dissociative identity disorder case study paula

Dissociative Identity Disorder Case Study: A Deep Dive

Have you ever wondered what it's like to live with more than one identity inhabiting your mind? As you explore the intricate case of a 55-year-old woman grappling with Dissociative Identity Disorder (DID), bipolar disorder, and substance use disorder, you'll encounter the complexity of human psychology laid bare.

This case study isn't just a recount of symptoms and treatments; it's a journey into the fragmented reality of an individual whose life is a mosaic of distinct personalities, each with their own history and way of interacting with the world. You'll scrutinize the triggers that provoke shifts between these personalities and the memory gaps that add layers of mystery to an already enigmatic condition.

Your understanding of DID will expand as you're introduced to the challenges faced by both the patient and the therapists committed to her recovery. What awaits is a narrative that blurs the lines between self and other, questioning the very nature of identity.

Key Takeaways

• Dissociative Identity Disorder (DID) involves fragmentation of one's identity into distinct personalities, resulting in disconnection between thoughts, identity, consciousness, and memory.
• DID often coexists with dissociative amnesia, and triggers can lead to switching between personality states.
• Severe trauma, especially during formative years, can contribute to the development of DID, as childhood neglect disrupts the development of a cohesive sense of self.
• Understanding and integrating the various alter personalities is vital for healing and managing triggers in DID treatment.

Understanding DID

To grasp the complexity of Dissociative Identity Disorder (DID), it's essential to recognize that it involves a fragmentation of one's identity into distinct personalities, each with their own perceptions and ways of interacting with the world. These alternate personality states aren't mere moods; they're profound shifts in your sense of self, memories, and consciousness.

The term dissociation refers to the disconnection between thoughts, identity, consciousness, and memory. DID is an extreme form of dissociation, where each personality may have its own name, history, and characteristics. Unsurprisingly, DID often coexists with dissociative amnesia, which means you might be unable to recall personal information, especially that related to traumatic events.

Understanding DID isn't just about the diagnosis; it's about recognizing the triggers that lead to the switching between personality states. You may find that certain situations, people, or feelings prompt the emergence of an alternate personality, particularly if they're associated with past trauma. It's not a choice; it's a coping mechanism that your mind has developed, often in response to severe abuse.

Case Background

Delving into the case background, we encounter a 55-year-old woman whose struggle with DID is compounded by substance use and bipolar disorder. Her fragmented personality showcases multiple exhibited personalities alongside a primary identity that veers between periods of control and overshadowing by alternate personality states. This complexity isn't unique to her, as DID, once known as multiple personality disorder, often manifests with a host of dissociative disorders, each with its own nuances and challenges.

Her violent behavior and the prevalence of suicide attempts in her history mirror the self-injurious patterns commonly seen in DID cases. It's important to note that the exact cause of DID remains elusive, but it's widely suggested that severe trauma, such as physical and sexual abuse, especially when experienced during formative years, can lay the groundwork for the disorder. Childhood neglect, in particular, is a significant factor that can disrupt a child's ability to develop a cohesive sense of self.

Understanding and managing triggers is paramount in her treatment, as they can provoke the emergence of different personality states. Ongoing research is vital in shedding light on these triggers, aiming to provide more effective strategies for those grappling with the complexities of DID.

Personality Manifestations

You'll notice that in DID, individuals exhibit various alter personality traits that are distinct and unique.

It's crucial to understand the triggers that cause identity switching, as these are central to managing the disorder.

Recognizing these cues can help you anticipate and prepare for the changes that come with each switch.

Alter Personality Traits

Individuals with Dissociative Identity Disorder (DID) may exhibit a range of alter personalities, each with distinct characteristics and memories that reflect their unique responses to traumatic experiences. These distinct identities alternately take control, demonstrating how DID fragments consciousness into a single person's multiple selves.

Typically, each alter has its own role, purpose, and view of the world, often starkly different from the others within the same individual. It's like having two or more distinct people sharing one body.

Understanding and integrating these personalities is vital in your journey towards healing. Current research strives to unpack the complexities of these traits, aiming to improve your life and how you cope with the profound challenges DID presents.

Identity Switching Triggers

When discussing traumatic events or facing intense emotions, people with Dissociative Identity Disorder may experience a sudden switch to an alternate identity. These identity switching triggers are deeply rooted in the person's history, often connected to instances of emotional abuse or sexual abuse. It's imperative that you understand the key stress factors that can prompt these switches:

• Confrontations that provoke past traumas
• Sensory stimuli reminiscent of the original trauma
• Unexpected life stressors that overwhelm coping mechanisms
• Internal conflicts among alternate identities
• Therapeutic interventions that probe into traumatic memories

Managing these triggers requires careful navigation, especially with professional guidance. It's crucial for you to work with a therapist to identify and mitigate these triggers, thereby reducing the frequency and intensity of involuntary identity switches in dissociative identity disorder.

Triggers and Memory Gaps

You may find that certain topics or experiences can unexpectedly lead to dissociation if you're living with Dissociative Identity Disorder (DID). It's crucial to identify these triggers and work with a therapist to understand how they contribute to memory lapses.

Learning to manage these episodes can help you gain more control over your life and reduce the disruption caused by unexpected dissociative states.

Identifying Common Triggers

Recognizing the triggers that can precipitate memory gaps and personality switches is a key component in the management of dissociative identity disorder (DID). These triggers are often related to past trauma, which is a core aspect of DID. To enhance your mental health, it's crucial to identify what sets off these episodes.

Here's what you should look out for:

• Stressful events that overwhelm your usual coping mechanisms.
• Reminders of past trauma , such as specific anniversaries, sounds, or places.
• Intense emotional situations that echo previous experiences.
• Substance abuse , which can destabilize mood and cognitive function.
• Encounters that may resemble past situations involving borderline personality disorder or other mental health conditions.

Understanding Memory Lapses

Building on the importance of identifying common triggers, it's equally crucial to understand how these triggers can lead to memory lapses in individuals with dissociative identity disorder. Triggers often activate dissociative states where you might experience significant memory gaps. These aren't just momentary lapses; they can correspond with a switch between different identities, each with a distinct history and sense of self.

As you grapple with dissociative identity disorder, recognizing and managing these triggers becomes a central part of your journey.

For patients with dissociative conditions, including depersonalization-derealization disorder, understanding post-event effects and the necessity to avoid known triggers is key. Active research continues to unearth how these memory lapses occur and how to effectively address them, aiming to improve your quality of life.

Treatment Approaches

Addressing Dissociative Identity Disorder (DID) requires a comprehensive treatment plan that often starts with psychotherapy to integrate the multiple identities. As you navigate this complex condition, which is detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), you'll find that treatment is multifaceted. It's not just about merging identities, but also improving your overall functioning and quality of life.

Here are some key components of treatment approaches for DID:

• Psychotherapy: The cornerstone of DID treatment, facilitating communication and integration of identities.
• Medication: While no drugs specifically treat DID, they can help with co-occurring symptoms like depression or anxiety.
• Support Networks: The role of family and friends in providing emotional support can't be overstated.
• Education: Learning about DID, including triggers and post-traumatic stress disorder (PTSD) symptoms, is vital.
• Coping Strategies: Developing skills to manage daily life and avoid triggers that exacerbate the disorder.

Challenges Faced

Navigating the complexities of DID, you'll encounter significant challenges, such as managing violent behavior and controlling substance use that can complicate treatment. Dissociative Identity Disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, presents a unique set of hurdles that require careful, tailored approaches.

Identifying and avoiding triggers for dissociation isn't straightforward. Each personality may have different triggers, and what soothes one might distress another. Anxiety symptoms can escalate, complicating the overall management of the disorder.

Coordinating care among multiple personalities demands specialized expertise, and without it, treatment can be fragmented and less effective. Furthermore, the stigma and misunderstanding surrounding DID create barriers in both personal relationships and interactions with healthcare professionals.

Balancing the needs and emotions of different personalities can overwhelm you, and without proper support, the risk of suicide attempts increases. It's crucial to address each personality's concerns while maintaining a cohesive treatment plan.

Here's a condensed view of the challenges faced:

Personal Impact

Living with Dissociative Identity Disorder (DID) can profoundly disrupt your sense of self and ability to navigate daily life. Once known as multiple personality disorder, DID isn't a single multidimensional experience; it's a complex condition that affects you in various ways. It's not akin to the temporary effects of a substance; it's an ongoing battle with identity and consciousness.

Here's how DID can personally impact you:

• Your relationships may struggle due to the presence of different identities, causing confusion and strain with loved ones.
• You might experience intense emotional distress, grappling with internal conflicts that can be overwhelming.
• The disorder can affect your work life, making it challenging to maintain consistent employment.
• Stigma and misunderstanding can lead to feelings of isolation, as society often misinterprets the complexities of DID.
• Daily functioning can be unpredictable, as different identities may emerge with distinct memories, behaviors, and needs.

Your personal impact from DID is multi-layered, often requiring professional support to manage. Understanding and acceptance from those around you can make a significant difference in how you cope with the condition.

Therapeutic Outcomes

When considering therapeutic outcomes for Dissociative Identity Disorder, integrating the various identities into a cohesive self is the cornerstone of successful treatment. You'll find that specialized therapies, particularly cognitive behavioral therapy (CBT), are at the forefront of managing this complex mental illness. They've proven effective in not just reducing symptoms but also in enhancing your day-to-day functioning.

Medications play a supportive role; they're not the main act but assist in controlling DID-related depression or anxiety. This medical support, when teamed with therapy, can significantly boost your therapeutic outcomes. Yet, it's the support from your circle—family and friends—that often becomes the unsung hero in your recovery journey. Their understanding and support can make a world of difference.

Your journey through DID treatment hinges on a comprehensive evaluation—understanding your unique symptoms and history is vital. This is where the Diagnostic and Statistical Manual of Mental Disorders (DSM) comes in, providing a framework for better understanding and categorizing your experiences.

Responding to psychotherapy and other treatments is a personal process; what works for one mightn't work for another. But rest assured, the goal is always the same: to help you lead a more integrated, functional life.

Frequently Asked Questions What Is a Famous Case Study of Dissociative Identity Disorder?

You're likely thinking of the case of Shirley Ardell Mason, also known as Sybil, which is a well-known study of Dissociative Identity Disorder that brought widespread attention to the condition.

What Have 95% of Those With Dissociative Identity Disorder Had?

You've faced severe trauma; 95% of those with dissociative identity disorder have suffered significant physical and sexual abuse, highlighting the profound impact such early life experiences have on mental health.

What Youtuber Has 40 Personalities?

You're wondering about a YouTuber with 40 personalities? That's DissociaDID, who shares their life with Dissociative Identity Disorder, aiming to educate and connect with others about mental health.

Are DID Patients Aware of Other Personalities?

You might not always be aware of other personalities if you have DID. Your awareness can vary and may change with therapy, stress, or triggers. It's different for each person.

You've journeyed through the shadowed corridors of a fragmented mind, witnessing the battle scars of a psyche splintered into disparate selves. Your eyes have opened to the complexities of DID, the struggle for unity, and the hope etched into every treatment plan.

Remember, this odyssey isn't just a clinical case; it's a mosaic of human resilience. As you step back into the light, carry the understanding that behind every diagnosis, there beats a heart yearning for wholeness.

Daniel Logan is a renowned author and mental health expert who specializes in psychology and mental health topics. Daniel holds a degree in psychology from the University of California, Los Angeles (UCLA). With years of experience in the field, he has become a trusted voice in the industry, sharing insights and knowledge on a variety of mental health issues.

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• March 15, 2024 | VOL. 77, NO. 1 CURRENT ISSUE pp.1-42

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Three Cases of Dissociative Identity Disorder and Co-Occurring Borderline Personality Disorder Treated with Dynamic Deconstructive Psychotherapy

• Susan M. Chlebowski , M.D. ,
• Robert J. Gregory , M.D.

SUNY Upstate Medical University, Syracuse, NY.

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E-mail Address: [email protected]

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

Introduction

Dissociative Identity Disorder (DID) is a relatively common disorder, especially in clinical populations. Johnson and colleagues found the prevalence to be 1.5% in a population of 658 adults in a community-based longitudinal study ( Johnson, Cohen, Kasen, & Brook, 2006 ). Foote and colleagues (2006) noted the prevalence of DID to be 6% in a study of inner city, psychiatric outpatients. Among adult psychiatric inpatients, estimates of prevalence have varied from 0.9 to 5% ( Gast, Rodewald, Nickel, & Emrich, 2001 ; Rifkin, Ghisalbert, Dimatou, Jin, & Sethi, 1998 ; Ross, 1991 ).

Figure 1. DISSOCIATIVE EXPERIENCES SCALE SCORES OF 3 PATIENTS WITH DISSOCIATIVE IDENTITY DISORDER

The conceptualization and treatment of DID has been rife with controversy, reflecting in part a dearth of empirical research. A PsychINFO search using the terms dissociative identity disorder and clinical trials indicated no published randomized controlled trials. Various treatment models have been applied to clients with DID, including psychodynamic psychotherapy, cognitive behavioral therapy (CBT), hypnosis, group therapy and family therapy. However, there is little empirical support for any model. In 1986, Putnam and colleagues published the results of a questionnaire given to 92 clinicians treating 100 cases of DID. Thirty six percent of the therapists asked to speak with specific alters, 32% awaited for alters to announce themselves, and 20% used hypnosis to elicit alters. Employing a survey of clinicians treating 305 clients with DID, Putnam and Lowenstein (1993) reported that individual therapy with hypnosis was the most common form of treatment. The average client was seen twice a week for an average of 3.8 years.

Many therapists utilize techniques that include speaking directly with the different alters. ( Caul, 1984 ; Congdon, Hain, & Stevenson, 1961 ; Fine, 1991 ; Kluft, 1987 ; Putnam, 1989 ; Ross et al., 1990 ; Ross and Gahan, 1988 ). Other therapists warn against attending to alters ( Gruenewald, 1971 ; Horton & Miller, 1972 ). There is concern that any acknowledgement of alters can result in “mutual shaping” of present or additional personalities. ( Greaves, 1980 ; Spanos, 1985; Sutcliffe & Jones, 1962 ; Taylor and Martin, 1944 ).

Although hypnosis is a commonly used modality, evidence supporting its use is based primarily on case reports and a single case series ( Coons, 1986 ). When using hypnosis, the therapist attempts to uncover and resolve traumatic experiences linked to specific alters. Coons (1986) reported on the outcomes of 20 clients treated with hypnosis and psychodynamic therapy. Based on global impressions by the treating clinicians, 5 of 20 clients with DID were reported to have “complete integration” over a 3-year period of treatment.

Another approach with preliminary empirical support is cognitive analytic therapy (CAT). In CAT practice, descriptions of dysfunctional relationship patterns and of transitions between them are worked out by therapist and client at the start of therapy and are used by both throughout its course ( Ryle & Fawkes, 2007 ). Employing a single-case experimental design, Kellet (2005) utilized the dissociative experiences scale (DES) to measure the effectiveness of CAT during 16 months with one client. The client received the standard CAT design of 24 sessions with four follow-up sessions. The client developed insight, had reduced fragmentation, and improved self-manageability, but did not establish integration.

The model with the largest empirical basis has been Kluft’s (1999) individualized and multi-staged treatment. It involves making contact and agreement among alters to work towards integration, accessing and processing trauma with occasional use of hypnosis, learning new coping skills, and eventually fusion among the alters and the self. Using this model, Kluft (1984) describes treatment of 123 DID clients over a decade of observation. Of the clients, 83 (67%) achieved fusion, including 25 who sustained fusion over at least a 2-year-follow-up period without any residual or recurrent dissociative symptoms. Kluft noted that individuals with borderline personality traits were less likely to achieve stable fusion. A major limitation of his study was the lack of valid outcome measures or formalized assessment of adherence to the treatment protocol.

Dissociative symptoms commonly co-occur with borderline personality disorder (BPD) and the prevalence of DID among outpatients with borderline personality disorder (BPD) was 24% in two separate studies that employed structured diagnostic interviews ( Korzekwa, Dell, Links, Thabane, & Fougere, 2009 ; Sar et al., 2003 ). Two treatment models targeting borderline personality disorder have been shown to be effective for reducing dissociative phenomena in randomized controlled trials. Koons and colleagues (2001) randomized 20 female clients who had BPD to either dialectical behavior therapy (DBT) or to treatment as usual. At 6 months, participants receiving DBT had a greater reduction in DES scores than those receiving usual care. However, in a shorter 12-week randomized controlled trial, 20 participants receiving DBT demonstrated no improvement in DES scores ( Simpson et al., 2004 ).

The other treatment modality shown effective for dissociative phenomena with BPD is dynamic deconstructive psychotherapy (DDP). Gregory and colleagues (2008) randomized 30 participants with borderline personality disorder and co-occurring alcohol use disorders to either DDP or to optimized community care. Over 12 months of treatment, DES scores were significantly reduced among those receiving DDP, but not among those receiving optimized community care.

Although DBT and DDP have shown promise in reducing dissociative symptoms among clients with BPD, it is unclear whether they would be effective in treating DID. To our knowledge there are no reported cases of any treatment modality for DID complicated by co-occurring BPD employing validated, quantifiable outcome measures. The present observational study attempts to fill that gap in the literature by describing three cases of co-occurring DID and BPD treated with 12 months of DDP, using the DES as an outcome measure.

Participants

Participants include three consecutive cases of DID who had been provided treatment with DDP. All of them were young adult women who had been diagnosed with co-occurring BPD. They were administered the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986 ) at baseline, 6 months, and 12 months into treatment with DDP. The DSM-IV diagnoses of DID and BPD were assigned clinically in each case by the treating therapist. Identifying information has been removed or modified within the case reports to protect the privacy of the participants.

Dissociative Experience Scale

The DES is a 28-item self-report measure assessing a wide array of dissociative phenomena, and it has become the most commonly used and extensively researched scale for measuring the severity of dissociation. Internal consistency has ranged from .83 to .93 and test-retest reliability from .79 to .96 for 4-to-8 week periods ( Carlson et al., 1993 ). There are no differences in scores associated with gender, race, religion, education, and income.

Clients rate their endorsement to each item on a continuum from 0% to 100%, and the mean score is calculated across items. The average DES score in clients with DID has ranged from 41 to 58 across studies, as compared to a median score of 11 for adults without mental disorders ( Bernstein & Putnam, 1986 ; Ross et al., 1990 ). Steinberg, Rounsaville, and Cicchetti ( 1991 ), comparing the DES to diagnosis from structured interviews, found a cutoff score of 15 to 20 yielded good sensitivity and specificity for DID, whereas Ross, Joshi, and Currie (1991) used a cutoff score of 30 in their epidemiological study.

Treatment Intervention

Dynamic Deconstructive Psychotherapy structure is manual based and time limited, involving weekly individual therapy sessions over 12 to 18 months. In a 12-month randomized controlled trial with 30-month follow up, DDP significantly improved interpersonal functioning and reduced self-harm, suicide attempts, alcohol and drug misuse, depression, and dissociation among clients with co-occurring BPD and alcohol use disorders ( Gregory et al., 2008 ; Gregory, Delucia-Deranja, & Mogle, 2010 ). Adherence to DDP techniques correlate strongly with positive outcomes ( r = .64), supporting the effectiveness and specificity of DDP interventions ( Goldman & Gregory, 2009 ).

Dynamic Deconstructive Psychotherapy theory combines the translational neuroscience of emotion processing with object relations theory and deconstruction philosophy ( Gregory & Remen, 2008 ). Through therapy, the individual attempts to remediate the connection between self and one’s experiences and to deconstruct attributions that interfere with authentic and fulfilling relationships.

The practice of DDP targets three purported neurocognitive functions: association , attribution , and alterity. Association is the ability to verbalize coherent narratives of interpersonal episodes, including identification and acknowledgement of specific emotions within each episode. Association techniques involve facilitating discussion of a recent interpersonal episode, helping the client to form a complete narrative sequence and to identify and label specific emotions within the episode.

Attribution is the ability to form complex and integrated attributions of self and others. Attributions of clients with BPD are often distorted and polarized, described in black and white terms ( Gregory, 2007 ). Attribution techniques involve deconstructing distorted, polarized attributions by exploring alternative meanings and motives within narratives.

Alterity is the ability to form realistic and differentiated attributions of self and others. Included within this function are self-awareness, empathic capacity, mentalization, individuation, and self-other differentiation. Alterity techniques are experiential within the client-therapist relationship; they attempt to disrupt the client’s stereotyped expectations by providing acceptance or challenge at key times.

Within the DDP model, DID is conceived primarily as an adaptation to severe trauma and as an end point along a continuum with other dissociative phenomena. Dissociation provides a mechanism for diminishing the emotional impact of trauma by splitting off awareness of feelings, perceptions, and memories from consciousness. However, once dissociation becomes established as a coping mechanism, even minor stresses can trigger it.

Given that clients with DID are often highly hypnotizable and may, therefore, be very suggestible ( Braun, 1984 ), the concern within DDP theory is that alters may become reified as they are individually named and characterized. A DDP therapist explicitly refrains from hypnosis and refrains from exploring the various alters or calling them by name; but insists on addressing the client by his/her legal name. These aspects of DDP differ from expert consensus treatment guidelines of DID, which emphasize negotiation and cooperation between alters, including the occasional use of hypnosis for calming and exploration ( International Society for the Study of Trauma and Dissociation, 2011 ). Also unlike the consensus guidelines, DDP explicitly avoids work on early trauma until later stages of therapy given the difficulty clients with BPD have in adaptively processing intense emotional experiences ( Ebner-Priemer et al., 2008 ) and instead emphasizes narration of recent interpersonal encounters.

The DDP therapist reframes alters as “different parts of you that need to be integrated” while not favoring one aspect of the self over another. This aspect of DDP is largely consistent with the expert consensus DID guidelines emphasizing awareness and resolution of conflict between competing identities, rather than suppressing or ignoring them ( International Society for the Study of Trauma and Dissociation, 2011 ). DDP theory and technique are summarized by Gregory and Remen (2008) and within the training manual (at http://www.upstate.edu/ddp ).

For the present study, the therapists included the founder of DDP (RG; cases 2 and 3) and a senior psychiatry resident (SC; case 1). Training for the senior resident involved several didactic sessions in DDP, reading the training manual, and ongoing weekly case supervision by the founder to ensure treatment fidelity.

Ms. A. was a 33-year-old Caucasian female with a history of chronic major depression, severe dissociation, and narcissistic and borderline personality disorders. She started DDP with a psychiatric resident trainee after several years of recurrent psychiatric admissions for depression, suicidal attempts, and self-mutilation. She would whip herself with chains and used torture devices with religious/medieval themes. She had twice required cardiac resuscitation after overdoses.

Ms. A. also described multiple dissociative symptoms that occurred on a frequent basis. These included flashbacks of traumatic experiences, psychogenic amnesia of important events, derealization, depersonalization, and lapses in time. In addition, the patient described having three separate alters, each having a different name, age, and characteristics. On admission her DES score was 57.

Ms. A. stated her childhood was saddened by her father leaving home when she was about 3 years old; she spent most of her childhood awaiting his return. She vividly recalls feeling alone and spending hours in a rocking in a chair staring at a wall.

Her mother remarried a man who sexually abused Ms. A.’s younger brother and older sister and physically abused Ms. A. When the children revealed the abuse to their mother, she sought counseling at their church, which recommended therapy and that he remain in the home. Ms. A. felt betrayed by her mother for allowing the terror in the home to continue. Ms. A. could not recall feeling loved by her mother, who was a nurse and busy portraying herself a caring individual for others.

Ms. A. did well in school despite having chronic dissociative symptoms, she described as “spacing out” and feeling detached from the world. She enjoyed writing, and she pursued her interest in literature.

Ms. A. became pregnant during her senior year of high school, married, and had a second child. She had difficulties recalling most of her married life, but remembered her husband as being demanding and unloving. Eventually, her husband left her for her best friend.

Initially Ms. A. took on raising the two children on her own, but she was unable to work or even to talk on the telephone due to anxiety. Because of her prolonged periods of dissociation, she was unable to provide adequate and safe care for her children; Child Protective Services eventually removed them from her custody. They went to live with their father in another state. Ms. A. lost contact with her children because they refused to communicate with her.

Ms. A. engaged well in treatment with DDP, attending weekly sessions and developing a therapeutic alliance over the first few months. Much of her early treatment focused on her relationship with her mother, with whom she was living. The predominant theme was, “Do I have a right to be angry?”

She was angry at her mother for her behaviors and attitudes; her mother sympathized with Ms. A.’s ex-husband, insisted that Ms. A. use bed sheets and clothing stained with blood from Ms. A.’s prior cutting episodes, and discouraged her from attending psychotherapy.

At 6 months of therapy, Ms. A. had developed a strongly positive and somewhat dependent transference with the therapist, and she was much better at identifying and articulating feelings of anger, guilt, and shame. She also felt much less need to punish herself, and self-mutilating episodes became less frequent and less severe. Her DES score had decreased from 57 at baseline to 29 at 6 months. However, during therapist vacations, feelings of abandonment would surface in Ms. A., and these sometimes resulted in an exacerbation of self-mutilation and/or severe depression needing hospitalization.

During the final 6 months of therapy, Ms. A. focused a great deal on the preset planned termination of treatment. Vacations and the pending termination were reminders of the limitations of the therapist as an all-caring idealized object. On the one hand, Ms. A. felt as if she had a more integrated self, and she was beginning to expand her functional capacity through the formation of friendships and returning to school part-time. On the other hand, she felt abandoned by the therapist, and this was accompanied with exacerbations of depression, as Ms. A. redirected the anger towards her therapist onto herself. Ms. A. expressed worries about the future and she devalued treatment and the therapist’s role. The therapist struggled to remain empathic with Ms. A.’s worries (without giving false reassurance) and to tolerate the devaluation without becoming defensive.

By the end of treatment, Ms. A. appeared to have a more balanced view of her treatment and of herself. She could express anger with less internal hatred. Depression and suicide ideation markedly improved and 12-month DES score was 12. At termination, she gave the therapist a drawing of a Celtic knot to symbolize the integration of her disconnected self. She was transferred to the care of another therapist; the exact nature of her treatment and course is unknown. However, a chance encounter with the DDP therapist 5 years later revealed that Ms. A. was generally doing well and participating in part-time college coursework.

Ms. B. was a married Caucasian female in her 30s with a long history of severe psychopathology. She delineated five alters, each with a separate name, gender, and age. She was unable to control unexpectedly switching between alters. Ms. B. also described frequent disruptive and embarrassing time lapses. On two occasions, these lapses occurred while she was in the changing room of a Department store: she would become aware of her surroundings after the store had closed and locked its doors.

In addition to dissociative symptoms, the client met criteria for multiple Axis I and II disorders, including BPD, Bipolar I, alcohol and drug dependence, post traumatic stress disorder, obsessive compulsive disorder, and anorexia nervosa, bingeing/purging type. She had a history of six psychiatric hospitalizations beginning in her early twenties; she was treated for suicide attempts, manic episodes, and/or psychosis.

Over the course of her illness, Ms. B. had tried multiple classes of psychotropic medications none successes in treatment, but she has some improvement with mood stabilizers and antipsychotic medications. She had been treated for 5 years in twice-weekly supportive psychotherapy, which had involved a progressively pathological and regressive client-therapist relationship, including cuddling and playing with blocks on the floor. As the client regressed, she also became intrusively demanding of her therapist’s time, which eventually led to the therapist terminating treatment and subsequent deterioration in the client’s condition.

Ms. B. began to see demons in her house, and develop paranoid delusions necessitating psychiatric hospitalization. Following hospitalization, the client was referred for a trial of DDP. At that time, her DES score was 62. Initial sessions focused on establishing clear parameters of treatment, boundary limitations within the client-therapist relationship, and psycho-education regarding the importance of avoiding boundary violations. The client repeatedly brought up interactions with her prior therapist, including her feeling abandoned by the therapist. She was able to work through conflicts regarding agency, i.e. if she or her therapist was to blame for various incidents. As the client gradually worked through her issues she had with her prior therapist, the focus shifted to her marital relationship. Her husband was extremely physically and emotionally abusive. He had prostituted her to his friends and acquaintances. Episodes of physical abuse would be followed by increased psychiatric symptoms, including dissociation. The DDP therapist helped the client identify, label, and acknowledge her emotions in interactions with her husband, and to work through her conflict of agency in that relationship, i.e. whether or not she provoked him to attack her. As Ms. B. worked this through, she decided to terminate the relationship with her husband. She temporarily lived with her parents and eventually lived independently. There was a mourning process involving de-idealization of her husband and of her parents, who pressured her to return to her husband.

Her symptoms of Axis I disorders steadily improved during the course of treatment, despite diminishing dosages of antipsychotic and mood stabilizer medications. Her symptoms of dissociation also improved and her DES score decreased to 45 by 6 months of treatment and to 35 by 12 months. Ms. B. described time lapses as less frequent and of shorter duration, and she began to sense an increased ability to control them. Shifts in personality style became less frequent and pronounced, and Ms. B. no longer described herself as having independent personalities, but rather described “parts of herself” that emerged at different times. She also described herself as “waking up” and feeling “more whole.”

As termination approached, the last phase of weekly treatment was difficult and involved working through feelings of abandonment. After 18 months of weekly sessions, monthly maintenance treatment, which was primarily supportive in nature, was initiated. Despite discontinuing all medications against advice 6 months after termination of weekly DDP, Ms. B. displayed gradual improvement in symptoms at 8-year post-treatment, however, she continued monthly supportive psychotherapy sessions.

During the follow-up period, Ms. B. decided to pursue a professional degree while on social security disability, which supported her efforts through Vocational and Educational Services for Individuals with Disabilities. She successfully completed her courses, came off disability, and has worked full time for the last 3 years of her follow-up period in a responsible professional position.

Ms. C. was a divorced African American woman in her 30s, having a history of alcohol and cocaine dependence. She had moved to the area to “get clean” and leave negative influences. She heard about the study for co-occurring BPD and alcohol use disorders ( Gregory et al., 2008 ), and subsequently enrolled and was randomized to DDP.

Ms. C. described lifelong difficulties with sudden shifts in mood and personality combined with impulsive behaviors, including misuse of alcohol, cocaine, and cannabis. Significant dissociative symptoms included frequent episodes of derealization, feelings of spaciness, fugue episodes, and three distinct personalities, each with a specific name. One of her alters was called “Sunlight.” Sunlight had been the primary alter in Ms. C.’s life for the past few years. Sunlight enjoyed dominating and manipulating men as a drug dealer and prostitute. Unlike Ms. C., Sunlight felt no emotional pain and saw no need for treatment.

Ms. C. was diagnosed with cocaine, alcohol and cannabis dependence, DID, and BPD at evaluation. An 18-month course of DDP therapy was planned. Her initial DES score was 41. Throughout treatment, the therapist addressed the client by her legal name, and reframed the different personalities as different being parts of Ms. C. that were poorly integrated. The focus in early treatment was an exploration of a series of tumultuous relationships with boyfriends. These men had histories of imprisonment and tended to be manipulative or threatening. Her relational pattern was initially to idealize the men. This was followed by disappointment, anger, and fear. She would then engage in manipulating or controlling them. In therapy, the client was able to identify, label, and acknowledge conflicting feelings towards them and to describe a core conflict between her desire to be taken care of by a strong man versus her desire to be independent and in control.

By 6 months in treatment, dissociative episodes were much improved; DES score was 34. Ms. C. was maintaining abstinence and she was able to avoid harmful relationships with men. She began to develop female friendships for the first time in her life and to pursue educational courses leading up to a professional degree.

By 9 months, Ms. C. began to take responsibility for her life but was felt overwhelmed by responsibilities. She became less committed to treatment and recovery, and she began to have increased cravings for substances along with drug dreams. She would speak glowingly about times in the past when she felt in control and without emotional pain in the role of Sunlight. Much of the remaining 6 months of treatment involved bringing Ms. C.’s ambivalence about recovery to consciousness and helping her to mourn the loss of grandiose fantasies. Ms. C. also had to mourn the loss of the therapy relationship. She left treatment 3 months before the scheduled termination so that she “wouldn’t have to say goodbye.” As part of the BPD and alcohol use disorder study, Ms. C. met with the research assistant for follow-up 30 months after enrollment ( Gregory et al., 2010 ). She remained abstinent during the follow-up period despite lack of further treatment, finished her course work for a professional degree, and had been working fulltime during the last 12 months of the follow-up period.

The three cases of DID with co-occurring BPD appeared to respond well to time-limited treatment with DDP. Average DES scores decreased from 53 to 25 over 12 months, indicating an average reduction of 54%. Long-term follow-up for Cases 2 and 3 indicated further improvement in symptoms and function occurred after termination of weekly DDP treatment. These findings are consistent with a randomized controlled trial of DDP for disorders that demonstrated significant improvement in DES scores over time (individuals with BPD and alcohol use Gregory et al., 2008 ).

A theoretical principal of DDP is that individuals with BPD have deficits in association, which involves a dis -association between emotional experience and verbal symbolic capacity ( Gregory & Remen, 2008 ). Individuals are often unable to verbally describe, label, and sequence specific emotional experiences. Association deficits are manifested by incoherent narratives of emotionally charged interpersonal episodes and there is difficulty identifying and appropriately expressing emotions within such episodes.

Dissociation has been linked in prior studies to aberrant processing of emotional experiences. Deficits in the ability to identify and express emotions (as assessed by the Toronto Alexithymia Scale [TAS]), have been noted in traumatized populations, and have been linked to dissociative symptoms, as measured by the DES ( Frewen, Pain, Dozois, & Lanius, 2006 ; McLean, Toner, Jackson, Desrocher, & Stuckless, 2006 ). Clients with DID have been noted to have a slowed response time to negative emotions on the Flanker test ( Dorahy, Middleton, & Irwin, 2005 ). In large, population-based studies ( Elzinga, Bermond, & van Dyck, 2002 ; Maaranen et al., 2005 ; Sayar, Kose, Grabe, & Topbas, 2005), the TAS and DES scores have been correlated with one another even when dissociative symptoms are severe enough to be pathological ( Grabe, Rainermann, Spitzer, Gansicke, & Freyberger, 2000 ; Maaranen et al., 2005 ).

Dynamic Deconstructive Psychotherapy specifically targets association deficits by helping clients to develop coherent narratives of recent interpersonal episodes and to identify, label, and acknowledge emotions within such episodes. Given that deficits in emotion processing have been linked to dissociative symptoms, targeting these deficits should theoretically be helpful for dissociation. This hypothesis was supported by recent research demonstrating a strong and statistically significant correlation (r = .79) between the use of association techniques, as assessed by independent raters, and improvement in DES scores ( Goldman & Gregory, 2010 ). It is, therefore, likely that the use of association techniques was a critical component of treatment response among the reported three cases of DID.

Since DBT also targets association deficits through helping clients to identify emotions associated with maladaptive behaviors, it is perhaps not surprising that this modality has been shown to be helpful in reducing dissociative symptoms ( Koons et al., 2001 ). Whether DBT can be helpful for DID per se, remains to be seen.

Limitations of the present case series include the observational nature of the study, exclusive reliance on clinical diagnoses, and restriction of the study sample to clients with co-occurring BPD. It is unclear whether DDP would be effective for DID clients who are free from this severe personality pathology. The small number of cases also limits the ability to generalize findings. Large controlled trials are needed to better evaluate the efficacy of DDP and other treatment modalities for individuals who suffer from DID.

Conclusions

Dissociative Identity Disorder is a common and under-researched disorder. Borderline Personality Disorders frequently co-occurs with DID and has been noted to worsen its course. DDP is a treatment modality previously found effective for dissociative symptoms of BPD. The active component of DDP for dissociative symptoms may be the use of association techniques, whereby verbal symbolic capacity is linked to emotional experiences within narratives. The three cases presented in this report suggest that DDP can be an effective treatment for clients suffering from DID complicated by co-occurring BPD.

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• Dissociative Identity Disorder
• Borderline Personality Disorder
• psychodynamic psychotherapy
• hypnotherapy
• dissociation
• dissociative disorders
• psychotherapy
• individual psychotherapy
• analytical psychotherapy

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A Documentary Explores Dissociative Identity Disorder

The condition, formerly called multiple personality disorder, affects a surprising 1 percent of the population.

By Jane E. Brody

Twenty-eight-year-old Marshay refers to herself as “the Little One” and says she feels as if she was born six years ago. Her mother knows something really bad must have happened to her when she was very young, although she doesn’t know what happened. When she asks her daughter why she thinks she’s still a small child, Marshay answers, “I don’t remember anything. I don’t want to grow up. I want to stay little.”

Marshay’s brain periodically seeks a safe haven, a persona where she feels immune to some horrific abuse she apparently suffered early in life. She has other identities as well who “come out” when provoked by certain triggering events and she needs these alternate identities to feel safe.

Marshay is one of several people with dissociative identity disorder who are featured in a new documentary called “Busy Inside,” available on public television’s World Channel: America ReFramed. It can be watched free online through April 15. She is among a surprising 1 percent of the population with this psychiatric condition, formerly called multiple personality disorder, which was famously portrayed decades ago in films like “ The Three Faces of Eve ” and “ Sybil. ” It mostly affects women.

The new film shows the challenges involved in learning to live with the disorder. Still, most of those affected never seek professional help until and unless their lives become unmanageable.

Karen Marshall, Marshay’s therapist, a licensed social worker, also has the disorder, and told me that 17 different personalities inhabit her psyche and can emerge from time to time. She suffered severe sexual and physical abuse as a young child at the hands of her mother, and said she experienced tremendous relief when she died “and couldn’t hurt me anymore.” She says her own trauma, and the ways she learned to manage it, has helped her be an effective therapist.

Dr. David Spiegel, a Stanford University psychiatrist who gave the disorder its modern name, explained, “We develop our identity in childhood, and if you’re abused by someone who is supposed to love and protect you, you try to detach yourself from” that abusive situation. “In extreme forms, you assume other identities. It becomes a disorder.” The hippocampus, a part of the brain that deals with stress, may shrink and cause an extreme sensitivity to stress hormones, he said.

Early in life when the brain can’t handle something, “it puts it in a little box in the brain,” Ms. Marshall said. Then something else it can’t handle goes into another compartment in the brain, and so forth, resulting in some people developing different personalities, any of which can take over for a time.

A woman in the film named Sarah who has seven or eight identities describes her childhood trauma as being in a freezing cold basement with few clothes on and two men grabbing at her while others stood around laughing. “I can see this happening but I can’t stop it,” she recalls. “The monster keeps coming out, obliterating everything.”

In the documentary, Ms. Marshall encourages Marshay to accept herself as an adult woman with many facets, saying reassuringly, “We all have different roles, and we all wear different masks in a way.”

For those with the disorder, when an alternate identity takes over, the person may lose track of time and have no memory of what the other personality did while it was “out.” Ms. Marshall said one woman she treated had an alternate personality who was a shoplifter and when she reverted to her main identity, had no idea how she had acquired all the things in her apartment.

Dissociative identity disorder is both underdiagnosed and often misdiagnosed as depression or anxiety disorder and consequently mistreated, Dr. Spiegel said. Once affected individuals acknowledge that they have a problem, it takes an average of six years for them to learn what is causing their symptoms if they should seek help, he said.

Some people with the disorder never do, and somehow manage to live normal lives until and unless something very stressful causes their alternate identities to take over and disrupt their ability to function. For example, Ms. Marshall told me, one person in the film performed well as a company executive for many years until a family trauma so unnerved her that her identities split, very hostile and disabling personalities emerged and she could no longer do her job.

Dr. Spiegel said some people with the disorder “are afraid of treatment or ambivalent about it; they don’t believe I’m here to help them because, based on their history, they see helpers as potentially harming them.”

Alternate identities can also emerge at the same time, as if the person is two people who oppose one another. The identities develop specialized roles, coming out under certain circumstances, Dr. Spiegel said. For example, one identity may “protect” against another that might be aggressive or harmful. The protective identity may think, “I’m going to stay out while so-and-so is around,” he said. As Ms. Marshall explained, people can have one or two identities that act as gatekeepers, keeping the others inside.

In treatment, by identifying and emphasizing the person’s core values and beliefs, the person’s adult identity that enables them to function normally can learn to take over for identities that are distressing or troublemakers, Ms. Marshall said.

Her approach to treatment does not necessarily try to rid people of their alternate identities unless, of course, that’s what they want to accomplish. Rather, she said, they may learn to use their alternates constructively so they can live a normal life as an adult in society.

Also helpful is learning to recognize circumstances that can prompt a distressing identity to emerge and temporarily replace the adult persona. Ms. Marshall said she has learned, “If I’m tired or sick or stressed, I can end up splitting,” and a childlike personality emerges.

As in post-traumatic stress disorder, people with multiple identities can have flashbacks and experience their abuse all over again. Ms. Marshall said, “I don’t watch shows about child abuse.” In treating dissociative identity disorder, she said, “I try to get the ‘Little Ones,’ who were traumatized, to know they’re safe, that they’re not going to be hurt again.”

Dr. Richard P. Kluft, a psychiatrist in Bala Cynwyd, Pa., focuses therapy for the disorder on providing “good, caring, nurturing, comforting support” that helps patients feel safe. “The mind starts to heal in the face of loving care,” he said. Both he and Dr. Spiegel often use hypnosis to facilitate therapy and teach patients how to calm themselves down with self-hypnosis between sessions.

For patients reluctant to leave behind their “rich inner world,” Dr. Kluft says he welcomes all parts of their personality, helping their various identities learn to empathize with and respect one another.

Ms. Marshall said that as people with multiple identities start to get healthier, “they can look at what they’re feeling and experiencing and then make a different choice. They can learn to use their alternates constructively so they can function in society as an adult person,” which Marshay is gradually learning to do.

Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers “Jane Brody’s Nutrition Book” and “Jane Brody’s Good Food Book.” More about Jane E. Brody

CASE REPORT article

Schema therapy for dissociative identity disorder: a case report.

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Commentary: Schema therapy for Dissociative Identity Disorder: a case report

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• 1 Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
• 2 GGZ-Oost Brabant, Department of Personality Disorders, Helmond, Netherlands
• 3 Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
• 4 Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
• 5 Department of Experimental Psychotherapy and Psychopathology, University of Groningen, Groningen, Netherlands

Treatment for Dissociative Identity Disorder (DID) often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation. The percentage of patients that reach the third phase is relatively low, treatment duration is long, and the effects of this treatment on the core DID symptoms have been found to be small or absent, leaving room for improvement in the treatment of DID. Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment. The presented case concerns a 43-year-old female patient with DID, depressive disorder (recurrent type), PTSD, cannabis use disorder, and BPD. Functioning was very low. She received 220 sessions of ST, which included direct trauma processing through Imagery Rescripting (ImRs). The patient improved in several domains: she experienced a reduction of PTSD symptoms, as well as dissociative symptoms, there were structural changes in the beliefs about the self, and loss of suicidal behaviors. After treatment she was able to stop her punitive mode, to express her feelings and needs to others, and to participate adequately in social interaction. This case report indicates that ST might be a viable treatment for DID, adding to a broader scope of treatment options for this patient group.

Introduction

Dissociative Identity Disorder (DID) is a highly disabling disorder, associated with high levels of impairment, high risk for self-harm, multiple suicide attempts, high mortality, and very high societal costs ( 1 ). The main diagnostic criterion for DID is the perceived presence of two or more distinct identities, accompanied by a marked discontinuity in the sense of self and agency, and alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. Also, patients often report recurrent gaps in the recall of important personal information, everyday events, and traumatic events ( 2 ). The estimated 12-month prevalence of DID is 1.5% in the general American population ( 2 ), and around 5% in psychiatric settings ( 3 ).

Treatment for DID often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation ( 4 ). The percentage of patients who reach the third phase of treatment is relatively low [17–33%, ( 5 )] and treatment duration is long, on average 8.4 years ( 6 ). The effectiveness of this treatment has been examined in several non-controlled studies ( 6 – 8 ) and one Randomized Controlled Trial [RCT; ( 9 )]. The results indicated that, although the general functioning of patients improved, the effects of this treatment on the core symptoms (i.e., dissociative symptoms) are small or absent. Hence, there is ample room for improvement in the treatment of DID.

Schema therapy (ST) has been introduced as a viable alternative treatment for DID ( 10 – 12 ). ST is thought to be applicable to and effective for DID for several reasons. First, ST as a whole, as well as its trauma processing component, Imagery Rescripting (ImRs), are effective for disorders that result from interpersonal trauma in childhood, including complex PTSD and personality disorders [e.g., ( 13 – 17 )]. Secondly, ST was found to reduce dissociative symptoms in patients with Borderline Personality Disorder (BPD) ( 18 ). Thirdly, perceived shifts between identities in people with DID are understood as shifts between modes (temporary states of mind) and compartmentalization is not assumed ( 19 ). Extreme shifts in emotions, cognitions, and behaviors that are present in DID also appear in other disorders that are related to severe and prolonged childhood abuse, such as BPD; ST delivers tools for dealing with these shifts ( 20 ). Fourthly, a recent RCT ( 15 ) investigating the effectiveness of ImRs in people with PTSD as a result of early childhood trauma showed that trauma treatment is highly effective and can be performed safely without a stabilization phase. As a first illustration of this new approach to the treatment of DID, this case report presents an illustration of the application of an adapted form of ST for DID.

Case description

Ella (fictitious name) is a 43-year-old patient with an extensive psychiatric history, who was referred to a specialized mental health center in the Netherlands to participate in a study on the treatment of DID with ST. Ella experienced nightmares and flashbacks about past traumatic experiences, and reported 17 identities, as well as dissociative amnesia (i.e., memory gaps for daily life events and traumas). Several identities were obsessed with self-hatred and self-punishment and repeatedly gave orders to hurt or kill herself. She broke her arm once by force, repeatedly cut herself on her arm, and attempted suicide several times. According to the patient's report, traumatic experiences involved recurrent sexual abuse by her father during her childhood (4–11 years), as well as several times by a teacher and a peer from secondary school. Her mother denied the abuse and behaved in a guilt-inducing way. Moreover, during her training as a dentist assistant after graduating from high school, a manager tried to sexually abuse her, after which she mentally broke down. She was hospitalized numerous times due to parasuicidal behavior and suicide attempts. She also received CBT for 3 years. This treatment focused on depressive and anxiety symptoms, (para)suicidal behaviors, and cannabis addiction. It was delivered in individual as well as group format and did not result in long-lasting results. Previous treatment in this case did not include trauma stabilization therapy. She met her husband 14 years ago and has a son who is 6 years old. She feels insecure about the upbringing of her son and feels unconnected to her partner. At the start of therapy, she was not able to work.

The patient gave informed consent for participation in the study and for the publication of this case report. The Structured Clinical Interview for DSM disorders Dissociative disorders-Revised [SCID-D-R; ( 21 )], SCID-I, and SCID-II ( 22 , 23 ) were used to assess the presence of clinical disorders by an independent experienced clinician. Ella was diagnosed with DID, depressive disorder, PTSD, cannabis use disorder, and BPD, and her Global Assessment of Functioning ( 2 ) score was 25. Table 1 shows the results of the baseline assessment. This case is part of a non-concurrent multiple baseline design study among 10 DID patients ( 10 ).

Table 1 . Results of baseline measures.

The treatment consisted of 160 sessions twice per week, followed by 40 weekly sessions. Thereafter, she received 6 monthly booster sessions which were aimed at reconsolidation and generalization of ST insights and skills learned during the active treatment. Each session lasted 50 min. ST for DID follows the same theoretical framework and makes use of therapeutic interventions as originally developed by Young et al. ( 25 ), though ST for DID is personalized to each patient as they present with different symptoms. Furthermore, several important adaptations to ST were made to meet the needs of DID patients. These will now be discussed.

Case-conceptualization and establishing a shared definition of problems in schema therapy language

At the start of treatment, the diagnosis of DID as well as the main problems of the patient were discussed. Ella was educated on the rationale of ST for DID with regards to basic needs and how frustration of these needs leads to schemas, modes, and psychopathology. To manage expectations, conditions of treatment were explained, such as treatment length (3.5 years), frequency of sessions, need for active participation, whom to contact in case of crisis, and the availability of the therapist. Much effort was put into building a working alliance throughout treatment by validating thoughts and emotions and being present, available, and consistent. Being really determined in finding solutions to deal with severe and persistent symptoms, not giving up but instead delivering hope and power is very important in working with DID patients. She was educated on how DID is understood in terms of schema theory (as modes), and identity states were thereafter translated into modes by clustering identities by their function and reformulating and merging them into a mode (see Table 2 ). There was no pressure to share all identities; the therapist worked with states that were present. Together with Ella a mode model was made (see Figure 1 ), containing the most prevalent modes: punitive and demanding mode (e.g., internal demanding and punitive messages), the vulnerable child mode (painful feelings, PTSD symptoms), the detached protector (e.g., withdrawing and disconnecting), avoidant protector (active avoidance behaviors), and self-soother (using cannabis and auto-mutilation to deal with painful feelings). This idiosyncratic model was consistent with the results of a recent empirical study into the most prevalent modes in patients suffering from DID ( 26 ). Moreover, (para)suicidal behaviors, coping mechanisms, and supportive relatives were assessed (level of parasuicidal behaviors was high and healthy coping mechanisms low), after which a basic safety plan was made in which Ella agreed to try to perform helpful behaviors (e.g., talking to my neighbor, talking to my husband, talking with my therapists) before harming herself (see Figure 2 ). This plan was used whenever basic safety became an issue, evident for example by the patient sending an appeal for help by e-mail or phone. She e-mailed texts like “ Death must be met with dignity. It is the only dignified thing left to do. I am never going to recover and if you really get to know me you would see how bad we are. I don't deserve to live .” Yet, it was possible to reassure her and prevent self-harm through email and short phone calls.

Table 2 . Overview of parts and the corresponding modes.

Figure 1 . Schema mode model of the patient.

Figure 2 . Safety plan of the patient.

Dealing with dissociation and working with the detached protector

Specific adaptations in ST were made to address dissociative responses. Ella was educated on dissociation, stressing that it is a natural reaction to extreme and ongoing stress, especially when (biologically) sensitive to stressors. Furthermore, dissociative behaviors such as detachment or being unresponsive to stimuli from the environment were framed as behaviors that once had a clear survival function, but at present were mainly maladaptive. A strip of fleece was used to make a literal connection between Ella and the therapist, and to gain control over what was happening during the session. Whenever Ella zoned out or started to dissociate, the therapist gave the fleece a slight tug to have her stay connected and more present. Also, Ella could tug the fleece whenever she was in need, e.g., when the pace of the therapist was too high. At the beginning, the tugging and exploration of what triggered the disconnection was mainly initiated by the therapist, but gradually Ella became more active in tugging and exploring. Other techniques that were used to stop disconnection were grounding, such as the “Stop, Freeze, and Breathe” exercise ( 27 ), naming five things you see, throwing a small ball, or pinching some things hard (a shell or a sharp wooden stick). Also, the therapist and Ella found out that a dog clicker helped Ella to orient in the present whenever she got overwhelmed by flashbacks. She used the clicker when she sensed that she was (about to) reexperience traumatic events. The clicker helped her to feel in control over flashbacks and reorient to the present. Moreover, chair exercises, such as interviews with the detached protector, validating its protective function in the past, asking it to be less present, and setting the chair more aside in order to connect and reparent the vulnerable child, were used to reduce detachment.

Working with the avoidant protector

Avoidance behaviors are highly prevalent in DID patients and are a strong maintaining factor. Therefore, in ST for DID there is a constant alertness for avoidance behavior shown by the various identities. Dependent on their function they are reframed as a coping mode. Because the avoidance behavior can be intense and strong, creative solutions on how to deal with it are needed.

Ella had a strong avoidant protector (interpersonal and situational avoidance). She tended to avoid multiple situations (e.g., talking to other mothers at the schoolyard, attending other social situations, or discussing shameful past situations with the therapist). Her awareness of avoidance increased by teaching her to identify the behaviors of the avoidant protector and turn her attention toward avoidance behaviors in and outside the sessions via homework assignments (mode awareness work sheets). Avoidance patterns were targeted by chair work [dialogue with the avoidant protector, validation of the protective function in the past, asking the mode to make space for healing of the vulnerable part, and empathic confrontation (e.g., confronting her with the fact that avoiding trauma processing maintains PTSD, and not going along with avoidance)]. Creative solutions were used to break through her avoidance (e.g., picking her up from the parking lot and outside the building when she was afraid to enter the health center building and using telehealth when she wanted to cancel a therapy session combined with discussing her avoidance). In addition to cognitive interventions such as exploring the pros and cons of avoidance, she was stimulated to exercise approach behaviors at home (e.g., sharing feelings with partner or talking to other moms). Gradually, Ella became more able to diminish her tendency to avoid in therapy, as well as in daily life situations.

Working with the self-soother

DID patients frequently use alcohol, drugs, or medication to avoid dealing with intense negative emotions. In ST for DID these behaviors are reframed as the self-soother mode. The patient is made responsible for her behavior instead of going along with her tendency to attribute her behavior to an identity over which she has no control.

In the case of Ella, her cannabis use was framed as an avoidance strategy; she used cannabis daily to avoid painful feelings from past traumatic experiences. After several attempts to reach abstinence of cannabis through CBT techniques for addiction used in the context of ST, an additional clinical detox at her request helped Ella to stop her cannabis use completely. During this detox she expressed that she did not get overwhelmed by flashbacks and painful feelings, which helped her to continue abstinence, because sedation was not necessary anymore.

Trauma processing

In ST for DID, trauma processing is seen as a crucial part of therapy, which needs to start as soon as possible (usually several weeks to a few months). In ST for DID there is no stabilization phase in which skill and emotion regulation strategies are taught nor is stabilization of symptoms a prerequisite for trauma processing, whilst trauma processing in itself is found to have a stabilizing effect in patients suffering from severe childhood traumas [e.g., ( 17 )]. Trauma processing is done by ImRs, a technique that aims to change the dysfunctional meaning of early aversive experiences. It consists of prompting patients to rescript painful autobiographical memories in line with their unmet needs ( 28 ). To adapt ST to the specific needs of DID patients, the use of ImRs has been broken down in steps, to customize the pace of trauma processing and level of trauma exposure to what patients are able to deal with, gradually increasing the level of exposure and the involvement of the healthy adult part of the patient. In the case of Ella, trauma processing started after 8 weeks. This was possible due to several factors such as raising her commitment, the good working alliance, not avoiding trauma work but carrying it out at a level that was manageable for her, performing it in small steps, and the high frequency of treatment sessions. Imagery work was built up slowly, starting with a neutral experience (imagining skiing together with the therapist), whereafter mild negative (soothing of her crying as a child or being excluded at school) and more adverse negative experiences were processed (neglect and abuse experiences by father, teacher, and peer). ImRs was performed in small steps in which first the therapist rescripted, whereafter Ella was motivated to gradually participate in the rescripting (“ what would you like to say to him, okay just say that ”), and finally carrying out the rescripting herself. In the first 2 years, trauma work often disrupted her, because it activated the punitive part, sometimes leading to (para)suicidal behaviors. Therefore, in ST for DID one frequently oscillates between trauma work and working with the punitive part. At these moments, the safety plan was used and if necessary we worked with the punitive mode in the next session. In Ella, the punitive part told her she was bad and faulty and it was not worth living, making it very difficult to take care of the needs of the vulnerable child. The therapist interspersed ImRs with punitive mode work (see next paragraph) and stimulating adult healthy perspectives on feelings and needs of people. At the start the therapist kept the trauma work short (5 min) and gradually increased the duration of trauma processing (to about 30–40 min in one session). Over time, Ella thus increasingly tolerated trauma work and gained power over the traumatic experiences.

It took a long time and many repetitions before she was able to comfort and fulfill the needs of her vulnerable child. Only in the 3rd year she was able to adopt a healthier perspective on who was guilty and responsible for the abuse. In the last year she was able to rescript on her own. As a tool for performing the rescripting at home, she made a collage for each individual person who abused her to visualize the rescripting. It contained pictures of actions to stop the abuser (hitting him with a baseball bat, stabbing him with a knife, or setting fire to the house/school where the abuse took place). Additionally, it contained messages to say to the abuser ( shame on you, you're bad ), actions to bring the vulnerable child to safety (bring her to the hospital, wrapping her in warm blankets, or bringing her to a new safe home), and sentences to emphasize the innocence of the child and to build her self-worth (“ it is not your fault, there is nothing wrong with you ”).

Banishing the punitive part

In ST for DID, aggressive, punitive, and highly demanding identities are reframed as the punitive and demanding mode. Repeated, persistent, and creative ways of fighting their messages and banishment are needed to reduce the impact on the patient. ST aims to stop these messages and to increase control over them by replacing them with realistic, healthier messages.

In Ella the punitive and demanding modes (e.g., telling her she was bad, guilty, worthless, and incapable) were highly prevalent and persistent, and had a profound impact on her quality of life. They played an important role in eliciting and maintaining strong negative feelings and thoughts, self-harm (e.g., damaging her arm), and suicide attempts (by auto-intoxication). In those moments, the safety plan was initially used, followed by punitive mode work. Early in therapy, Ella felt that getting rid of the punitive mode was invalidating, because she felt that it was a part of her, and she was afraid of losing other identities as well. Repeated education and exploration of the impact of the punitive and demanding modes was necessary to work on banishing the punitive and demanding modes. Through time, and after numerous repetition of these exercises, the impact of the punitive mode was diminished. Numerous ST techniques were used in this process, such as balloon techniques (e.g., putting an imaginative protective balloon around herself to shield her from the negative messages and blowing punitive messages into a balloon after which the balloon was released). Other techniques used were imaginative muting of the mode (using a remote control to diminish the volume or using duct tape to silence the voice), shrinking the punitive mode to a smaller size, incarcerating it, chair work (e.g., putting the punitive mode on a chair, ordering it to stop, and placing it outside the room), and rituals such as burying and burning the images and messages of the punitive mode. A major breakthrough was achieved during a clinical admission due to a suicide attempt induced by the punitive mode. At this moment in time, the therapist had become really fed up with the punitive mode, and authentically and very strongly directly addressed this mode: “ I want you to get out of Ella's life, you are making her life miserable. You must leave .” Thereafter, the therapist motivated Ella to take back control and to bid farewell to the punitive mode once and for all. During an imagery exercise that followed, she imagined the punitive mode to change into a statue whereafter she shrank it, and chopped it into a thousand pieces. In the sessions that followed, Ella reported that the punitive part did not return, but she felt an empty hole within herself. The therapist and patient filled this hole with helpful messages for her vulnerable child.

Healing the vulnerable child mode

In ST for DID, child identities are conceptualized as vulnerable child modes. The therapist frequently and repeatedly reparents the vulnerable child, using imagination exercises to fulfill the needs of the vulnerable child, and gradually stimulating the healthy adult part of the patient to participate in healing the vulnerable child. Ella did not show her vulnerable side during the first treatment sessions. She feared maltreatment by the therapist. It was possible to gain her trust by creating a sense of safety within the therapy, after which she was able to let the therapist get in contact with the vulnerable child. The high treatment frequency, repeated validation of feelings and needs, and availability of the therapist might have all contributed to the relatively quick formation of a good working alliance. The therapist reparented the vulnerable child by validating and comforting Ella, but also by educating her on universal basic rights and needs of children, and responsibilities of parents as well as by recurrent rescripting of traumatic events that contributed to her negative self-image and guilt and shame feelings.

Stimulating autonomy

In ST for DID there is a strong focus on the stimulation of autonomy and taking responsibility for changing lifelong patterns throughout the treatment, because of the high levels of learned helplessness in DID patients. Ella often felt overwhelmed by her symptoms and unable to cope with most aspects of her life. Right at the start of treatment, personal goals were formulated to increase commitment and take responsibility for direction of the treatment. Also, homework exercises were given, in which Ella was asked to make summaries of each session, and was stimulated to express feelings and needs within sessions and at home (“ What does your little child mode think, feel, and need, and what does your healthy adult mode want to say to your father? ”). Especially in the last year of therapy, instead of doing the work for her, the therapist stimulated Ella to become more personally active in interventions. Autonomy and mastery were also stimulated by building a clear identity, figuring out what her likes and dislikes were, and which societal goals she wanted to pursue. In the last few months of treatment, the therapist and patient made a mode management plan together, in which all the helping interventions were included.

Review of successes

Because of a persistence of symptoms and strong feelings of helplessness, continuous focusing on the strengths of the patients and the progress they make is very important. Every 6 months, successes were reviewed by both the therapist and Ella by looking back at the positive steps she made (e.g., “ You completely stopped using cannabis for 6 months now ”, “ Lately, you were able to stay present during each entire session ”, and “ You were able to rescript yourself ”), and by looking at changes in the Mode Pie Chart [a pie chart in which the relative attendance of each mode is estimated; see ( 27 )].

The effectiveness of ST for DID is currently being investigated in two non-concurrent multiple baseline design studies in the Netherlands ( 10 ). This case report is one of the first descriptions of the practical application of ST for DID [also see ( 12 , 29 )], and illustrates that ST might be a viable and effective treatment for DID. Ella reported dissociative amnesia for traumatic experiences at the start of treatment. However, during therapy she shared that she was able to access traumatic experiences but feared confrontation and thus tried to avoid them. ImRs helped her to gradually process these traumas. ImRs was adapted to the limitations of Ella; it started as soon as possible (after several weeks), was built up gradually, and was performed continuously during the course of treatment. Furthermore, she was able to go along with a new conceptualization of the self in terms of modes instead of identities.

Ella showed strong improvement in psychiatric symptoms; there was a strong reduction of dissociative symptoms, PTSD, and depression symptoms including absence of suicidal behaviors, and abstinence from cannabis. She improved in social interaction and societal participation: she now takes care of her son and dog, her relationship with her husband has improved, she is meeting with friends, and sings in a choir. She also works as a volunteer for a needy elderly person and is applying for a job as a dentist assistant. These results are in line with studies into the effectiveness of ST and ImRs in adjacent populations ( 17 , 30 ). Ella found the termination of treatment very difficult, especially saying farewell to her therapist. Working so closely together during several years created a strong attachment bond, and ending of treatment can be difficult for both therapist and patient. Furthermore, because of the descriptive nature of this case report, no conclusion can be drawn about the evidence base of ST for DID; follow-up assessments were performed but cannot be presented because this case is part of a non-concurrent multiple baseline design study amongst 10 DID patients which is not yet finalized, so the results of individual participants cannot be shared ( 10 ).

This case report shows how ST can be applied to DID and suggests the possible effectiveness of ST for DID in general. An important next step is to systematically investigate the effectiveness of ST for DID in methodologically well-designed treatment studies, possibly leading to evidence-based treatments that go beyond stabilization of symptoms.

Patient perspective

Ella reported that ST for DID was and still is hard work. She has learned tools with which she can take and keep more control over modes and flashbacks. Where she used to avoid many situations and places, she now has the confidence to know that she can manage these on her own.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving human participants were reviewed and approved by the Ethics Committee of the Faculty of Behavioral and Social Sciences of the University of Groningen (EC-GMW). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

NB wrote the first draft of the manuscript. All authors read, commented on, and approved the manuscript.

Acknowledgments

We thank Ella for her participation in the study and her consent for the publication of this case report. We also thank Ida Shaw for her supervision of this ST trajectory.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: schema therapy, Dissociative Identity Disorder, case report, PTSD, personality disorder

Citation: Bachrach N, Rijkeboer MM, Arntz A and Huntjens RJC (2023) Schema therapy for Dissociative Identity Disorder: a case report. Front. Psychiatry 14:1151872. doi: 10.3389/fpsyt.2023.1151872

Received: 26 January 2023; Accepted: 04 April 2023; Published: 21 April 2023.

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Copyright © 2023 Bachrach, Rijkeboer, Arntz and Huntjens. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nathan Bachrach, n.bachrach@tilburguniversity.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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International Journal of Psychology and Psychological Therapy

• Volume 23 Num. 3

Volume 23 Num. 3 - October 2023

Empathic Resonance: A Case of Dissociative Identity Disorder (DID)

Volume 23 Num. 3 - October 2023 - Pages 333-337

García Vázquez, Paula , Serrano García, Antonio , Vilella Martín, Carmen , Franch Pato, Clara M , Gómez Martínez, Rocío

[email protected]

Dissociative identity disorder (DID) also referred as multiple personality disorder can be accompanied by related alterations in affect, behavior and sensory-motor functioning. This article describes the case of a 33-year-old woman with a diagnostic of DID and who required intensive treatment, who suffered bullying at the age of 15 with a demon personality. Despite psychopharmacological treatment there was no improvement until the emphatic resonance therapy was carried out. Our case report shows the complexity of providing treatment for patient with DID. How to cite this paper García-Vázquez A, Serrano-García, Vilella-Martín C, Franch-Pato CM, & Gómez-Martínez R (2023). Empathic Resonance: A Case Study of Dissociative Identity Disorder (DID). International Journal of Psychology & Psychological Therapy, 23, 3, 313-337

dissociative identity disorder, medical therapy, emphatic resonance, case study

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The Debate Over Whether Dissociative Identity Disorder Is "Real"

The "enactment" of dissociative identities and multiple personalities..

Posted February 7, 2023 | Reviewed by Abigail Fagan

• What Is Trauma?
• Find counselling to heal from trauma
• Whether or not dissociative identity disorder (DID), formerly known as multiple personality disorder, is "real" is a much-debated question.
• Different models agree that identities in DID are enacted but disagree about just what that means.
• It's likely that the meaning of enacted identities in DID varies across cultures, social settings, and individuals.

In psychiatry, there’s no more controversial diagnosis than dissociative identity disorder (DID), the disorder formerly known as multiple personality disorder (MPD). First appearing in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) published in 1980, proponents of the disorder have claimed that DID is woefully underdiagnosed, especially among those with a history of sexual trauma , with a true prevalence upwards of 20% across inpatient and outpatient psychiatric settings. 1

But others have suggested that DID is by definition overdiagnosed because they claim it isn't a real disorder. 2-4 Instead, they argue, it’s a diagnosis manufactured by those claiming to have it based on a blueprint established in Hollywood with the “based-on-a-true-story” films The Three Faces of Eve (1957) and Sybil (1976) . A related charge is that DID is largely “iatrogenic”—that is, a product of a small handful of self-proclaimed experts that have managed to “sell” the disorder to psychotherapists and their patients, similar to how hysteria based on false memories of ritual Satanic abuse in children sprang up in the 1980s and later faded.

Why is there so much disagreement over this controversial entity? The main point of contention is that while we’re all familiar with dissociation—the idea that we can have out of body experiences in the face of trauma like sexual assault or can zone out, seemingly unconscious of our surroundings while driving on the freeway—it’s more difficult to fathom the kind of extreme dissociation that’s a defining feature of DID. Indeed, it can seem incredible to those who have never seen or experienced DID that one's identity and sense of self can fragment into two or more, or even dozens of, distinct personalities or “alters” with different names, genders, ages, and recollected pasts, each potentially unaware of the other.

After all, we might ask ourselves, "If multiple personalities go by different names, who it is that gives them those names?" Just as there’s only one logical answer to that question, skeptics likewise claim that the other characteristics of alters must likewise be manufactured by the individual who purportedly has DID.

A Sociocognitive Perspective

How then can we best understand the undeniable fact that some people do present with the symptoms of DID? There's no doubt that such people exist, but in what sense do their dissociative identities exist and if they don’t, does that mean that those who manifest them are “faking it?”

University of Wisconsin psychiatrist Dr. Charles Raison offers an answer that reflects how many psychiatrists think of DID:

“There is no doubt that some people behave as if they have multiple personalities. And not all of them have been to therapists who have trained them to interpret their dissociative experiences in this way. Does this mean that dissociative identity disorder exists? In my opinion it depends on what we mean by "exists." Yes, dissociative identity disorder exists if by exists we mean there are people who complain of its symptoms and suffer its consequences. Do I think that some people have many biologically distinct entities packed into their heads? No. I think that some people dissociate so badly that either on their own or as a result of therapeutic experiences it becomes the case that the most convincing way for them to see their own experience is as if it is happening to multiple people. ” 5

In 1994—the same year that DSM-IV replaced the term "multiple personality " in MPD with "dissociative identity" in DID—Carlton University psychologist Nicholas Spanos published an influential paper that similarly characterized MPD through a sociocultural perspective:

“In short, the sociocognitive perspective suggests that patients learn to construe themselves as possessing multiple selves, learn to present themselves in terms of this construal, and learn to reorganize and elaborate on their personal biography so as to make it congruent with their understanding of what it means to be a multiple.” 6

Spanos chose the word “enactment” to describe how people identifying as having DID follow “rule-governed social constructions” with “multiple identities [that] are established, legitimated, maintained, and altered through social interaction.” People with DID, he wrote, are “actively involved in using available information to create a social impression that is congruent with their perception of situational demands and with the interpersonal goals they are attempting to achieve.” 6

While there are many psychiatrists and psychologists who agree that DID is socioculturally constructed as Spanos argues, 2-4, 7-8 there are many others—often including clinicians who work with DID and researchers who study it—who dispute the sociocognitive account in favor of a trauma model. 9-13 Within this seemingly two-sided debate, there are several legitimate and meaningful points of contention—such as to what extent DID is really iatrogenic or how to best treat it—whose resolution is thwarted when the debate is reduced to arguments about whether DID is “real” or “fake.” In fact, the sociocultural model and the trauma model aren't really mutually exclusive—according to a unifying biopsychosocial model , DID can be both a trauma reaction as well as highly shaped by sociocultural factors—and may share some potential overlap. 14,15

Enacted Identities

Within the sociocognitive model, “enactment” doesn't mean the same thing as "fabrication" or “faking it," which suggests more of a conscious and deliberate act of deception . If, as Spanos suggests, we instead think of DID as similar to other phenomena including hypnotic suggestion, past-life regression , spirit or demonic possession—to which I would add speaking in tongues, alien abduction experiences, or having imaginary friends as children—we can better appreciate how the enactment of multiple identities might arise consciously, unconsciously, or semi-consciously within the bounds of a certain sociocultural framework.

In other words, while asking whether DID exists or not and whether those with DID are faking it or not implies only two possible answers, the reality is something more nuanced and complex. For example, when people are “possessed by a demon” or the “Holy Spirit” during a culturally-sanctioned trance ritual or describe “past lives” during psychotherapy , they’re not simply “making it up” for the sake of making it up or for “ attention .” While that could be the case (e.g., it is possible to simulate or “malinger” DID 16 just as the woman upon which the movie Sybil was based later admitted to “lying” about her alters 17 ), enacting demonic possession, like enacting DID, instead suggests an experience that involves tapping into something within one’s psyche that draws upon an existing sociocultural framework such as a religious practice, séance, psychotherapy session, or something else.

While none of those examples of cultural ritual imply that anyone is “faking it” or merely "acting," the sociocognitive model does make clear that demons, past lives, or distinct personalities don’t really exist apart from being enactments—or creations—of one’s mind.

This perspective isn’t actually very far afield from that of psychiatrist and psychoanalyst Richard Kluft, one of the leading proponents of the trauma model and the legitimacy of DID as a “real” mental disorder (see Kluft's interesting backstory on the fight to keep DID in DSM-III-R here ). For example, Kluft characterizes the personalities or identities of DID as:

“…behaviorally enacted with noteworthy role-taking and role-playing dimensions and sensitive to intrapsychic, interpersonal, and environmental stimuli… The personalities are not unconscious in the traditional psychoanalytic sense… [and] arise as desperate coping strategies in an overwhelmed child [that] initially have an adaptational and defensive design… The patient forms and auto-hypnotically envisions an illusory embodiment of an identity that could manage the adaptation that is believed to be required. What is envisioned with a great sense of reality is believed to be real, and the mind undergoes a cognitive restructuring that accepts and interprets what is believed to be real as real, and makes it possible to act as if it were real.” 1

So it is that both Spanos and Kluft use the term “enacted” to account for the multiple identities of DID. The devil of what exactly that means—that is, why and by what mechanism those enactments occur—is in the details, with variability between models as to whether or to what extent such enactments are best understood as volitional fantasies or unconscious creations and whether or to what extent they’re causally linked to trauma.

In addition to conceding overlap, another way to resolve these differences is to acknowledge that such diversity not only reflects variations from one from model to another, but also from one culture, social setting, or individual to another. For those with DID, the term "enactment" will no doubt resonate with some better than others.

In my next post, we’ll take a closer look at how culture, social factors, and individual differences are changing how we think about and understand the concept of “multiplicity” in DID and to what extent this phenomenon is best understood or framed as a mental disorder.

To read more: ► Enacted Identities: Multiplicity, Plurality, and Tulpamancy

1. Kluft RP. Current issues in dissociative identity disorder. Journal of Practical Psychiatry and Behavioral Health 1999; 5:3-19.

2. Piper A, Merskey H. The persistence of folly: A critical examination of dissociative identity disorder: Part I. The excesses of an improbable concept. Canadian Journal of Psychiatry 2004; 49:592-600.

3. Piper A, Merskey H. The persistence of folly: A critical examination of dissociative identity disorder: Part II. The defence and decline multiple personality or dissociative identity disorder. Canadian Journal of Psychiatry 2004; 49:678-683.

4. Paris J. The rise and fall of dissociative identity disorder. The Journal of Nervous and Mental Disease 2012; 200:1076-1079.

5. Raison C. Is dissociative identity disorder real? Expert Q&A, CNN, February 23, 2020.

6. Spanos NP. Multiple identity enactments and multiple personality disorder: A sociocognitive perspective. Psychological Bulletin 1994; 116:143-165.

7. Lilienfeld SO, Jay Lynn S, Kirsch I et al. Dissociative identity disorder and the sociocognitive model: recalling the lessons of the past. Psychological Bulletin 1999; 125:507-523.

8. Boysen GA, VanBergen A. A review of published research on adult dissociative identity disorder. The Journal of Nervous and Mental Disease 2013; 201:5-11.

9. Gleaves DH. The sociocultural model of dissociative identity disorder: A reexamination of the evidence. Psychological Bulletin 1996; 120:42-59.

10. Reinders AATS, Willemsen ATM, Vos HPJ, et al. Fact or factitious? A psychobiological study of authentic and simulated dissociative identity states. PLoS ONE 2012; 7: e39279.

11. Dell PF. The weakness of the sociocognitive model of dissociative identity disorder. The Journal of Nervous and Mental Disease 2013; 201:438.

12. Brand BL, Sar V, Stavropoulos P, et al. Separating fact from fiction: An empirical examination of six myths about dissociative identity disorder. Harvard Review of Psychiatry 2016; 24:257-270.

13. Vissia EM, Giesen ME, Chalavi S, et al. Is it trauma or fantasy-based? Comparing dissociative identity disorder, post-traumatic stress disorder, simulators, and controls. Acta Psychiatrica Scandinavica 2016; 134:111-128.

14. Sar V, Krüger C, Martínez-Taboas A, et al. Sociocognitive and posttraumatic models of dissociation are not opposed. The Journal of Nervous and Mental Disease 2013; 201:439-440.

15. Sar V, Dorahy M, Krüger C. Revisiting etiological aspects of dissociative identity disorder: A biopsychosocial perspective. Psychology Research and Behavioral Management 2017; 10:137-146.

16. Thomas A. Factitious and malingered dissociative identity disorder. Journal of Trauma and Dissociation 2001; 2:59-77.

17. Neary L. Real ‘Sybil’ admits multiple personalities were fake . NPR October 20, 2012.

Joseph M. Pierre, M.D., is a Health Sciences Clinical Professor in the Department of Psychiatry and Behavioral Sciences at University of California, San Francisco and the Unit Chief of the Langley Porter Psychiatric Hospital Adult Inpatient Unit.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Dissociative identity disorder.

Paroma Mitra ; Ankit Jain .

Affiliations

Last Update: May 16, 2023 .

• Continuing Education Activity

Dissociative identity disorder (DID) is a rare psychiatric disorder diagnosed in about 1.5% of the global population. This disorder is often misdiagnosed and often requires multiple assessments for an accurate diagnosis. Patients often present with self-injurious behavior and suicide attempts. This activity reviews the evaluation and treatment of dissociative identity disorder and explains the role of an interprofessional team in caring for patients diagnosed with dissociative identity disorder (DID). This activity also reviews the association between DID and suicidal behavior.

• Describe the constellation of behavioral symptoms that lead to a diagnosis of dissociative identity disorder.
• Review risk factors for the development of a diagnosis of dissociative identity disorder.
• Explain the different modalities of evidence-based treatment for dissociative identity disorder.
• Outline some interprofessional strategies that can improve patient outcomes in patients with dissociative identity disorder.
• Introduction

Dissociative identity disorder (DID) is a rare disorder associated with severe behavioral health symptoms. DID was previously known as Multiple Personality Disorder until 1994. Approximately 1.5% of the population internationally has been diagnosed with dissociative identity disorder. [1] Patients with this diagnosis often have several emergency presentations, often with self-injurious behavior and even substance use. [2]

Of note, DID has been observed and described in several countries and associated with terms such as "outer world possession" and "possession by demons." [3]  Several case reports have been described with those terms; however, trauma and its association came with DID much later.

Dissociative identity disorder is typically associated with severe childhood trauma and abuse. [4] Dalenberg and his team have detailed the role of trauma in the development of dissociative disorder and dismissed the previous model, which was based on fantasy and often associated with suggestibility, cognitive distortions, and fantasy. However, newer research tends to describe a combination of both severe traumas (which may be in any form physical/emotional/sexual)as well as some effects of cognitive suggestion. Stress experienced by an individual secondary to trauma has been seen to contribute to the formation of an accurate understanding of the trauma being unreal, even posttraumatic dissociation such as leaving one's body, etc., and poor sleep. However, in the fantasy theory-it has been seen that people with high levels of vulnerability, predisposition of psychological symptoms, media influences, and likely social isolation and vulnerability. [5]

Several prominent psychologists, such as Kluft, have broken down the theory behind DID-in-sum. The theory describes predisposing factors for dissociation, which include an ability to dissociate, overwhelming traumatic experiences that distort reality, creation of alters with specific names and identities, and lack of external stability, which leads to the child's self-soothing to tolerate these stressors. These four factors must be present for DID to develop. [6]

• Epidemiology

Dissociative disorders show a prevalence of 1% to 5% in the international population. Severe dissociative identity disorder is present in 1% to 1.5% of this population. Patients may spend up to 5 to 12.5 years in treatment before being diagnosed with dissociative identity disorder. [7] Patients with DID come with increased rates of non-suicidal self-injurious behavior and suicide attempts. [8]

• Pathophysiology

The DID person, per the International Society for the Study of Trauma and Dissociation,  is described as a person who experiences separate identities that function independently and are autonomous of each other. The International Society describes alternate identities or "alters" as independent identities with distinct behaviors and memories distinct from others and may even differ in language and expressions used. Signs of a switch to an altered state include trance-like behavior, eye blinking, eye-rolling, and changes in posture. 

The major hypothesis by Putnam et al. is that "alternate identities result from the inability of many traumatized children to develop a unified sense of self that is maintained across various behavioral states, particularly if the traumatic exposure first occurs before the age of 5."  [9]  The theories have been studied by groups in the inpatient unit services in the 1990s.

• History and Physical

The way to diagnose dissociative identity disorder is via detailed history taken by both psychiatric practitioners and experienced psychologists. Often, persons with DID are misdiagnosed with other personality disorders, most commonly borderline personality disorder, as elements of dissociation are prominently seen and even amnesia. Longitudinal assessments over long periods and careful history-taking are often required to complete diagnostic evaluations. History is often gathered from multiple sources as well. Neurological examinations are often required to rule out autoimmune encephalitis, often requiring electroencephalograms, lumbar punctures, and brain imaging.

Dissociative Disorders are classically characterized as disrupting normal consciousness/memory/identity and behavior. The disorders are classically broken down into "positive " and "negative " symptoms -positive symptoms are often associated with "new personalities, derealization," and negative symptoms are symptoms such as autism and paralysis. [10] Dissociative identity disorder is part of the larger dissociative disorders spectrum; however, it has more specific criteria outlined by the Diagnostic And Statistical Manual Edition-5.

The Diagnostic and Statistical Manual (DSM-5)criteria for DID include at least two or more distinct personalities. Each personality varies in behavior, sense of consciousness, memory, and perception of the outside world. Persons with DID experience amnesia, distinct gaps in memory, and recollections of daily and traumatic events. They cannot be directly related to substance use or part of cultural norms or practices. Importantly, these symptoms must cause a notable lack of daily functioning. [11] [10]

As explained above, a detailed history from multiple sources and multiple longitudinal assessments over time is of the essence. However, some evaluation tools have been developed to diagnose DID. Some of these are below:

• Dissociative Experiences Scale - a 28-item self-report instrument whose items primarily tap the absorption of outside information, use of imagination depersonalization, derealization, and amnesia. [12]
• Dissociation Questionnaire - 63 questions that measure identity confusion and fragmentation, loss of control, amnesia, and absorption.
• Difficulties in Emotion Regulation Scale (DERS) - 36-question subjective questions around challenges in goal-directed work, impulsivity, emotional responses to situations, ability to self-regulate emotions, etc. [13]
• Treatment / Management

Some treatment approaches for dissociative identity disorder include basic structures from work with personality disorders in a three-pronged approach:

• Establishing safety, stabilization, and symptom reduction;
• Confronting, working through, and integrating traumatic memories
• Identity integration and rehabilitation. [14]

The first step focuses on the safety of patients with DID, as many present with suicidal ideation and self-injurious behavior. [8]  It is important to mitigate that risk. The second phase focuses on working with traumatic memories and includes tolerating, processing, and integrating past trauma. This may focus on continuing to re-access traumatic memories with different alternate identities and may help share memories. The third and final treatment phase focuses on the patient’s relationship to self as a whole and to the rest of the world. Through all the phases of treatment, a strong therapeutic alliance and trust are encouraged

The most common approach is via psychodynamic psychotherapy steps, broken down above. Recent approaches include trauma-focused cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). [15]  There are no controlled clinical trials for CBT. The reason DBT skills are used is essentially secondary to some of the overlapping symptoms between borderline personality disorder and DID. Even with varying therapy approaches, some core treatment features include more education, emotional regulation, managing stressors, and daily functioning.

Another mode of treatment is the use of hypnosis as therapy. According to the literature, DID patients are more hypnotizable than other clinical populations. [16]  There have been some studies as recent as 2009 that have shown efficacy in the use of hypnosis to treat DID. [17]  Many DID patients are considered autohypnotic. Some techniques include accessing alternate identities not present in the session, an intervention that can facilitate the emergence of identities critical to the therapeutic process. [6]

Another mode of treatment has been the use of Eye Movement Desensitization and Reprocessing ( EMDR ). The guidelines, however, advocate for EMDR to be used as part of integrative treatment. EMDR processing is recommended only when the patient is generally stable and has adequate coping skills.EMDR interventions for symptom reduction and containment, ego strengthening, work with alternate identities, and, when appropriate, the negotiation of consent and preparation of alternate identities. [18]

Psychopharmacology is not the primary treatment for DID. Medications may be used to target certain symptoms reported. The most commonly used medications include medications for mood disorders and PTSD (post-traumatic stress disorder). [19]  The challenges of using psychopharmacological medications remain as different alters may report different symptoms. Some alters may report compliance, and some may not. The literature review has shown that many medications have been used for DID, including antipsychotic medications, mood stabilizers, and even stimulants; however, no medication has been effective in the treatment of DID. [20]

• Differential Diagnosis

As mentioned above, the most common differential diagnosis includes borderline personality disorder, histrionic personality disorder, and even primary psychotic disorders such as schizophrenia and schizoaffective disorders. As mentioned, patients with DID often present with symptoms of dissociation and amnesia, which are also seen in patients with borderline personality disorder. Often, patients' symptoms are considered symptoms of psychosis as alters as mistaken as hallucinations, which often precipitate the use of antipsychotic medications. Given that trauma is a focus, post traumatic stress disorder is also a differential diagnosis.

The most common differential diagnosis is borderline personality disorder. [21]  Borderline personality disorder is also associated with extensive trauma, which often presents with micropsychotic and dissociative symptoms.

• Pertinent Studies and Ongoing Trials

There have been case studies and case reports formerly reported in the '90s and early 2000s. Some more treatment interventions have been described in naturalistic and longitudinal studies that continue to inform outcomes. [7]

Unfortunately, Dissociative identity disorder is a medical condition often diagnosed later in life. Often, patients are misdiagnosed with other diagnoses as described above and treated with medications and even therapies that may not directly address DID. Once in treatment, this tends to be lifelong as DID patients continue to require reality-based and grounding interventions. Safety planning with DID patients is lifelong. The prognosis without treatment and correct diagnosis is poor.

• Complications

The patients remain at increased risk of self-injurious behavior given the presence of alters as well as latent trauma. [22]  There have been newer research studies that have described suicidal ideation, especially during dissociation, which describes decreased pain tolerance and more emotional dysregulation. Most treatment interventions advocate for safety planning and reality testing before the use of more advanced psychotherapy techniques

Inpatient hospitalizations and day treatment programs may also be recommended for patients who struggle with thoughts of self-injurious behavior, poor impulse control, or acute mood dysregulation. Medications may be added for mood stabilization.

• Deterrence and Patient Education

Patient education must focus on informing patients on the correct diagnosis when it is determined. Family members are encouraged to be educated about the nature of this illness, including the presence of alters, as well as safety and grounding techniques. Another vital aspect continues to maintain a strong therapeutic alliance with the treatment team and engage in maintaining safety techniques.

Education may be done with multiple alters that do not communicate with each other, and this must be recognized. On the other hand, DID patients often do not want their diagnosis shared publicly, and their privacy must be respected.

• Enhancing Healthcare Team Outcomes

Dissociative identity disorder requires treatment by an interprofessional healthcare team - this will often consist of medical specialists such as a psychiatrist, mid-level practitioners, nursing staff, specialized therapists, trauma counselors, peer counselors, and therapists who all communicate and collaborate. A psychiatrist and primary care physician complete the team. Maintaining a strong therapeutic alliance with the patient and involved family members continues to be of utmost importance. DID patients require frequent check-ins and follow-up appointments and an almost daily focus on safety planning and reality-based interventions.

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Disclosure: Paroma Mitra declares no relevant financial relationships with ineligible companies.

Disclosure: Ankit Jain declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Mitra P, Jain A. Dissociative Identity Disorder. [Updated 2023 May 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Case Studies in Abnormal Psychology

Thomas f. oltmanns, michele t. martin, john m. neale, dissociative identity disorder: multiple personality - all with video answers.

Chapter Questions

The initial presentation of DID can be very confusing, both for the patient and the therapist. What were the various diagnostic options that Dr. Harpin originally considered when he began working with Paula? Why was DID a more appropriate diagnosis?

After he had been working with Paula for several years, Dr. Harpin stopped asking to talk to her alter personalities by name, preferring instead to address only Paula. Should he have adopted that strategy from the beginning of the case? Do you think his willingness to talk to her using different names could have contributed to the problem? Or did it help him sort out the problem and establish a strong working relationship with his client?

Have you seen reports or discussions of DID in the popular media? Why do you think some therapists say they have treated dozens of patients with DID while the vast majority of mental-health professionals have never seen a single case?

Like patients with PTSD, people with DID have often been the victims of serious sexual abuse. How are the symptoms of the two disorders similar? In what ways are they different?