Dissociative identity disorder

Dissociative identity disorder (DID), previously known as multiple personality disorder (MPD), is a mental disorder characterized by at least two distinct and relatively enduring personality states. This is accompanied by memory gaps beyond what would be explained by ordinary forgetfulness. These states alternately show in a person's behavior; presentations, however, are variable. Other problems which often occur in people with DID include borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), depression, substance use disorders, self-harm, or anxiety.Many features of dissociative identity disorder can be influenced by the individual's cultural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the characteristics of other identities(e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion.Several changes to the criteria for dissociative identity disorder have been made in DSM-5. First, Criterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. Second, Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions. Dissociative identity disorder (DID), previously known as multiple personality disorder (MPD), is a mental disorder characterized by at least two distinct and relatively enduring personality states. This is accompanied by memory gaps beyond what would be explained by ordinary forgetfulness. These states alternately show in a person's behavior; presentations, however, are variable. Other problems which often occur in people with DID include borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), depression, substance use disorders, self-harm, or anxiety. Some professionals believe the cause to be childhood trauma. In about 90% of cases, there is a history of abuse in childhood, while other cases are linked to experiences of war or health problems during childhood. Genetic factors are also believed to play a role. An alternative hypothesis is that it is a by-product of techniques employed by some therapists, especially those using hypnosis. The diagnosis should not be made if the person's condition is better accounted for by substance abuse, seizures, imaginative play in children, or religious practices. Treatment generally involves supportive care and counselling. The condition usually persists without treatment. It is believed to affect about 2% of the general population and 3% of those admitted to hospitals with mental health problems in Europe and North America. DID is diagnosed about six times more often in females than males. The number of cases increased significantly in the latter half of the 20th century, along with the number of identities claimed by those affected. DID is controversial within both psychiatry and the legal system. In court cases, it has been used as a rarely successful form of the insanity defense. It is unclear whether increased rates of the disorder are due to better recognition or to sociocultural factors such as media portrayals. A large proportion of diagnoses are associated with a small number of clinicians, which is consistent with the hypothesis that DID may be therapist-induced. The typical presenting symptoms in different regions of the world may also vary depending on how the disorder is depicted by the media. Dissociation, the term that underlies the dissociative disorders including DID, lacks a precise, empirical, and generally agreed upon definition. A large number of diverse experiences have been termed dissociative, ranging from normal failures in attention to the breakdowns in memory processes characterized by the dissociative disorders. Thus it is unknown if there is a common root underlying all dissociative experiences, or if the range of mild to severe symptoms is a result of different etiologies and biological structures. Other terms used in the literature, including personality, personality state, identity, ego state and amnesia, also have no agreed upon definitions. Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones. The most widely used model of dissociation conceptualizes DID as at one extreme of a continuum of dissociation, with flow at the other end, though this model is being challenged. Some terms have been proposed regarding dissociation. Psychiatrist Paulette Gillig draws a distinction between an 'ego state' (behaviors and experiences possessing permeable boundaries with other such states but united by a common sense of self) and the term 'alters' (each of which may have a separate autobiographical memory, independent initiative and a sense of ownership over individual behavior) commonly used in discussions of DID. Ellert Nijenhuis and colleagues suggest a distinction between personalities responsible for day-to-day functioning (associated with blunted physiological responses and reduced emotional reactivity, referred to as the 'apparently normal part of the personality' or ANP) and those emerging in survival situations (involving fight-or-flight responses, vivid traumatic memories and strong, painful emotions, the 'emotional part of the personality' or EP). 'Structural dissociation of the personality' is used by Otto van der Hart and colleagues to distinguish dissociation they attribute to traumatic or pathological causes, which in turn is divided into primary, secondary and tertiary dissociation. According to this hypothesis, primary dissociation involves one ANP and one EP, while secondary dissociation involves one ANP and at least two EPs and tertiary dissociation, which is unique to DID, is described as having at least two ANP and at least two EP. Others have suggested dissociation can be separated into two distinct forms, detachment and compartmentalization, the latter of which, involving a failure to control normally controllable processes or actions, is most evident in DID. Efforts to psychometrically distinguish between normal and pathological dissociation have been made, but they have not been universally accepted. According to the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5), DID symptoms include 'the presence of two or more distinct personality states' accompanied by the inability to recall personal information, beyond what is expected through normal forgetfulness. Other DSM-5 symptoms include a loss of identity as related to individual distinct personality states, and loss referring to time, sense of self and consciousness. In each individual, the clinical presentation varies and the level of functioning can change from severely impaired to adequate. The symptoms of dissociative amnesia are subsumed under the DID diagnosis but can be diagnosed separately. Individuals with DID may experience distress from both the symptoms of DID (intrusive thoughts or emotions) and the consequences of the accompanying symptoms (dissociation rendering them unable to remember specific information). The majority of patients with DID report childhood sexual or physical abuse, though the accuracy of these reports is controversial. Identities may be unaware of each other and compartmentalize knowledge and memories, resulting in chaotic personal lives. Individuals with DID may be reluctant to discuss symptoms due to associations with abuse, shame, and fear. DID patients may also frequently and intensely experience time disturbances. Around half of people with DID have fewer than 10 identities and most have fewer than 100; as many as 4,500 have been reported.:503 The average number of identities has increased over the past few decades, from two or three to now an average of approximately 16. However, it is unclear whether this is due to an actual increase in identities, or simply that the psychiatric community has become more accepting of a high number of compartmentalized memory components. The primary identity, which often has the patient's given name, tends to be 'passive, dependent, guilty and depressed' with other personalities being more active, aggressive or hostile, and often containing a current time line that lacks childhood memory. Most identities are of ordinary people, though historical, fictional, mythical, celebrity and animal identities have been reported.:503 The psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures. The most common presenting complaint of DID is depression, with headaches being a common neurological symptom. Comorbid disorders can include substance abuse, eating disorders, anxiety, post traumatic stress disorder (PTSD), and personality disorders. A significant percentage of those diagnosed with DID have histories of borderline personality disorder and bipolar disorder. Further, data supports a high level of psychotic symptoms in individuals with DID, and that both individuals diagnosed with schizophrenia and those diagnosed with DID have histories of trauma. Other disorders that have been found to be comorbid with DID are somatization disorders, major depressive disorder, as well as history of a past suicide attempt, in comparison to those without a DID diagnosis. Individuals diagnosed with DID demonstrate the highest hypnotizability of any clinical population. The large number of symptoms presented by individuals diagnosed with DID has led some clinicians to suggest that, rather than being a separate disorder, diagnosis of DID is actually an indication of the severity of the other disorders diagnosed in the patient.