may report four main psychiatric symptoms: depersonalization, derealization, amnesia, and identity confusion (Johnson, 2012). Depersonalization refers to the idea that many patients with DID feel detached from their bodies. It is not uncommon to hear childhood sexual assault victims describe the sensation of leaving their bodies during assaults, which is a form of depersonalization (Johnson, 2012). Derealization refers to a feeling that the world is either not real or is somehow separate and distinct from the person's physical reality (Johnson, 2012). Amnesia refers to forgetfulness and refers to such a substantial lack of information about one's personal life that it cannot be attributed to mere forgetfulness; this can be chronic or acute (Johnson, 2012). Finally, identity confusion suggests that a person has a problem understanding who they are, sometimes engaging in behavior that he or she would find abhorrent at other times (Johnson, 2012).

It is worth discussing the issue of amnesia because it has traditionally been one of the diagnostic criteria for DID, but may not be as all-encompassing as previously assumed. Huntjens et al. used a concealed information task to assess recognition of autobiographic details in an identity of a patient with DID, which was supposed to be an amnesic identity. What they discovered was the patients did subjectively report amnesia for autobiographical details that were present in the task, there was a transfer of information between the identities (Huntjens et al., 2012). The ability of the identities to transfer information suggests that complete amnesia may not be a hallmark of patients with DID. Instead, identities may share some of the factual and informative recall of other identities and still fail to share the personal history associated with that identity.

Whether or not the patients have an inability to remember facts between identities does not negate the fact that there do appear to be distinct identity states that are suggestive of multiple personalities or identities within DID patients. For example, in a case study describing a woman who had previously been diagnosed with DID, and was admitted to a psychiatric hospital during an amnesic state precipitated by a family crises:

During the psychiatric exam, she calmly sat with her eyes closed and insisted that they were already open when asked to open them. She also repeatedly fluctuated between referring to herself as "I" or "she." When asked to write a complete sentence during the Folstein Mini-Mental State Exam, Ms. A took the pen with her right hand and effortlessly wrote, from the right margin to the left, the mirror image of "I'm tired of being here." When asked to write the sentence again, she wrote the same sentence in the same direction as fluidly as she had done before. She later reported that she was normally right handed (Le et al., 2009).

The woman had no history of using mirror writing. More significantly, the preference for her left hand in an alternate identity suggests a very high degree of dissociation.

Treating DID is similar to treatment of all DDs and is complicated by several factors. First, patients suffering from DDs are often sufficiently mentally ill that they are unable to interact in the community in a positive and healthy way. This means that they frequently have difficulty with school, work, and interpersonal relationships. As a result, when they do obtain treatment, it is likely to be through introduction into the public system in one of two ways: the social welfare system, or the criminal justice system. Both of these pathways introduce special challenges for the patients. However, in both systems patients are likely to be misdiagnosed. Not only are many providers reluctant to believe in DID, they are also frequently unfamiliar with the disorders. Furthermore, when a patient is also a criminal defendant, people may believe that the patient is faking the disorder in order to avoid criminal culpability for an underlying bad act. However, while these disorders may not be highly recognized, it should not be assumed that they are, therefore, not prevalent. "Despite the belief of some psychiatrists that these disorders are very rare and others who question their existence, some recent prevalence estimates range from 12 to 28% in adult outpatients for all DDs." (Gentile et al., 2013).

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