The main aim of this paper is to investigate a number of factors associated with the diagnosis and treatment of dissociative identity disorder (DID). The epidemiological aspects, such as the socio-cultural factors and risk factors, are also discussed in this paper. What is more, the paper makes a number of suggestions regarding the best treatment strategies for dissociative identity disorder.
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The current paper also analyses the existing literature that lends credence to the psychological and neurological aspects of dissociative identity disorder in order to provide a precise diagnosis as well as suitable treatment. In addition, the current paper discusses the bio-psychosocial approach that is commonly used to conceptualize dissociative identity disorder.
This paper also investigates the treatment options that are currently used by therapists to alleviate the adverse symptoms of dissociative identity disorder. Finally, the paper explores the characteristics of dissociative identity disorder in order to provide a better understanding regarding the most effective diagnosis and treatment of dissociative identity disorder.
Introduction to Dissociative Identity Disorder (DID)
It is important to note at the onset of this paper that dissociative identity disorder is one of the psychiatric disorders extensively discussed in the history of diagnostic categorization. Nonetheless, a limited number of studies have been carried out to explore the characteristics and treatment options of this disorder.
It is against this backdrop that mental health experts do not have a common position regarding the effective diagnosis and treatment of dissociative identity disorder. In many cases, dissociative identity disorder occurs when a person experiences a disruption in his/her normally synchronized functions of identity, memory and consciousness of the immediate surroundings.
In other words, the thoughts and feelings of a person no longer work in harmony. A person suffering from dissociative identity disorder may experience intense emotions but fail to remember the cause of these emotions.
Description of DID Diagnosis
The current edition of the DSI stipulates the diagnostic procedure that must be followed during the DID prognosis. For instance, it stipulates that prognosis should be carried out among patients who exhibit two or more personalities. According to DSI, personality is defined as an entity that demonstrates an exceptional pattern of thought, discernment and relational style that entails both the environment and self.
What is more, the personalities must demonstrate a pattern of manipulating the behaviour of the individual. In many cases, a person suffering from dissociative identity disorder will experience memory loss and consequently forget crucial personal information.
Therefore, different prognoses usually overlook the adverse effects of medical conditions and chemical substances. For example, the American Psychiatric Association (2000) recommends that proper DID diagnosis should be done among children in order to differentiate real symptoms from imaginary play.
The current research seeks to investigate the characteristics of dissociative identity disorder and compare them to those obverses among patients suffering from dissociative disorder not otherwise specified (DDNOS). The researcher interviewed 44 patients suffering from dissociative disorders (n=44).
In addition, 22 patients suffering from dissociative disorder not otherwise specified (n=22) were interviewed. The researcher used the Diagnostic Interview for Psychiatric Disorder to collect responses from the two groups. Later on, the researcher compared results from these two groups with those of patients suffering from other disorders.
These groups included patients suffering from nonclinical controls (n=30), patients with depression (n=17), patients suffering from post-traumatic stress disorder (n=13) and patients with other anxiety disorders (n=14). The researcher did not find any comorbid disorder among patients with nonclinical control.
The findings of this research showed that people with dissociative identity disorder were also likely to suffer from comorbid disorder. The researcher also found that post-traumatic stress disorder (i.e., Elevated levels of depression, somatoform disorders, and anxiety) were the most widespread comorbidity in dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS).
However, post-traumatic stress disorder (PTSD) varied considerably among those patients suffering from anxiety disorders and depression.
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It is against this backdrop that the results of the current study corroborate the hypothesis that dissociative identity disorder (DID), dissociative disorder not otherwise specified (DDNOS) and post-traumatic stress disorder (PTSD) exhibit a phenomenological relationship that should be presented within a new category of diagnosis.
Client characteristics, course, & prognosis
A study by Gleaves, May and Cardera (2001) reported that many patients suffering from dissociative identity disorder also suffer from borderline personality disorder, commonly known as post-traumatic stress disorder. What is more, the study revealed that patients with dissociative identity disorder had previously suffered from Schizophrenia.
Nonetheless, there is a high probability that this finding signifies an erroneous diagnosis rather than comorbidity. This is because patients suffering from both Schizophrenia and dissociative identity disorders also exhibit symptoms of the Schneiderian disorder (Ibid).
In addition, other symptoms of comorbid disorder are potentially caused by an organic mental disorder, psychotic disorders, personality disorders, somatoform disorders, eating disorders, drug abuse, and anxiety and mood disorders (ISSD, 2005). Kaplan and Sadock (2008) also report that a combination of somatoform and conversion disorders can result in comorbid disorder.
A number of studies have reported that the prevalence of other compounding symptoms can mitigate the benefits derived from proper prognosis and therapy of dissociative identity disorder.
Client characteristics, course, & prognosis
The nature and diagnosis of the untreated dissociative identity disorder remain unclear. What is more, the diagnosis is complicated further when patients suffer from comorbid disorder. There are several factors that inhibit effective diagnosis of dissociative identity disorder. These include: antisocial personality traits, eating disorders, drug abuse, taking part in unlawful activities, and staying in abusive environments.
In spite of the fact that many people show symptoms of dissociative identity disorder in their adulthood or late adolescence, the mean age at which DID diagnosis occurs is 30. However, the majority of the DID prognosis is performed between 5 and 10 years after the symptoms have already emerged.
According to Kaplan and Sadock (2008), a risk factor entails having first-degree relatives who have undergone prognosis of dissociative identity disorder.
A study by Pasquini et al. (2002) reported that children are seven times at risk of suffering from a dissociative disorder if they were exposed to a traumatic experience. Subsequent prognosis of dissociative disorder revealed that a child is two times at risk of experiencing disruptive disorder if his/her mother suffered from trauma within two years of the child’s birth.
In another study, Korol (2008) reported that 95-98 percent of child abuse cases resulted in dissociative identity disorder among children. Nevertheless, prior history of child abuse is not the only cause of dissociative identity disorder among children.
Other factors that contribute to dissociative identity disorder include disoriented or disorderly attachment lifestyle as well as absence of familial or social support that play a major role in the development of dissociative identity disorder among children (Ibid).
A similar prevalence of DID was detected among study participants from Turkey, Norway, Netherlands, Canada and the United States (Kluft & Foot, 1999). On the contrary, a study by Fujii et al. (1998) reported lower prevalence levels of disruptive identity disorder in Japan, Germany and India.
In another study, Xian et al. (2006) sought to establish the prevalence rates of disruptive identity disorder among the inpatients, outpatients and the general population in China. The results of his study revealed a prevalence level of 0.5, 0.3 and 0.0 for the three categories in that order.
What is more, the prevalence and etiology of dissociative identity disorder are attributed to those factors associated with collective and individual cultures.
For instance, Fujii et al. (1998) reported that the prevalence of DID in Japan was lower compared to that in the United States and attributed these differences to cultural factors. His findings revealed that a majority American participants suffering from dissociative identity disorder had experienced either sexual or physical abuse during their childhood.
On the contrary, Japanese participants suffering from dissociative identity disorder had experienced fewer incidences of sexual or physical abuse during their childhood. What is more, Fujii et al. (1998) revealed that the occurrence of split-personality among the sampled patients from Japan was extremely lower than that observed among the sampled respondents from the United States.
Psychotherapeutic Treatment of People with DID
According to the International Society for the Study of Dissociation (ISSD), an all-embracing treatment strategy is required to mitigate split-personality disorders such as dissociative identity disorder and comorbid disorders (ISSD 2005).
Consequently, the International Society for the Study of Dissociation (ISSD) has issued some elementary instructions to help the therapist in treating dissociative identity disorder. Dissociative identity disorder is treated using the following framework: “(1) safety stabilization and symptom reduction, (2) working directly and in-depth with traumatic memories, and (3) identify integration and rehabilitation” ((ISSD 2005, p. 89).
Although these phases are administered during the treatment phases, they define the major therapeutic issues that emerge during the phases of treatment. As noted earlier, a traumatic event can result in intense emotions. Therefore, people suffering from dissociative identity disorder are likely to behave in a way that may cause harm to themselves and others.
Consequently, the treatment should address violent behaviours among people with dissociative identity disorder. In addition, behavioural or cognitive therapy should be administered to help the victims learn how to control their impulses. Therapists must also understand that some patients are not willing to synchronize their personalities.
If this happens, the therapists should not consider personalities as problems to be alleviated but as the creative reaction of a patient to trauma. One of the best strategies for treating dissociative identity disorder is to recognize relationships between alters and communicating with them directly.
Therapists must also encourage the patients to listen to their personalities in order to facilitate essential conversation among the therapist, alters and the victim (ISSD 2005).
According to Sno and Shalken (1999), no clinical experiments have been carried out to determine the effectiveness of a range of hypothetical orientations or therapeutic procedures in treating Dissociative Identity Disorder.
However, a study conducted by various psychiatrists specialised in treating Dissociative Identity Disorder established that the most effective ways of treating this condition include personal therapy, anxiolytics, and antidepressants. In the cases where Dissociative Identity Disorder leads to self-injury drugs such as carbamazapine, parazosin, and nutrition are very useful.
Even though studies exploring the use of pharmacotherapy in treating Dissociative Identity Disorder are very limited, two studies exploring the use of diazepam and perospirone are promising.
Ballew, Morgan, and Lippmann (2003) conducted a case study on the use of pharmacotherapy in treating Dissociative Identity Disorder. In the study they suggest that the diazepam’s ability to minimise anxiety may be very useful in memory recovery in case Dissociative Identity Disorder where memories hold traumatic materials.
Diazepam is used in this study to facilitate memory recovery in a client suffering from amnesia and is not able to remember his location or identity. The study concluded that “Intravenous diazepam is an effective, safe intervention to consider for facilitation of memory recovery in amnesic patients, “and that Dissociative Identity Disorder results in some level of amnesia.
Nonetheless, since the success rate and satisfactoriness of diazepam have not been shown in the treatment of a sufficient number of Dissociative Identity Disorder cases, it will be very misleading to make a conclusion on the appropriateness of this type of pharmacotherapy treatment.
Psychological experts argue that medications are only applicable when tackling secondary characteristics and comorbid disorders, and not for treating Dissociative Identity Disorder.
Treating DID using an Integrative Approach
As noted earlier, the medical experts are yet to agree on the most effective strategy that can be adopted in treating dissociative identity disorder. It is against this backdrop that an integrative treatment strategy is developed in order to deal with the various negative effects of dissociative identity disorder.
What is more, the therapist should monitor the progress of the patients in order to deal with any side-effects that may arise during the treatment period.
There are various psychosocial methods that can be used to tackle particular problems accordingly. Deliberate use of one approach may hamper successful treatment for Dissociative Identity Disorder normally entails numerous disorders that need to handle separately.
Besides the integrative individual approach, Kaplan and Sadock (2008) suggest that knowledge of system theory and somatoform disorder is very important because they help in understanding the somatic symptoms and the link between them. Dissociative Identity Disorder can be treated effectively through long-term, adapted and reasonably based psychotherapy.
Most of these therapies are carried out at least once a week and are dependent on certain factors. These include individual or family resources, support and impetus. Dissociative Identity Disorder therapies can last up to five or more years depending on the patient’s rate of recovery.
A wide range of techniques, including cognitive behavioural therapy, reduction of eye movement, reprocessing, and Neuro-psychotherapy, among others can be normally applied. However, the use of these techniques must follow a clear guideline and adjustments must be made only when necessary. This will help in minimising cases of flooding patients with dangerous traumatic materials and medication (Reinders et al., 2006).
Most experts front for treatment that are phase-oriented (follow three distinct steps). The first step entails establishment of safety standards, stabilization and symptom minimization. The second phase involves operating through and integrating negative memories.
The last stage entails client integration and rehabilitation. This is the stage where Dissociative Identity Disorder patient requires maximum support from the family and the society at large (Buchele, 1993).
Many studies support the use of social support in treatment of psychological disorders. Therefore, individuals suffering from Dissociative Identity Disorder should be given all the necessary support once they have attained stability. One of the most excellent methods of achieving this is group psychotherapy.
The benefit of group therapy includes minimising seclusion, which is common among patients suffering from Dissociative Identity Disorder, provides patients with the opportunity to interrelate with both genders in heterogeneous groups, and replaces secrecy and desolation since the group is more accommodating and hospitable.
Group therapy also offers provides patients with the opportunity to learn from each other, understand the objective of alters and give the hope of recovery like other members of the group (Buchele, 1993). Each and every treatment methods have their own pros and cons and therefore, it’s important for the therapists explore viable options and help clients to recover fully.
Conclusions & Future research
The contemporary research trends focus on Neuro-biological and psycho-biological variables that are exceptional to Dissociative Identity Disorder. For instance, among the most recent studies was the evaluation of the disparities that exists between alters that can still recall traumatic past events and those that have contained such memories.
The findings of this study show that different alters display disparity in emotional, nervous system, heart rate, and blood flow in the brain in reaction to traumatic memories (Reinders et al., 2006).
Another study recent study on Dissociative Identity Disorder sought to use the results of other studies to find related disorders. Since most patients diagnosed disorders resulting from stress (for example, post-traumatic stress disorders, Major Depressive disorder, Borderline personality disorder, among others) have exhibited a decrease in hippocampus volume.
The study used magnetic resonance imaging and volumetric analysis to find out whether there is any correlation between Dissociative Identity Disorder and decreased hippocampus volume.
The study findings show that the volume of the hippocampus of the sampled individuals with Dissociative Identity Disorder was 19.2 percent lower and the amygdale was 31.6 percent lower than the normal value (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006).
A number of researchers have tried to explain the relationship between trauma and memory in patients suffering from Dissociative Identity Disorder (Tsai, Condi, Wu, & Chang, 1999). A study exploring the link between brain and the process of switching from one personality to another utilized a magnetic resonance imaging to identify the processes involved during the switching process.
The study findings show that during the switching process, a patient’s bilateral hippocampus is subdued, in addition to the right parahippocampal gyrus, right medial temporal lobe, globuspallidus, and substantianigra. Nonetheless, during the process of recovering from split personality, studies show that the activities of the right hippocampus generally increase with no sub durance of the brain (Tsai, Condi, Wu, & Chang, 1999).
The results of this study add to the understanding of amnesia between alters because the neural parts involved in the memory are either subdued or triggered.
Nowadays, most studies pursue bio-psychosocial approach which links psychological disorders to a complex network and interface of biological, psychological and socio-cultural factors. A number of studies hold the opinion that split personality in people suffering from psychological disorders protects them against obnoxious thoughts and past traumatic events.
Personal memories may possibly be different among split personalities and this normally helps people suffering from psychological disorders to keep hold of positive thoughts and contain negative thoughts (Bryant, 2005).
Another research investigating directed forgetting established that “dissociative patients showed directed forgetting between states, but not within the same identity state” (Bryant, 2005, p. 241).
The study sheds light on mechanism and functions in different personalities and helps in understanding their development through trauma. Ejecting negative traumatic memories out of the brain can be facilitated by switching from one personality to another (Elzinga, Phaf, Ardon, & van Dyck, 2003).
Despite of the fact that many physicians now understand Dissociative Identity Disorder more than they did in the past, more studies are required to shed light on and to further investigate the nature of this disorder. Many studies conducted on this disorder still leave a huge gap that needs to be filled.
For instance, further clinical trials should explore the risk factors involved and shed more light on the part played by inherited and ecological factors in this disorder.
Further clinical trials should find out the nature of the physical and psychological disparities evident among personalities, what causes these disparities, and their importance. Psychopharmacological researches should find out the medication that works best for this condition and their effectiveness.
Studies on how culture and social environment impacts the development and clinical presentation of dissociative Identity Disorder should be carried out. Future clinical trials related to this disorder will not only assist the victims’ family, but also the field of medical research. In addition, these studies will play a vital role in the field of clinical psychology.