Introduction
Dissociative identity disorder (DID) manifests in 1-5% of psychiatric patients, many of whom have never had former dissociative disorder diagnosis.[1] The term dissociation refers to irregularities in conscious function; the most severe form of dissociative disorder is DID.[2] Patients exhibiting DID experience having distinct identities each with their own personality and psychological independence.[1] Many theories surround the causes of DID; the general view is that severe and sustained experiences of trauma lead to the development of unique behavioral states.[1] The trauma is generally seen to be caused by a principal caregiver, such as a parent.[3] Diagnoses are made according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), which has four main criteria for proper diagnosis of DID.[1] Common symptoms associated with DID include, but are not limited to, color blindness, inter-identity amnesia, and menstrual cycle irregularities.[1] Treatment is often given by means of psychotherapy and drugs to treat specific symptoms.[1][4] The therapy is given in phases, followed by various modes of personal therapy, including family therapy.[4] Due to unfinished research on detailed recommendations for pharmacotherapy, psychotropic medication is not the principal treatment.
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1. Causes


1.1 Childhood Trauma
Dissociative Identity disorder has been seen in many cases to cultivate as a result of childhood trauma, fear, and pain.[6] Trauma and terror in a child’s life may lead to the child experiencing inundating pain and affect to such a great extent that he/she dis-identifies with the events.[5] This leads to the child becoming an observer of the transpiring events rather than the individual experiencing the trauma.[5] The observer protects the host, or original personality, from being burdened from the trauma and terror by taking the memories and affects of the stress.[5] The new personalities, or alters, can then become personal “protectors” or “guides” that each serve their purpose in different ways.[5] A 2010 study took into account trauma resulting from sexual abuse in childhood and adolescence; the analyses were done on groups of women from the general population as well as DID Patients.[7] A positive correlation was found when matching severity of sexual abuse and severity of the disorder.[6] In several cases, results presented almost baseline symptom levels when exposure to sexual trauma in childhood was zero.[6]


2. Symptoms


2.1 Behavioral Changes
Behavioral changes are more prominent and identifiable than the physiologic changes; however, many of these symptoms often overlap with symptoms of other disorders such as bipolar disorder, schizophrenia, and borderline personality disorder.[8] In some instances, these overlaps lead to misdiagnoses of other disorders as DID.[7]
Major characteristic behavioral changes associated with DID occur as the result of the creation of alters in the host.[4] The individual alters possess their own identities, names memories, opinions, and most of all, they have distinct behavioral characteristics.[9] Each alter may also have their own comorbid disorders, such as disorders pertaining to personality, eating, sleep, mood, or substance-related.[8] The original host personality has the birth name of the individual and is often seen to be depressed, overly compliant, guilt-ridden, and dependent on other people and the other alters.[8]
Some Clinicians and investigators have noted perceptible changes in the DID patients’ handwriting, presentment, and voice between the different alters.[10] In a 2002 review, Merckelback, et al. describe this phenomenon with an analogy of a theater play, where the actor (DID patient) must perform the roles of two different characters, and to aid the audience in differentiating the characters the actor employs distinct changes in vocalization and behavior.[9]
Dr. Ross, in preliminary study performed in 2011, stated that DID patients in North America experienced periods of possession; the possessions were characterized as a demon, living person, dead person, or some other power or force.[11] The DID patients in the study also stated having higher than normal rates of trance, sleepwalking, and other paranormal experiences.[10]

2.2 Physiologic Changes

Physiologic changes between alters of DID patients have been documented as far back as the early 1900s.[9] Evidence of physiologic changes has been shown by simply evaluating different processes and activity in the multiple alters of DID patients. In one particular case, two alters of a patient were observed for changes in hippocampal activity using fMRI.[9] One alter was seen to have relatively reduced activity in the hippocampus, while the other’s activity was at normal levels.[9] Electroencephalograms have also been obtained illustrating that there is different EEG activity not only between alters within DID patient, but also between the patient and a control from the general population.[9] Different tests and imaging techniques have presented cases in which the alters are so different, it was as though evaluating physically independent individuals; other instances simply show alterations in the individual’s emotional state.[9]
These physiologic changes are seen to take effect in other areas of the body’s internal workings as well; the alters have been seen to have discontinuities in “visual acuity, medication responses, allergies, plasma glucose levels in diabetic patients, heart rate, blood pressure readings, galvanic skin response, muscle tension, laterality, immune function,… among others.”[1][12]

2.3 Inter-Identity Memory Loss and Transfer

The different identities of a DID patient exhibit a form of amnesia that is often more severe than normal forgetfulness; this phenomenon is given the term interidentity amnesia(IIA).[13] It has been now demonstrated that implicit memories pertaining to unconscious tasks such as “word-fragment completion, sequence learning, and masked-word recognition” do transfer between alters; similar evidence has been found for explicit memory tasks, like those found to be in use for “story recall and cued recall.”[12] A study conducted in 2008 by Kong et al., tested the validity of the aforementioned conclusions by performing a cross-modal exclusion test on DID patients and an amnesic control group.[12] The proposed hypothesis stated that since DID patients are better at compartmentalizing memories between alters, they should be able to distinguish memories between alters more efficiently than the control group where individuals would recognize all the stimuli and have to decide which group it belonged to.[12] The results shows that DID patients were capable of refusing the distractor words in the test, but were not able to distinguish between the two lists of words shown to each alter.[12] These conclusions illustrate that IIA may not be as effective as the patients perceive it to be; however, some instances do continue to show more severe, or complete, IIA in which the inter-identity memory transfer is considerably lower.[12]


3. Diagnostic Criteria


3.1 Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
The DSM IV has a set of four criteria for DID; they are as follows[14] :
A. “The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person’s behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex
partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.”[13]

These guidelines are used by clinicians to determine the presence and severity of DID in the patient.[11] Three major modules of instruments are used to assess the dissociative symptoms of the patient and to reach a diagnosis; the three modules are “comprehensive clinician-administered structured interviews, comprehensive self-report instruments, and brief self-report screening instruments.”[1] Clinicians must also take into account various behaviors and mannerisms of the patient during the diagnostic interview, as ignoring any subtle symptoms can lead to a misdiagnosis, especially in regards to cases in which the patient is unaware that their own internal experiences are different from those of the general population.[1] A considerable number of cases are classified as DDNOS, which is the conclusion reached when the case is similar in many ways to DID, but does not meet the full set of criteria.[1] Clinicians are very meticulous in diagnosing DID, so as to avoid false negative and false positive diagnoses (due to similar symptomology to other behavioral and psychological disorders).[1] Many variables spanning from the patients’ body language and speech to the comments they make can lead a clinician to give the patient a positive or negative diagnosis; it is this multitude of variables that makes the diagnosis of DID as complicated and sensitive as it is.


4. Psychotherapy


The goal of treatment is to essentially incorporate each of the alters into one personality, the original host.[1] This is done partly by helping the different alters to be aware of each other’s existence as parts of the self and resolving their internal conflicts.[1] Therapy is initially treated not as individual therapy, but rather as if there are multiple individual persons present, then gradually flows into fusion of the alters.[15] Treatment usually takes place on an outpatient basis; however, for patients with risks of self-harm or impeding harm on others, inpatient treatment may be employed.[11] The length of total psychotherapy can span anywhere from two to ten years of treatment.[1] A number of comorbid disorders, such as Bipolar Disorder, can make treatment difficult by further reinforcing general symptoms of DID.[16]

4.1 Phase Oriented Treatment

There is an agreeance amongst professionals in the field of DID study that treatment given in steps, or phases, is the most efficient way of unifying the alters of a DID patient.[11]

Phase 1- Establishing Safety, Stabilization, and Symptom Reduction[11]
In this phase of treatment, focus is placed on educating the DID patient about the diagnosis and symptoms present, therapeutic alliance, and the methods of treatment.[11] The goals of phase 1 include regulating symptoms, establishing a tolerance to stress, improve functioning of day-to-day life, and enhancing relational capacities.[11] This phase of treatment, in some cases, may continue throughout the entire course of treatment depending on the severity and individual symptoms of DID in the patient; some patients may require higher amounts of functionality treatments while other require treatment on a more emotional level.[11] A major part of the initial treatment is to increase internal communication between the patient’s alters usually by employing strategies such as encouraging inter-identity negotiation, realization of each alter’s importance, and establishing and maintaining a commitment from each alter against self-harm.[11]

Phase 2- Confronting, Working Through, and Integrating Traumatic Memories[11]
The main focus here is to work with the patient’s memories pertaining to traumatic experiences; work is mainly done by “remembering, tolerating, processing, and integrating overwhelming past events.”[11] Before this phase of treatment begins, the individual memories to be used, the alters to participate, and procedures to contain the memories if too intense are all decided and planned out.[11] As the patient’s different alters relive memories of the traumatic experience, the array of emotions across the alters broadens.[1] As the memories are relived, they gradually chance from being a “traumatic memory” to a “narrative memory.”[11] The patient is also gradually able to recall the traumatic memories across the different alters; however, overindulgence in these traumatic memories across the alters may cause retraumatization or destabilization in the patient.[11] As the memories and experiences are unified internally, the alters begin to feel less detached and unique; it is then that facilitated fusion by means of “fusion rituals” (using imagery and hypnosis) is employed.[11] After repeated sessions of phase 2 treatment, the patient’s alters will no longer serve a purpose and the disconnectedness no longer seems important; at this time, the patient is ready for “fusion”.[11]

Phase 3- Integration and Rehabilitation[11]
This is the final step in phase oriented treatment in which the patient enhances “internal cooperation, coordinated functioning, and integration.”[11] The patient continues to fuse alters together while achieving peace and collaboration internally, as well as with those in the outside world.[11] Patients may require assistance in dealing with everyday emotions and tasks, now that there is only one personality residing in the individual; eventually the patient becomes able to see the full extent of their functioning within and with other individuals.[11]

4.2Individual and Family Therapy
Individual and family therapy is used in most cases in which the DID patient is a parent.[1] The patient may need to be informed as to how they should function suitably as a parent; this includes working with the alters that deny being parents or fail to recognize needs of the child/children.[1] When necessary, the children of the patient are evaluated by a therapist that is acquainted with DID and signs of abuse in children.[1] Couples therapy and family therapy in which the patient is included may also be conducted as necessary.[1]

4.3 Other Methods

4.3.1 Hypnosis
Hypnosis is used not only to facilitate fusion of the patient’s alters, but also to induce recall of memories in the patient.[1][11] There are many risks associated with hypnotic techniques, such as inducing retraumatization; therefore, therapists must take care to employ hypnosis at the right time, and must first gain informed consent.[1]


4.3.2 EMDR
EMDR is known to aid in quick resolution of traumatic experiences and memories; early use of EMDR in DID patients however, caused severe clinical problems (breaches of dissociative barriers, emergence of new alters, and destabilization).[1] Now, engaged at the correct time, EMDR is used in “symptom reduction and containment, ego strengthening, work with alternate identities, and… the negotiation of consent and preparation of alternate identities for modified EMDR processing of traumatic memories.”[1]


5. Psychotropic Medications


Psychotropic is not the initial form of DID treatment; however, medications are used as an aspect of the overall DID therapy given to the patient.

5.1 Treated Symptoms

Psychotropic medications given to DID patients aim to alleviate hyperarousal and other comorbid disorders such as affective disorders (including obsessive-compulsive disorder and generalized anxiety disorder.[11] Each alter may respond differently to the medications given due to different physiologic activation between the alters, or the patient’s experience of discordance across the alters; this results in different symptoms being treated across the different alters.[11] The therapist, in order to solve problems of sleep, anxiety, and other symptoms may increase the doses of medication.[11]

6. Case Study Video

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References
  1. ^ International Society for the Study of Trauma and Dissociation (2011): Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, Journal of Trauma & Dissociation, 12:2, 115-187.
  2. ^ Hasan Belli, Cenk Ural, Melek Kanarya Vardar, Sema Yesılyurt, Fatıh Oncu (2012): Dissociative symptoms and dissociative disorder comorbidity in patients with obsessive-compulsive disorder, Comprehensive Psychiatry, 10:44.
  3. ^ Helen M. Farrell (2011): Dissociative Identity Disorder: Medicolegal Challenges, The Journal of the American Academy of Psychiatry and the Law, 39:3, 402-406.
  4. ^ Shobha Pais (2009): A Systemic Approach to the Treatment of Dissociative Identity Disorder, Journal of Family Psychotherapy, 20:1, 72-88.
  5. ^ Dissociative Identity Disorder: It is very real **Caution!, Malcolm McLaren. [video] Retrieved April 3, 2012 from http://youtu.be/x4EOw8wPBN8
  6. ^ Petrucelli, Jean. "Dissociative Identity Disorder: The Abused Child and the Spurned Diagnosis."Knowing, Not-knowing, and Sort-of-knowing: Psychoanalysis and the Experience of Uncertainty. London: Karnac, 2010. 79-87.
  7. ^ Colin A. Ross MD & Laura Ness PsyD (2010): Symptom Patterns in Dissociative Identity Disorder Patients and the General Population, Journal of Trauma & Dissociation, 11:4, 458-468.
  8. ^ Guy A. Boysen (2011): The Scientific Status of Childhood Dissociative Identity Disorder: A Review of Published Research, Psychother Psychosom, 80, 329-334.
  9. ^ Vincent, Christian. Viewing Dissociative Identity Disorder Through a Jungian Lens. Diss. Pacifica Graduate Institute, 2010. UMI, 2011.
  10. ^ Herald Merckelback, Grant J. Devilly, Eric Rassin (2002): Alters in dissociative identity disorder Metaphors or genuine entities?, Clinical Psychology Review, 22, 487-497.
  11. ^ Colin A. Ross MD (2011): Possession Experiences in Dissociative Identity Disorder: A Preliminary Study, Journal of Trauma & Dissociation, 12:4, 393-400.
  12. ^
    International Society for the Study of Trauma and Dissociation (2011): Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision: Summary Version, Journal of Trauma & Dissociation, 12:2, 188-212.
  13. ^
    Lauren Kong, John Allen, and Elizabeth Glisky (2008): Interidentity Memory Transfer in Dissociative Identity Disorder, Journal of Abnormal Psychology 117(3):686-692.
  14. ^
    American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  15. ^
    Jo L. Ringrose (2011): Meeting the needs of clients with dissociative identity disorder: considerations for psychotherapy, British Journal of Guidance & Counselling, 39:4, 293-305.
  16. ^ Manu N. Lakshmanan, Stacey L. Colton Meier, Robert S. Meier, Ramaswamy Lakshmanan (2010): An Archetype of the Collaborative Efforts of Psychotherapy and Psychopharmacology in Successfully Treating Dissociative Identity Disorder with Comorbid Bipolar Disorder, Psychiatry (Edgemont), 7(7), 33-37.
  17. ^
    Dissociative Identity Disorder, The Extraordinary, Seven Network. [video] Retrieved April 1, 2012 from http://www.youtube.com/watch?v=11oD_8jYy0c.