Dissociative Identity Disorder of Personality (TIDP) is a complex disorder that has been little studied and that represents a challenge for clinical professionals. The complexity lies in part in the difficulty of identifying it. Therefore, many cases are lost in anonymity.
Dissociative Personality Disorder: what is it?
One of the first challenges that TIDP patients face in therapy is that they often receive incomplete or simply wrong diagnoses. Incomplete in the sense that they may be relevant to one of the alter egos , while inadequate in the context of multiplicity.
Many people with Dissociative Personality Disorder never go to a psychological or psychiatric consultation. And when they do, they are often misdiagnosed. This makes it impossible for them to get the help they need.
What is TIDP?
Among the specialists of this disorder, we find Valerie Sinason , psychoanalyst and director of the Clinic for the studies of dissociation. She is the editor of the book “Attachment Trauma and Multiplicity” and in the introduction of this book she comments:
“Over the past decade I have counseled and treated children and adults, especially women, who have Dissociative Personality Disorder (DIDP). There is a very significant gender bias among people with this condition. Male victims of abuse are more likely to externalize their trauma, even though both sexes employ externalizing responses. Most of the children and adults I have evaluated have been misdiagnosed as schizophrenic, borderline, antisocial or psychotic . Despite the fact that the antipsychotic medication had little or no effect on them, that the voices they heard came from within and not from without, and that they did not have a disorder of thinking about time and place except when they were in a trance-like state, despite all this, mental health professionals did not perceive diagnostic failure. In the face of professional confusion and social denial, some patients have managed to hide their multiplicity when accused of making it up. In response to the key question concerning the small number of children with severe dissociative states, some patients confirmed negative responses to their childhood confessions that led them to hide their symptoms. These children were told that it would pass and that it was a phenomenon of imaginary friends” (2002 p. 5).
The purpose of the concept of dissociation: refers to the process of encapsulating or separating the memory or emotion that is directly associated with the trauma from the conscious self . Dissociation is a creative way of keeping something unacceptable out of sight. Dissociative Personality Identity Disorder is a way that the internal system creates to protect secrets and continually learns to adapt to the environment. It is a survival mechanism. It also promotes and maintains attachment to the abuser. It allows, on a mental level, some conflicting emotions to be kept in separate compartments.
More specifically, dissociation involves a wide variety of behaviours that represent lapses in the cognitive and psychological process . The three main types of dissociative behaviour that have been recognised are Amnesia, absorption and depersonalization.
- dissociative amnesia involves suddenly finding oneself in a situation or having to face the evidence of having performed actions that the person does not remember.
- The absorption involves getting so involved in what is being done that the person forgets what is happening around them.
- Depersonalization refers to experiencing events as if the individual were an observer, disconnected from the body or feelings.
North et al. (1983; cited by Sinason p. 10) found that this condition was not only linked to a high percentage of child sexual abuse, but also to an occurrence of 24-67% of sexual abuse in adulthood, and 60-81% of suicide attempts.
It is clear that TIDP is an important aspect of trauma clustering. In the USA, in a sample of 100 TIDP patients, it was found that 97% of them had experienced significant trauma in childhood and almost half of them had witnessed the violent death of someone close to them. (Putman et al. 1986; quoted by Sinason p. 11)
Until very recently, it has been extremely difficult to document children’s cases of TIDP. Although some argue that this doesn’t mean they don’t exist. The same is true of adolescent cases, and it is only adult TIDP cases that are supported by the scientific community.
Richard Kluft believed that his efforts to find the trail of TIDP’s natural history had little success. His attempts to find children’s cases were an “unmitigated fiasco”. He described the case of an 8-year-old boy who seemed to manifest “a series of developed personality states” after witnessing a situation in which someone nearly drowned in water and was physically abused. However, he realized with other colleagues that his field of vision was too narrow. He noticed that Gagan and MacMahon (1984, cited by Bentovim, A. p. 21) described a notion of an incipient multiple personality disorder in children; they raised the possibility of a broader spectrum of dissociative phenomenology that children might manifest.
TIDP diagnostic criteria
The criteria of the DSM-V specify that the TIDP is manifested with:
- The presence of one or more distinct identities or personality states (each with its relatively stable patterns of perception, in relation to, and thinking about, the environment and the self.
- At least two of these identities or personality states assume recurrent control of the person’s behavior.
- The inability to remember important personal information that is too widespread to be explained by ordinary forgetfulness and that is not due to the direct effects of a substance (e.g., loss of consciousness or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures)
Guidelines for diagnosis and treatment
Regardless of the diagnosis, if dissociation is present, it is important to explore what role it plays in the patient’s life . Dissociation is a defence mechanism.
It is important for the therapist to discriminate against dissociation and to talk about defense mechanisms as part of a process. The therapist can then accompany the patient in exploring the reasons why they may be using this mechanism as a defence. If the therapist addresses the issue of dissociation as soon as there is any indication that it is occurring, the diagnosis will come more easily. Using the Dissociative Experience Scale (DES) or the Somatomorphic Dissociation Questionnaire (SDQ-20) can help determine the degree and role that dissociation plays in the person’s life. (Haddock, D.B., 2001, p.72)
The International Society for the Study of Dissociation (ISSD) has developed general guidelines for the diagnosis and treatment of TIDP. It states that the basis for a diagnosis is a mental state exam that focuses on questions related to dissociative symptoms. ISSD recommends the use of dissociative screening tools such as the DES, the dissociative disorder interviewing program (DDIS), and the DSM-IV structured clinical interviewing for dissociative disorders.
DDIS, developed by Ross, is a highly structured interview that covers topics related to the diagnosis of TIDP, as well as other psychological disorders. It is useful in terms of differential diagnosis and provides the therapist with the mean of the scores in each subsection, based on a sample of TIDP patients who answered the inventory. The SCID-D-R, developed by Marlene Steinberg, is another highly structured interview instrument used to diagnose dissociation.
An important aspect of Steinberg’s work consists of the five central dissociative symptoms that have to be present to diagnose a person with TIDP or TIDPNE (non-specific). These symptoms are: dissociative amnesia, depersonalization, unrealization, identity confusion and identity alteration.
TIDP is experienced by the dissociator as identity confusion (whereas the non-dissociator typically experiences life in a more integrated way). The TIDP experience is composed of the dissociator feeling frequently disconnected from the world around him, as if he were living in a dream at times. SCID-D-R helps the clinician identify the specifics of this story.
In any case, the therapist’s basic components related to the diagnostic process include, but are not limited to, the following:
A comprehensive history
An initial interview that can last between 1 and 3 sessions.
A special emphasis on issues related to family of origin, as well as psychiatric and physical history . The therapist should pay attention to memory gaps or inconsistencies found in the patient’s stories.
It is helpful to make notes regarding amnesia and avoidance that are occurring in the session. It is also necessary to appreciate changes in facial characteristics or voice quality, in case they seem out of context to the situation or to what is being discussed at the time. Notice an extreme sleep state or confusion that interferes with the patient’s ability to follow the therapist during the session (Bray Haddock, Deborah, 2001; pp. 74-77)
Review of dissociative experiences
If disassociation is suspected, a screening tool such as the DES, DDIS, SDQ-20 or SCID-R could be used to collect more information.
Note symptoms related to amnesia, depersonalization, unrealization, mistaken identity, and altered identity before diagnosing TIDP or TIDPNE.
Differential diagnosis to rule out specific disorders
You can start by considering the above diagnoses. That is, taking into account the number of diagnoses, how many times the patient has received treatment, goals achieved in previous treatments. Previous diagnoses are taken into consideration even though they are not used, unless they currently meet the criteria of the DSM.
The DSM criteria must then be compared with each disorder that has dissociation as part of its composition and a diagnosis of TIDP only after observation of the change in alter egos.
Check for substance abuse and eating disorders. If disassociation is suspected, using a screening tool such as the CD or ED can provide a greater perspective on the role of the disassociation process.
Confirmation of diagnosis
If dissociation is confirmed, again by comparing the DSM’s criteria for possible diagnosis and the diagnosis of TIDP, only after observing the shift in the alter egos. Until then, the most appropriate diagnosis will be Non-specific Personality Dissociative Identity Disorder (NPSIDD) or Post-Traumatic Stress Syndrome (PTSD).
- Bray Haddock, Deborah, 2001. The dissociative identity disorder. Sourcebook. McGrow-Hill Publishers, New York.
- Fombellida Velasco, L. and J.A. Sánchez Moro, 2003. Multiple personality: a rare case in forensic practice. Cuadernos de Medicina Forense. Seville, Spain.
- Orengo Garcia, F, 2000. Prevalence, diagnosis and therapeutic approach of dissociative identity disorder or multiple personality disorder. www.psiquiatria.com
- Rich, Robert, 2005. Got parts?: An insider’s guide to managing life successfully with dissociative identity disorder. ATW and Loving Healing Press. USA.
- Sinason, Valerie, 2002. Attachment, trauma and multiplicity. Working with Dissociative Identity Disorder. Routledge, UK.