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• June 15, 2024 | VOL. 77, NO. 2 CURRENT ISSUE pp.43-100
• March 15, 2024 | VOL. 77, NO. 1 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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• A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults 26 December 2023 | Journal of Trauma & Dissociation, Vol. 25, No. 2
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Case Series of Dissociative Identity Disorder in Teenagers: Clinical Features and Treatment Consideration

Zakaria, Rozanizam; Kamarulbahri, Tengku Mohd Saifuddin Tengku 1 ; Harun, Noorul Amilin 1 ; Hussin, Suria 2

Department of Psychiatry, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

1 Department of Psychiatry and Mental Health, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

2 Department of Psychiatry and Mental Health, Hospital Raja Perempuan Zainab 2, Kota Bharu, Kelantan, Malaysia

Address for correspondence: Dr. Rozanizam Zakaria, Department of Psychiatry, Kulliyyah of Medicine, International Islamic University Malaysia, 25200, Kuantan, Pahang, Malaysia. E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Dissociation is an unconscious defense mechanism that helps to protect oneself from trauma. It comes in various forms, such as dissociative identity, memory loss, and altered perception. Dissociative identity disorder (DID) is a serious psychological disturbance that can occur due to maladaptive dissociation patterns. However, it is not commonly identified in clinical practice. This case series presents three clinical cases of DID in adolescents with different predispositions. One case involved a male adolescent with autism spectrum disorder, while the other two cases involved female adolescents with depression and a history of sexual abuse. The report emphasizes the importance of screening for dissociative symptoms, proper diagnosis and treatment approaches, and the challenges in diagnosis and management. This information can help clinicians to improve their knowledge and skills in managing similar cases involving adolescents.

I NTRODUCTION

Dissociation as a phenomenon in psychiatry has its unique and controversial position. Since the beginning of the 19 th century, dissociation has been discussed along the spectrum of hypnotic or hysterical phenomenon to the posttraumatic phenomenon as we understand it today. [ 1 ] Dissociation is defined as a form of psychological defense, against psychologically traumatic experience that leads to disintegration of a person’s thoughts, memories, feelings, actions, or sense of who he or she is. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association divides disorders of dissociation into dissociative identity disorders (DIDs), dissociative amnesia, and depersonalization/derealization disorder. [ 2 ] DID, previously identified as multiple personality disorder, is a complex, chronic disorder which is usually linked with psychological complications of trauma. Its clinical presentation includes disruption in identity by two or more distinct personality states which results in disturbance of sense of self, alteration in memory, affect, behavior, perception, cognition, and/or sensory-motor functioning. [ 3 ] Based on a cross-sectional study, the prevalence of DID tends to rise depending on the level of psychiatric severity, ranging from about 2% in outpatient clinics to about 5% in inpatient units, with even higher rates in emergency settings. [ 4 ] DID prevalence was found to be 16.4% in a survey of adolescents who were admitted to hospitals, with considerable percentages (93.9%) having another primary psychiatric diagnoses. Assessment of the presence of dissociative identity symptoms is primarily done by clinical and exclusion of other causes such as epilepsy and substance. Therefore, careful and thorough history is warranted in order to establish symptoms and diagnosis of DID. Despite significant prevalence reported, symptoms of dissociative identity are poorly recognized. This would potentially lead to low identification rate and poor integration in the treatment. This case report aims to highlight the importance of screening for dissociative symptoms, establishing proper diagnosis and different treatment approaches for these cases. The challenges in diagnosis and management were also emphasized in order to improve clinicians’ knowledge and skills in managing similar cases involving adolescents.

C ASE R EPORTS

A 16-year-old boy with underlying high-functioning autism spectrum disorder (ASD) was referred to local child psychiatry services following a 6-month episode of gradually worsening depressive symptoms. The episode was associated with loss of interest, poor sleep, appetite, energy, and poor concentration, which affected his daily function at home and school. He expressed a feeling of hopelessness, but there has been no history of suicidal ideation or attempt. His condition has gradually worsened to the point where he started experiencing recurrent episodes of catatonia, marked by mutism, psychomotor retardation, negativity, and reduced oral intake. A physical examination revealed mild dehydration but no other abnormality. Blood tests and neuroimaging imaging did not reveal any abnormalities. His initial condition improved in the ward with high-dose lorazepam for the management of catatonia, risperidone for his agitation, and oral fluoxetine for his depression.

Further history revealed that he has experienced dissociative states as early as 5 years old, precipitated by his traumatic experiences following parental conflicts and bullying at school. This was when his first identity developed, which later expanded into more complex multiple identities. By the age of 16 years, he had identified seven different identities with different names, characters, interests, and sets of emotions. This different identity will emerge in response to different traumatic life events, such as being bullied at school due to his autistic behavior, losing a friend, or separation from significant family members. He described the identities as being present in his mind and not as hallucinations or delusion. Each of these identities has a different temperament, emotions, set of behaviors and interests, problems, strengths, and weaknesses. He initially had difficulty making sense of his experience and never mentioned any of these to anyone. His parents noticed occasional differences in his character, especially with regard to his appearance and behavior. He admitted that his refusal to speak or eat anything was due to one of the personalities that had issues with anger toward his family members. The changes in identities were also evident during observation in the ward and outpatient follow-up.

He was treated in the ward with regular dose of lorazepam, up to 2 mg daily, fluoxetine 20 mg for his depression, and a combination of low-dose risperidone 0.5 mg at night. Risperidone was used in view of its evidence in managing children and adolescents with behavioral problems, including agitation and aggression. [ 5 ] He was discharged once his catatonia resolved, his oral intake improved, and his depressive symptoms partially subsided. He was followed up in clinics for ongoing pharmacological and supportive psychological intervention. His family was involved in the intervention, but their involvement has been minimal due to their poor insight, lack of trust, and difficulty engaging with the changes suggested.

The main challenges in this case were due to his underlying ASD, which in itself limits his emotional resilience capacity. He has always had difficulty connecting to people, including his family, and regulating his emotions. His lack of expression and superficial rapport during initial sessions blinded the treating team to his dissociative symptoms. Even after the discovery of his symptoms, it was difficult to engage him in therapy. As dissociative disorder requires primarily psychological input, his lack of psychological awareness made it challenging for the therapist to explore ways to connect, explore any opportunities for trauma-oriented intervention, and help him integrate his identities.

A 17-year-old Malay female secondary school student with a history of childhood trauma was admitted to our psychiatric ward due to her suicidality and mood symptoms. Further history revealed depressive and anxiety symptoms and episodes of fragmentation into different alters since the age of 6 years after repeatedly being bullied. These states were very different from one another in terms of age, gender, mood, memories, and characters, and they would take control of her when she was triggered. Seven identities were reported, including the identity of a 15-year-old girl who behaved as a troubled teenager and seductive killer. Two of her alters were small children, aged 6 and 9 years, with depressive and hyperactive personalities, respectively. Typically, her dissociation of identity would occur following any stressful events and whenever she felt unsafe.

In the ward, routine blood investigations, electroencephalograms (EEGs), and magnetic resonance imaging (MRI) of the brain were normal. No organic pathology was detected in this case. She was treated for major depressive disorder with anxious distress and comorbid DID. After being discharged from the ward, she still has a few episodes of dissociation from different alters if exposed to stressful situations related to schoolwork, issues with peers, parents, and teachers. Occasionally, she was found to be aggressive and act harsher toward people and pets whenever she split into other identities.

This case was very challenging as the patient needed to sit for a major examination, and she was easily triggered at school. There were a few incidents of violent behavior provoked by certain remarks and actions by teachers and friends that caused her to dissociate from different alters. Therefore, collaboration with the patient, parents, and school was an important approach to facilitate and support the return to school with the safety of everyone as the main objective. There were multiple discussions and meetings carried out where the treatment team had planned a few strategies and contingency plans that were agreed upon by the patient, parents, and school administration.

The patient was allowed to return to school when she was more stable, able to recognize her triggers and early signs of relapse, and able to seek help from the school counselor. The host and the alters were repeatedly reminded of the agreement that, as far as possible, they were encouraged to reduce switching at school. The patient was also treated with psychotherapy and pharmacotherapy. The patient was prescribed fluoxetine 60 mg/day for depressive and anxiety symptoms and risperidone 3 mg/day for her impulsive behavior. Risperidone was used in view of supporting evidence in its use in managing adolescents with dissociative identity and aggression, as well as its benefit in reducing aggression in adolescents with severe mood dysregulation. [ 6–8 ] The patient showed some improvement in terms of depressive symptoms after medication but occasionally still switched to different alters in a stressful situation. She is still undergoing treatment and regular supportive psychotherapy sessions to control her mood symptoms.

A 16-year-old Malay female secondary school student with an introverted personality visited the psychiatry department because her behavior had changed after an amnesia attack. It took place on the morning of the 1 st day of classes following the COVID-19 pandemic-related movement control order (MCO). She instantly gave her parents a bear embrace and a kiss after waking up that morning, as if she had not seen them in a while. She had not been at her own house for a week, but she was not sure where she was and thought she was still at her grandparents’ place. Prior to that, she had a depressed and agitated mood along with panic episodes after learning that school will resume following the MCO, which continued for about a year. She has been unable to specifically recall what transpired throughout the MCO session since the morning. Retrospective memory suffered from major lapses for around 6 months. Additional background: Her parents noticed that she occasionally had abrupt changes in her mood and attitude at home, causing them to remark that she appeared to have changed into a few different persons. According to the patient, it initially started in primary school after a humiliating incident of verbal bullying. She described it as having imaginary friends who talked to her and calmed her down. However, it worsened after MCO, when she began to realize that she was dissociating from different alters whenever she experienced anxiety. Six identities were described, including those of a seductive adolescent and a depressed girl.

A physical and neurological examination revealed no significant findings. Organic workup, including blood parameters, EEG, and CT brain, was all normal. She was treated as having major depressive disorder with anxious distress, DID, and dissociative amnesia.

This case was very challenging as one of the alters tends to have an outgoing and seductive personality, which often puts the patient at risk by behaving seductively toward males and occasionally sending inappropriate photos of herself to a male friend. Fortunately, the friend seemed to understand her condition and did not distribute the photos. The patient was unaware until her friend informed her about it. This perpetuated her stress as the behaviors contrasted with her introvert and religious character, as well as being teased by her peers when she dissociated at school.

The patient was treated with a combination of supportive psychotherapy and pharmacotherapy. She was prescribed fluoxetine (20 mg/day) for depressive and anxiety symptoms. She responded well to the treatment and subsequently dissociated only rarely. After about 18 months of treatment with regular therapy sessions, she became more stable and her altered states were fully integrated. She described that all her alters were parts of her personalities, and she had full control over them. In contrast to the other two cases, the process of integration for her had happened much earlier. This could be due to the fact that the patient did not experience any extreme or repeated childhood trauma, which is routinely reported in cases of DID. Another important protective factor for her is the presence of good family support, especially from her parents, who were accepting, empathetic, and committed to strengthening their relationship with her.

D ISCUSSION

DID is previously known as multiple personality disorder, characterized by two or more distinct personality states. [ 9 ] Patients with DID were typically diagnosed with other types of disorders before eventually recognized to have this specific diagnosis. A study also highlighted that in some cases, the process of recognizing DID diagnosis may take up to 12 years on average. [ 10 ] It is a severely debilitating controversial diagnosis and prone to underdiagnosis or misdiagnosis. [ 11 ] DID is also viewed as a form of chronic posttraumatic disorder that occurs due to developmental adverse childhood events such as abuse, emotional neglect, disturbed attachment, and border violations. [ 12 , 13 ]

It is therefore important that the diagnostic process should include a detailed assessment of trauma history. [ 14 ] All forms of childhood traumatic experiences such as sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect were found to be associated with dissociation in people diagnosed with severe mental illness. [ 15 , 16 ] Duration of abuse and age of onset were strongly associated with DID, consistent with early life stress research on later stress reactions, neurobiological changes, and psychopathology. [ 17 ] Familial, societal, and cultural factors may give rise to the trauma and/or they may influence the expression of DID. [ 14 ] People exposed to betrayal, abandonment, and abuse at the hands of their caretakers can suffer significantly more complex psychobiological disturbances than those who experience natural disasters, serious accidents, or violent crimes. [ 18 ]

Psychodynamic theory proposes that the affected individual dissociates into different alter-personalities as a means to deal with an all-encompassing inner conflict while hiding contradictory impulses from herself. [ 19 ] Cognitive processes which are clearly and centrally disturbed in DID are memory and self-identity construction and relate to its etiology. Continuing psychological dissociation can create separate senses of the person, and inter-identity amnesia can involve metamemory processes. [ 12 ] Two etiology models for DID have been proposed, namely a childhood trauma model and an iatrogenic or fantasy model. [ 20 ] DID is etiologically linked with chronic neglect and physical and/or sexual violence in childhood, according to the trauma model of DID. The fantasy model instead suggests that DID can be simulated and mediated through high suggestibility, prone imagination, and sociocultural influences. [ 21 ]

Neurobiological differences have been demonstrated between dissociative identities within patients with DID and between patients with DID and controls. [ 10 ] Certain studies, including MRI, showed a decrease in size, especially hippocampus and amygdala in the limbic system of DID patients. In addition, decreased orbitofrontal cortex function is also seen in DID patients with decreased cerebral blood. [ 22 ] It is an empirically robust chronic psychiatric disorder based on neurobiological, cognitive, and interpersonal nonintegration as a response to unbearable stress. [ 10 ] Therefore, DID may be seen as an exemplary disease model of the biopsychosocial paradigm in psychiatry. [ 12 ]

There is a very limited study that links ASD and DID specifically. However, a prior study has highlighted the high prevalence of childhood trauma in a population with autism, which possibly explains the presence of dissociative symptoms in this population. A study by Haruvi-Lamdan, for example, reported that there is a higher rate of probable-posttraumatic stress disorder in the ASD group (32%) compared with the typical adult group (4%). [ 23 ]

Management of dissociative identity disorder

Managing DID involves several basic principles, including comprehensive assessment, an individualized treatment plan, a trauma-focused approach, and coordinated care. This should start with a comprehensive assessment involving a thorough assessment to accurately diagnose DID. Clinicians must include evaluating symptoms, identifying dissociative experiences, and considering the impact of trauma and psychosocial factors on the child’s functioning. This should be followed by tailored treatment plans, considering their developmental stage, symptom severity, trauma history, and individual strengths. The goal is to promote stabilization, integration, and improved functioning. [ 23 ]

At this stage, psychotherapy is the primary treatment modality for DID. Kluft (1996) highlights the importance of establishing a safe and therapeutic relationship with the child, utilizing techniques such as play therapy, cognitive-behavioral therapy, and supportive therapy to improve symptoms of DID. [ 24 ]

In the context of children and adolescents, creating a safe and stable environment is crucial for children with dissociative disorders. The therapist helps the child develop coping skills, emotion regulation techniques, and a sense of safety. This includes establishing a secure attachment with the therapist and addressing any immediate safety concerns. [ 24 , 25 ] Trauma-focused therapy, which addresses traumatic experiences, is a critical component of treatment. Therapists work with the child to process and integrate traumatic memories, utilizing techniques such as trauma-focused cognitive-behavioral therapy or eye movement desensitization and reprocessing.

In settings where resources for specific psychotherapy are limited, supportive interventions should be provided as an alternative. This includes basic coping skills, problem-solving, family therapy, education for carers, and support groups to promote understanding, communication, and healing within the child’s support system. [ 24 ]

To ensure a coordinated strategy, the child’s treatment team must work together. This can entail constant communication between the child’s therapists, psychiatrists, and other carers. Sometimes, comorbid illnesses such as depression, anxiety, or sleep issues can be treated with medication. Utilizing medication wisely and in conjunction with psychotherapy is recommended. The process of treating DID is often lengthy, frequently lasting many years. For sustained success, continuity of care, regular follow-up, and continuous support are essential. [ 26 ]

C ONCLUSION

The three cases illustrated in this report emphasize the value of identifying dissociative symptoms, making a correct diagnosis, and using various therapy modalities in these situations. It is important to work with a qualified mental health professional experienced in treating DID, as they can guide and support individuals throughout the treatment process. More evidence is needed to manage this complex disorder, especially in a special population like adolescents. Treatment for DID can be complex and lengthy, often spanning several years, but with proper support and therapy, many individuals can experience improvement and enhanced functioning in their daily lives.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Dissociative Identity Disorder Cases: Famous and Amazing

There are many famous dissociative identity disorder (DID) cases, probably because people are so fascinated by the disorder. While DID is rare, detailed reports of DID have existed since the 18th century. Famous cases of dissociative identity disorder have been featured on the Oprah Winfrey show, in books and have been seen in criminal trials. (See Real Dissociative Identity Disorder Stories and Videos and Celebrities and Famous People with DID )

A Dissociative Identity Disorder Case in Court: Billy Milligan

In 1977, Billy Milligan was arrested for kidnapping, robbing and raping three women around Ohio State University. After being arrested, he saw a psychiatrist who diagnosed him with DID (See how DID is diagnosed ). It was argued in court that Milligan wasn't guilty as, at the time of the crimes, two other personalities were in control -- Ragen, a Yugoslavian man and Adalana, a lesbian ( Understanding Dissociative Identity Disorder Alters ).

The jury agreed with the defense and Milligan became the first person ever to be found not guilty due to dissociative identity disorder . Milligan was confined to a mental hospital until 1988 when psychiatrists felt that all the personalities had melded together.

An upcoming film, The Crowded Room , will be based on his famous case of dissociative identity disorder.

Famous Cases of DID: Kim Noble

Kim Noble was born in 1960 and, from a young age, was physically abused. As a teenager, she suffered many mental problems and overdosed several times.

It wasn't until her 20s that other personalities began to appear. "Julie" was a very destructive personality that ran Noble's van into a bunch of parked cars. "Hayley," another personality, was involved in a pedophile ring.

In 1995, Noble received a DID diagnosis and has been getting psychiatric help ever since. It's not known how many personalities Noble has as she goes through four or five personalities a day, but it is thought to be around 100. "Patricia" is Noble's most dominant personality and she is a calm and confident woman.

Noble (as Patricia) and her daughter appeared on The Oprah Winfrey Show in 2010. In 2012, she published a book about her experiences: All of Me: How I Learned to Live with the Many Personalities Sharing My Body.

A Dissociative Disorder Case Study

In 2005, a dissociative identity disorder case study of a woman named "Kathy" (not her real name) was published in Journal of the Islamic Medical Association of North America.

Kathy's traumas began when she was three. At that age, she would have terrible nightmares during which her parents would often entertain leaving the child to cry for hours before falling asleep only to awake a few hours later frightened and screaming.

At age four, Kathy found her father in bed with a five-year-old neighbor. At that time, her father convinced her to join in on the sexual activity. Kathy felt guilty and cried for several hours only stopping once she began to attribute what had happened to an alternate personality, Pat. Kathy would insist on being called Pat during the abuse the father committed for the next five years.

At age nine, Kathy's mother discovered Kathy and her father in bed together. Her mother insisted on the child sleeping in her bed every night thereafter leading to a sexual relationship with the child. Kathy could not accept this and created another identity, Vera, who continued the relationship for another five years.

At age 14, Kathy was raped by her father's best friend and began calling herself Debbie. At that time, she became very depressed and mute and was admitted to a hospital (read why some go to dissociative identity (DID) treatment centers ).

According to the case study, "she showed a mixture of depression, dissociation and trance-like symptoms, with irritability and extensive manipulation which caused confusion and frustration among the hospital staff."

At age 18, Kathy became very attached to her boyfriend but her parents forbid her to see him. Kathy then ran away from home to a new town. However, she could not find a job and her need of money drove her to prostitution. She began to call herself Nancy at this point.

The alternate personality Debbie rejected Nancy and forced her to overdose on sleeping pills. It was then that Kathy was admitted to a psychiatric hospital and given the diagnosis of multiple personality disorder (as it was known at the time). (More on the history of dissociative identity disorder here.)

Kathy is now 29, married, and continues to struggle with mental health problems including dissociative episodes.

article references

APA Reference Tracy, N. (2022, January 4). Dissociative Identity Disorder Cases: Famous and Amazing, HealthyPlace. Retrieved on 2024, June 18 from https://www.healthyplace.com/abuse/dissociative-identity-disorder/dissociative-identity-disorder-cases-famous-and-amazing

Medically reviewed by Harry Croft, MD

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

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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.

Key words', dissociative identity disorder, medical therapy, emphatic resonance, case study.

Dissociative identity disorder (DID) also referred as multiple personality disorder (Ashraf et alia, 2016) is a chronic post-traumatic condition (Dell, 2010). It is characterized according to DSM-5 by "disruption of identity characterized by two or more distinct personality states" (American Psychiatric Association, 2013), with "marked discontinuity in sense of self... accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning."

DID estimate prevalence in inpatient and outpatient settings generally ranging between 2%-ll% (Dell, 2010), and over 1% in general population (Şar et alia, 2017). Despite these data, the validity of the diagnosis is often questioned due to the lack of reliable diagnostic measures (Reinder et alia, 2018; Vanijzendoom & Schuengel, 1996; Weninger et alia, 2008). The lack of understanding in the etiopathogenesis makes the existence of this condition called into question (Brand et alia, 2009; Merckelbach et alia, 2016; Vissia et alia, 2016). There are no randomized controlled trials researching treatments for DID (Brand et alia, 2009; Duffy, 2010; Şar & Ross 2010).

METHOD AND RESULTS

Case Descripción

We present the case of a 33-year-old Caucasian female with no psychiatric history until 2 years ago. She suffered bullying at age 15. The patient is admitted to the Psychiatry Service due to worsening of her sudden movements of neck and arms, they were involuntary and associated anguish. These episodes began in 2019, after an esoteric experience lived by her sister, and the evolution has been fluctuating, although allowing a normalized life.

Treatment and Monitoring of Treatment Progress

During admission, consultations are made to the Neurology Service and the Neurophysiology Service, who request an electroencephalogram, an MRI and a brain scan, resulting in normality. The rest of the complementary...

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10 Famous Cases Of Dissociative Identity Disorder

Dissociative identity disorder (DID), often called multiple personality disorder (MPD), has fascinated people for over a century. Although it is a very well-known disorder, mental health professionals are not even sure if it exists. It is possible that it is a form of another illness, like schizophrenia. [1] Another theory is that it doesn’t exist at all, and those who have it, including the following people, are simply acting.

10 Louis Vivet

One of the first recorded cases of multiple personalities belonged to Frenchman Louis Vivet. Born to a prostitute on February 12, 1863, Vivet was neglected as a child. By the time he was eight, he had turned to crime. He was arrested and lived in a house of treatment into his late teens.

When he was 17 years old, he worked in a vineyard, and a viper wrapped itself around his left arm. While the viper didn’t bite him, it terrified him so much that he had convulsions and psychosomatically became paralyzed from the waist down. While paralyzed, he was housed in an asylum, but he started walking again after a year. Vivet now seemed like a completely different person. He didn’t recognize any of the people at the asylum, his mood was much darker, and even his appetite was different. [2]

When he was 18, he was released from the asylum but didn’t stay out long. Over the next several years, Vivet was in and out of hospitals. During a stay between 1880 and 1881, he was diagnosed with multiple personalities. Using hypnosis and metallotherapy (placing magnets and other metals on the body), a doctor discovered up to 10 different personalities, all with their own traits and history. However, upon reviewing the case in later years, some experts believe he may have only had three personalities. [3]

9 Judy Castelli

Growing up in New York State, Judy Castelli suffered physical and sexual abuse, and afterward, she struggled with depression. A month after she enrolled in college in 1967, she was sent home by the school psychiatrist. Over the next several years, Castelli struggled with voices inside her head telling her to burn and cut herself. She nearly ruined her face, almost lost sight in one eye, and almost lost the use of one of her arms. She was also hospitalized several times for suicide attempts. Each time, she was diagnosed with chronic undifferentiated schizophrenia.

In the 1980s, she began singing in clubs and cafes in Greenwich Village. She almost got signed to a record label, but that fell through. However, she was able to find work and headlined a successful off-Broadway show. She also found success in sculpting and making stained glass.

Then, during a therapy session in 1994 with the therapist she’d had for over a decade, multiple personalities started to emerge, seven at first. As she continued her therapy, 44 personalities appeared. [4]

Since finding out that she has DID, Castelli has become a strong advocate for the disorder. She was on the board of the New York Society for the Study of Multiple Personality and Dissociation. She continues to work as an artist and teaches art to people with mental illness.

8 Robert Oxnam

Robert Oxnam is a distinguished American scholar who has spent his life studying Chinese culture. He is a former college professor, the former president of the Asian Society, and currently a private consultant for matters regarding China. While he is quite accomplished, Oxnam has struggled with his mental health.

In 1989, a psychiatrist diagnosed him with alcoholism. That changed after a session in March 1990, when Oxnam planned to leave therapy. While speaking with Oxnam, the doctor was addressed by one of his personalities, a young, angry boy named Tommy, who lived in a castle. After that session, Oxnam and his psychiatrist continued their therapy and found that Oxnam actually had 11 separate personalities.

After years of treatment, Oxnam and his psychiatrist whittled down the personalities to just three. There is Robert, or Bob, who is the core personality. Then there is Bobby, a younger, quizzical, free-spirited man who loves rollerblading in Central Park. Another is a “Buddhist-like” personality known as Wanda. Wanda used to be part of another personality known as the Witch. [5]

Oxnam wrote a memoir about his life titled A Fractured Mind: My Life With Multiple Personality Disorder . It was published in 2005. [6]

7 Kim Noble

Born in the United Kingdom in 1960, Kim Noble says her parents were factory workers who were unhappily married. From a young age, she was physically abused, and then she suffered from many mental problems as a teenager. She overdosed a few times and was placed in a mental institution.

In her twenties, her other personalities emerged, and they were incredibly destructive. Kim was a van driver, and one of her personalities named Julie took over her body and plowed the van into a bunch of parked cars. She also somehow got involved in a pedophile ring. She went to the police with information, and when she did, she started receiving anonymous threats. Then someone threw acid in her face and set her house on fire. She couldn’t remember anything about the incidents. [7]

In 1995, Noble was diagnosed with dissociative identity disorder, and she has been getting psychiatric help ever since. She is currently working as an artist, and while she does not know the exact number of personalities she has, she thinks it is somewhere around 100. She goes through about four or five different personalities a day, with Patricia being the most dominant one. Patricia is a calm, confident woman. Another notable personality is Hayley, the one involved with the pedophile ring that led to the acid attack and the fire.

Noble (as Patricia) and her daughter appeared on The Oprah Winfrey Show in 2010. She published a book about her life, All of Me: How I Learned to Live with the Many Personalities Sharing My Body , in 2012.

6 Truddi Chase

Truddi Chase claims that since she was two, in 1937, her stepfather physically and sexually assaulted her, while her mother emotionally abused her for 12 years. As an adult, Chase was under tremendous stress while working as a real estate broker. She went to a psychiatrist and discovered that she had 92 different personalities that were vastly different from each other.

The youngest was a girl about five or six years old named Lamb Chop. Another was Ean, an Irish poet and philosopher 1,000 years old. None of the personalities worked against one another and seemed to be aware of one another collectively. She didn’t want to integrate the personalities because they all had been through so much together. She referred to her personalities as The Troops.” [8]

Chase, along with her therapist, wrote the book When Rabbit Howls , and it was published in 1987. It was adapted into a TV miniseries in 1990. Chase also appeared on a very emotional segment of the Oprah Winfrey show in 1990. [9]

Chase died on March 10, 2010.

5 Karen Overhill

In 1989, Dr. Richard Baer began treating a young 20-year-old mother suffering from depression and surgical pain. She was also suicidal. After working with the woman he calls Karen Overhill, he was unsure what was happening with her. She explained to the doctor that she had gaps in her memory and that there were times when she would find herself somewhere but not remember how she got there. After a while, Dr. Baer received a letter from a 7-year-old-girl named Claire, who stated she lived inside Karen. The doctor now determined what was happening with Overhill. After three years of sessions, he finally had a diagnosis, determining that she had 17 personalities—girls, boys, women, and men.

Each personality revealed parts of Overhill’s traumatic childhood, ranging from satanic rituals to torture and rape. Her father and grandfather founded a cult that allegedly practiced ritual abuse of children, both physical and sexual. Through one of her personalities, Overhill claimed that her father and the cult took her to a funeral home after hours and placed her on an embalming table. According to the alter, her father then jabbed her in the abdomen with needles while strangers “caressed” her. Other personalities spoke of some other instances of abuse, such as being pierced with coat hangers and fish hooks, carved with knives, and beaten with hammers and baseball bats. [10]

Overhill was also allegedly raped by an older relative at the age of 12. Her alter, Jensen, was formed to help Overhill cope with this, yet another, trauma. Eventually, Dr. Baer met all 16 of her personalities and stated that she and the alters were consistent in their stories and recollections for more than 10 years, leading him to decide that she was not faking the condition. He also convicted some research after some years and discovered that Overhill’s father was convicted on 19 counts of sexual abuse in 1993. He reportedly assaulted Overhill’s niece.

After nearly twenty years of working with Overhill, Dr. Baer integrated her personalities into one and continued to treat her issues of self-esteem, self-worth, and shame over what happened to her in the past. Overhill married and had children, although she does not remember her wedding or the birth of a daughter. She is now divorced from an abusive husband and raising her children. Dr. Baer chronicled Overhill’s case in a book titled Switching Time . [11]

4 Shirley Mason

Born January 25, 1923, in Dodge Center, Minnesota, Shirley Mason apparently had a difficult childhood. Her mother, according to Mason’s accounts, was nothing less than barbaric. Her many acts of abuse included giving Shirley enemas and then filling her stomach with cold water.

Starting in 1965, Mason sought help for her mental problems, and in 1954, she started seeing Dr. Cornelia Wilbur in Omaha. In 1955, Mason told Wilbur about weird episodes where she would find herself in hotels in different cities with no idea how she got there. She would also go into shops and find herself in front of destroyed products with no clue what she had done. Shortly after the admission, different personalities started to emerge in therapy.

Mason’s story about her horrible childhood and her multiple personalities was turned into a best-selling book, Sybil . It was turned into a top-rated TV miniseries of the same name featuring Sally Fields.

While Sybil/Shirley Mason is one of the most well-known cases of DID, it also has come under a lot of scrutiny for its authenticity. Many people believe that Mason was a mentally ill woman who adored her psychiatrist, and Cornelia planted the idea of multiple personalities in her head. Mason apparently even admitted making everything up in a letter she wrote to Dr. Wilbur in May 1958, but Wilbur told her it was just her mind trying to convince her she wasn’t sick. So Mason continued with therapy. Over the years, 16 personalities emerged. [12]

In the made-for-TV version of her life, Sybil lives happily ever after, but the real Mason became addicted to barbiturates and dependent on her therapist, who paid her bills and gave her money. Mason died on February 26, 1998, from breast cancer.

3 Chris Costner Sizemore

Chris Costner Sizemore remembers her first personality split when she was about two years old. She saw a man pulled out of a ditch and thought he was dead. During this shocking event, she saw another little girl watching.

Unlike many other people diagnosed with DID, Sizemore didn’t suffer from child abuse and came from a loving home. However, from seeing that tragic event (and another gory factory accident later), Sizemore claims that she started acting strange, and family members often noticed. She would often get into trouble for things she had no memory of doing.

Sizemore sought help after the birth of her first daughter, Taffy, when she was in her early twenties. One day, one of her personalities, known as “Eve Black,” tried to strangle the baby, but “Eve White” was able to stop her. [13]

In the early 1950s, she started seeing a therapist named Corbett H. Thigpen, who diagnosed her with multiple personality disorder. While working with Thigpen, she developed a third personality named Jane. Over the next 25 years, she worked with eight different psychiatrists, and during that time, she developed a total of 22 personalities. All the personalities were quite different when it came to demeanor, age, sex, and even weight.

In July 1974, after four years of therapy with Dr. Tony Tsitos, all the personalities integrated, leaving her with just one.

Sizemore’s first doctor, Thigpen, and another doctor named Hervey M. Cleckley wrote a book about Sizemore’s case called The Three Faces of Eve . It was adapted into a film in 1957, and Joanne Woodward won the Academy Award for Best Actress for her portrayal of three of Sizemore’s personalities.

Sizemore died of a heart attack in hospice care on July 24, 2016, in Ocala, Florida. She was 89 years old.

2 Billy Milligan

From October 14-26, 1977, three women around Ohio State University were kidnapped, taken to a secluded area, robbed, and raped. One woman claimed the man who raped her had a German accent, while another one claimed that (despite kidnapping and raping her) he was actually kind of a nice guy. However, one man committed the rapes: 22-year-old Billy Milligan. [14]

After his arrest, Milligan saw a psychiatrist, and he was diagnosed with DID. Altogether, he had 24 different personalities. So, when the kidnapping and rapes happened, Milligan’s defense attorney said it wasn’t Billy Milligan who was committing the crimes. Two different personalities were in control of his body—Ragen, a Yugoslavian man, and Adalana, a lesbian. The jury agreed, and he was the first American found not guilty due to DID. He was confined to a mental hospital until 1988 and released after experts thought that all the personalities had melded together. [15]

In 1981, Daniel Keyes, the award-winning author of Flowers for Algernon , released a book about Milligan’s story called The Minds of Billy Milligan . Hollywood has made several attempts at adapting the book into a feature film. None have yet to be made, but it may be developed into a 10-episode TV series in 2021.

Milligan died from cancer on December 12, 2014, at the age of 59.

1 Juanita Maxwell

In 1979, 23-year-old Juanita Maxwell was working as a hotel maid in Fort Myers, Florida. In March that year, 72-year-old hotel guest Inez Kelley was brutally murdered; she was beaten, bitten, and choked to death. Maxwell was arrested because she had blood on her shoes and a scratch on her face. She claimed she had no idea what happened. [16]

While awaiting trial, Maxwell saw a psychiatrist, and when she went to trial, she pleaded not guilty because she had multiple personalities. She had six personalities besides her own, and one of the dominant personalities, Wanda Weston, committed the murder.

At her trial, the defense team, through the use of a social worker, drew Wanda out on the stand. The judge thought that the transformation was quite remarkable. Juanita was a soft-spoken woman, but Wanda was boisterous and flirtatious and liked violence. She laughed while she admitted to beating the senior citizen with a lamp over a disagreement about a pen. The judge was convinced that she either had multiple personalities or deserved an Academy Award.

Maxwell was sent to a psychiatric hospital, where she says she didn’t get proper treatment and simply received tranquilizers. She was released, but in 1988, she was again arrested, this time for robbing two banks. She again claimed Wanda did it; the pressure of the outside was too much, and Wanda had taken over again. She pleaded “no contest” and was released from prison for time served. [17]

Robert Grimminck is a Canadian crime-fiction writer. You can follow him on Facebook , on Twitter , or visit his website .

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Dissociative Identity Disorders in Korea: Two Recent Cases

Department of Psychiatry, Hanyang University College of Medicine, Seoul, Republic of Korea.

Hyun-Jin Jung

Although dissociative identity disorder (DID), the most severe of the dissociative disorders, has retained its own diagnostic entity since its introduction in the DSM-III, cases of DID are rarely seen in South and East Asia, likely due to the higher prevalence of possession disorder. We report two patients with DID who were recently admitted to our inpatient psychiatric unit and demonstrated distinct transitions to several identities. Their diagnoses were confirmed through a structured interview for dissociative disorders and possible differential diagnoses were ruled out by psychological, neuroimaging, and laboratory tests. The rapid transition to a Westernized, individualized society along with an increase in child abuse, might contribute to an increase in DID, previously under-diagnosed in this region.

INTRODUCTION

Dissociative identity disorder (DID) is rarely reported in Asia. It is so uncommon that some authors have speculated that DID is a culture-bound syndrome primarily found within Euro-American cultures. 1 In fact, DID does appear in Asian countries, though its prevalence is much lower than that in Western countries. The prevalence of DID in the clinical population ranges 1 to 5% in North America, Europe, and Turkey, 2 but only 0 to 0.5% in India, Bangladesh, and China. 3 , 4 , 5 Only two case studies of DID have been reported in academic journals of South Korea. 6 , 7 Here, we report two recent cases of Korean patients who experienced multiple childhood traumas and displayed several alternate identities.

A 20-year-old Korean male was transferred from the military hospital and admitted to an intensive psychiatric ward due to complaints of episodic violent behaviors toward fellow soldiers and changes in character and personality, which began at the onset of his military service two months earlier. Four months prior to admission, the patients returned home after six years of study abroad. His parents reported that the patient's behaviors differed from those of a visit one year prior, when he was shy and timid. After his return to Korea, the man appeared very confident and told his parents he would fare well in military service. In addition, he was very forgetful, often losing his belongings. The patient was on one occasion found by police in an alley far from his house, and he could not remember how he got there. Shortly after these incidents, the patient reported to the army for mandatory military service. At training camp, he seemed passionate and outgoing, quite different from his usual identity.

On several occasions, he only spoke English, which is not his native language. One incident involved a violent assault, in which the man injured another soldier. Alarmed by his emergent psychiatric problems, the military sent him to a psychiatric unit, where the staffs observed several different personalities. After one week, the military psychiatric staff decided to send him to a specialized civilian psychiatric hospital.

During the course of one month of hospitalization, seven alters were observed. The main host was very quiet and intimidated. John, an arrogant and uncooperative personality speaking only English, appeared on several occasions during the interviews. Another violent alter appeared twice when the patient thought of his childhood. During the transition to the violent alter, the patient broke a window with his fist and tried to hit his physician. Another alter named Cho appeared once. Cho introduced himself as the patient's story watcher and teller. Cho insisted he knew the host and other alters very well. He spoke both Korean and English, depicting the host as a "pity thing," the violent as a "thirsty killer," and the arrogant alter, John, as a "shit." While talking, Cho produced automatic writing with his left hand, of which he did not seem to be aware. We observed an additional three alters including a five-year-old boy, a mother-like personality, and a "metro-sexual swagger" alter. Cho was aware of the transition processes and he emphasized that there were more identities, although they were not observed during the hospitalization.

Laboratory tests including drug use screening and brain computerized tomography (CT) scan indicated no abnormalities of the host ego. Electrocardiogram (ECG) indicated "normal sinus rhythm." Interestingly, when retested as an alter, "Cho", the ECG indicated a "right bundle branch block." Cognitive impairment or malingering was ruled out through a full psychological battery, and no other psychiatric comorbidities were found. A structured clinical interview for DSM-IV dissociative disorder (SCID-D) confirmed the current diagnosis of DID.

In the SCID-D, the patient scored the severe category in amnesia, depersonalization, derealization, and identity confusion and identity alteration with additional fulfillment of mood change, age regression, and internal voice. He demonstrated the existence of alternate personalities with distinct names, ages, and character traits. Each alter took complete control of the patient's behavior, resulting in such occurrences as finding himself in a strange place, losing or discovering possessions in spots different from where he remembered leaving them, and speaking English. The patient also reported total amnesia during the domination of an alter.

The patient reported repeated childhood physical and emotional abuse and neglect by his parents. Each time he accessed these memories, he became agitated and transitioned to a violent alter. The treatment focused on stabilization, including affect regulation, grounding exercise and imagery techniques. Treatment made him more grounded and relaxed and decreased the frequency of alter emergence, particularly the violent alter. After one month of hospitalization, the patient was discharged.

A 19-year-old female was admitted to our inpatient unit with episodic irritability and violence. These episodes first began one year prior to admission, after a severe conflict with her mother. The patient became agitated and panicked, with sweating and tremors; she then showed violent behaviors, including the destruction of household items and furniture. Thereafter, when she quarreled with others or her mother, the patient frequently experienced unrestrained irritability and violent behaviors. The patient did not recall these emotional episodes or behaviors.

During the course of hospitalization, four alters, including the host, were observed. Whenever the patient talked about childhood experiences, a 15-year-old girl named "Eunju" appeared. Before transitions, the patient experienced severe sweating and tremors. She did not recognize others, including her therapist and did not allow others near her. The patient was emotionally irritable and sobbed for nearly two hours in a typical sitting. She displayed a withdrawn posture before the transition back to her original identity, and had not recollection of her after. The patient also had a five-year-old-girl alter with childish speech. This alter began to appear relatively late during hospitalization, when the frequency of appearances of the violent alter gradually diminished. This young alter whines for her mother to come and comfort her at night. Another alter was a 30-year old woman with controlling nature. This alter was aware of the other identities, including the host ego, and expressed deep sympathy for their immaturity and suffering. Nevertheless, there were no signs of direct communication among the alters.

Laboratory tests including drug use screening and brain CT scan indicated no abnormalities of the host ego. Cognitive impairment or malingering was ruled out from a full psychological battery, and the patient met the criteria for diagnosis panic disorder with agoraphobia. The patient met diagnostic criteria of SCID-D, her symptoms falling into the severe category in amnesia, depersonalization, derealization, identity confusion and identity alteration with additional satisfaction of mood change and age regression. The patient met the diagnostic criteria for dissociative identity disorder in DSM-IV. She had distinct alternate personalities, each of which took complete control of her behavior, experienced episodes of severe amnesia during the domination of an alter, and was not influenced by either substance or any general medical condition.

The patient was a survivor of childhood emotional abuse and neglect from both parents. She remembered a time when she was left home alone at without food for several days. Treatment focused on stabilization, using affect management skills training and ego state therapy. The frequency of transitions to other altars gradually decreased, as did feelings of helplessness. The patient was discharged after the irritable alter remained absent for two continuous weeks.

Both patients' diagnosed were confirmed through a structured interview (SCD-D), and both patients demonstrated transitions to other personalities during one month of hospitalization. Full psychological assessments, brain imaging studies, and laboratory tests were performed to rule out any influence of medical conditions, substances, or other psychiatric disorders. The two previously reported case reports of DID in Korea did not confirm the diagnosis through a structured interview, and in one case, alters were identified during hypnosis. 6 , 7 Thus, our cases have better diagnostic validity than the previously reported cases in Korea. Additionally, our first patient demonstrated physiological changes during the alteration of identity, including horizontal eye movements, automatic hand writing with the opposite hand, and abnormal ECG findings.

Not surprisingly, both patients experienced repeated childhood physical abuse and neglect. Their violent alters appeared only when childhood traumatic event was remembered or recalled through emotional triggers, suggesting the role of the alter as a part of the ego created to deal with unacceptable experiences with overwhelming emotions on behalf of the original ego. 8

During the last 15 years, no other of DID cases were diagnosed at our inpatient psychiatric unit prior to these two cases in 2014. Previously, the lower frequency of DID in Asia was believed to be due to a relatively higher prevalence of possession disorder, reflecting a strong cultural influence of polytheism and shamanism in the region. 1 It is also likely that, in Korea, patients with possession disorder are more frequently seen in psychiatric practices, and as such, clinicians are less familiar with DID. 9 Increased public awareness of mental illness and decreased psychological barriers to seeking psychiatric help 10 might have contributed to recent increase in DID cases.

In sum, the recent social transition of Asian countries from traditionalism and collectivism toward Westernization and individualism, increasing awareness of dissociative phenomena in Korea, and possibly increasing recognition of child abuse and neglect recognition of child abuse and neglect 11 might influence the increasing rates of DID. Mental health professionals from Asian regions who have rarely encountered patients with DID require specialized training to recognize and manage this chronic, often misdiagnosed, and difficult to treat condition.

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A cross-sectional survey on French psychiatrists' knowledge and perceptions of dissociative identity disorder

Affiliations.

• 1 Pôle hospitalo-universitaire de psychiatrie d'adultes du Grand-Nancy, centre psychothérapique de Nancy, Laxou, France; Faculté de médecine, université de Lorraine, Vandœuvre-Lès-Nancy, France.
• 2 Pôle de psychiatrie et d'addictologie, CHRU de Tours, Tours, France.
• 3 Pôle hospitalo-universitaire de psychiatrie d'adultes du Grand-Nancy, centre psychothérapique de Nancy, Laxou, France; Département de neurologie, CHRU de Nancy, Nancy, France.
• 4 Centre du psychotraumatisme de Lorraine-Sud (CPN), Nancy, France.
• 5 Unité de recherche, institut La-Teppe, Tain-l'Hermitage, France.
• 6 Pôle hospitalo-universitaire de psychiatrie d'adultes du Grand-Nancy, centre psychothérapique de Nancy, Laxou, France; Faculté de médecine, université de Lorraine, Vandœuvre-Lès-Nancy, France; Centre du psychotraumatisme de Lorraine-Sud (CPN), Nancy, France; Département de neurologie, CHRU de Nancy, Nancy, France. Electronic address: [email protected].
• PMID: 38824042
• DOI: 10.1016/j.encep.2024.02.003

Objective: The aim of this study was to determine French psychiatrists' level of general knowledge about dissociative identity disorder and to evaluate their perceptions of this condition.

Methods: In this study, French psychiatrists were invited by e-mail to answer an online survey. The questionnaire asked about their general knowledge and perceptions of dissociative identity disorder.

Results: We received 924 answers including 582 complete questionnaires. The survey revealed that almost two-thirds (60.8%) of psychiatrists working in France had never received any training on dissociative disorders and 62% had never managed patients suffering from dissociative identity disorder. Only 19.5% of them claimed to believe unreservedly in the existence of the diagnosis of dissociative identity disorder. The psychiatrists' confidence in diagnosing or treating dissociative identity disorder was low (mean confidence in diagnosis: 3.32 out of 10 (SD 1.89), mean confidence in treatment: 3.1 out of 10 (SD 1.68)). Fifty percent believed that dissociative identity disorder is an entity created by cinema, medias or social networks. Seventy-seven point seven percent thought that confusion with borderline personality disorder is possible, and 41.3% with schizophrenia.

Conclusion: In France, there is a lack of training and knowledge about dissociative identity disorder, as well as persistent skepticism about the validity of the diagnosis. Specific training seems essential for a better understanding of dissociative identity disorder.

Keywords: Connaissances; Dissociative identity disorder; Knowledges; Perceptions; Scepticisme; Skepticism; Trouble dissociatif de l’identité; Validity; Validité.

Copyright © 2024 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.

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