Dissociative identity disorder: improving treatment outcomes

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Gwendolyn Cox
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1 Dissociative Identity Disorder: Improving Treatment Outcomes. HCPJ. 14 (1), Dissociative identity disorder: improving treatment outcomes Cath Slack Citation: Slack, C. (2014). Dissociative Identity Disorder: Improving Treatment Outcomes. Healthcare Counselling & Psychotherapy Journal, 14(1), Copyright: This is an open-access article distributed under the terms of the Creative Commons 4.0 Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Dissociation was described as the hidden epidemic over a dozen years ago 1 and yet dissociative disorders remain a hidden and often neglected mental health problem. Dissociative identity disorder alone affects between one and three per cent of the population 2, a number comparable to those each affected by bipolar disorder, schizophrenia, and obsessive-compulsive disorder (OCD). Dissociative disorders have their roots in trauma, and are characterised by disruption in the usually integrated functions of consciousness, memory, identity, or perception, causing clinically significant distress or impairment in important areas of functioning 3. Sufferers may feel detached from their mind or body, forget major life events or significant periods of time, act like a totally different person whilst having no recollection of it, or feel no emotion when describing very traumatic experiences. The dissociative disorders listed in the American Psychiatric Association s Diagnostic and statistical manual of mental disorders (DSM-V) are: dissociative amnesia (including fugue), depersonalization/derealisation, other specified dissociative disorder (OSDD) and unspecified dissociative disorder (together replacing dissociative disorder not otherwise specified (DDNOS), and dissociative identity disorder (DID). DID, considered the most severe dissociative disorder, is the disruption of identity characterised by two or more distinct personality states or an experience of possession and is accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning 3. OSDD is a very similar dissociative disorder, sometimes referred to as partial DID; some cases may be covert (hidden) DID 4. Difficulties in diagnosis Mental health assessments often do not include enquires about dissociation or posttraumatic symptoms 2. People with dissociative disorders tend to hide or rationalise symptoms, and may avoid disclosing intrusive thoughts, impulses or actions, inner voices, lost time, feeling unreal, and flashbacks (eg visual/auditory hallucinations) due to shame or fear of being crazy 4. Multiple self-injurious behaviours, suicide attempts, dysfunctional relationships and additional diagnoses are common; physical health problems may include severe headaches, pain, and other somatoform symptoms 2. Some psychiatrists refuse to accept the validity of DID 5 and many have little dissociative disorder training 2. The infrequent and hidden switching which is characteristic of the vast majority of persons with DID 4 may have caused this scepticism. In fact, symptoms occur in people from diverse cultures and in diverse locations, including every continent except Antarctica 2,3 (the latter due to lack of clinical data).

2 Dissociative Identity Disorder: Improving Treatment Outcomes. HCPJ. 14 (1), DID and OSDD are often misdiagnosed as borderline personality, psychotic or bipolar disorders 3. Reliable diagnostic tests include the (DDIS) 6 and the extensive 7. The self-administered is a useful screening tool 8. DID: common misconceptions Media representations of DID typically portray dual adult personalities with bizarre and violent behaviour, and total amnesia between personalities. This conflicts with the true nature of dissociative identities; DID is a defensive mechanism used to cope with chronic childhood abuse normally beginning before the age of five; PTSD is the most common co-occurring diagnosis; and switching between identities is typically hidden 2,4. Dual identities appear to be rare, but distressed child identities and disorganised attachment to caregivers during childhood are commonly reported. DID was previously called Multiple Personality Disorder but is not a personality disorder and people with DID may feel and act as if they have multiple personalities, but these different identities are fragments or parts of a single personality which act as a system in a subjectively logical way. The alternate identities (called parts or alters ) develop during early childhood, each with different roles, experiences, beliefs and personality traits; traumatic memories are divided between them 2.The number of identities is believed to increase with the duration and severity of abuse 9. Organised and ritual abuse Ritual and organised abuse typically includes sadistic and sexually horrific abuse, and convictions for these crimes exist within the UK 10,11. A significant minority of people with DID report this type of abuse, including being coerced or forced to abuse others from early childhood 2,12. This can cause complex forms of DID, with dozens or hundreds of parts/alters, and initial amnesia for ongoing abuse and past abuse. Several dissociative parts may hold different aspects of each memory; and people with DID should be allowed to determine the accuracy of memories themselves including identifying any indoctrination, lies or tricks used (eg projectors, fake blood and sound effects, costumes) 12. Treatment goals and outcomes Kluft and Fine 13 described integration as undoing all aspects of dissociative dividedness that begins long before there is any reduction in the number or distinctness of the identities. Increasing communication and cooperation between identity states is essential. Fusion refers to permanent joining of two or more alternate identities; final fusion (unification) is the complete integration, merger, and loss of separateness - of all identity states 2. This may not be achievable or seen as desirable for a considerable number of DID patients. An alternative goal is cooperation, with sufficiently integrated and coordinated functioning among alternate identities to promote optimal functioning 2. During treatment, dissociative symptoms, PTSD, depression, anxiety and general distress reduce, and adaptive functioning improves 14. Treatment principles for DID Despite relatively recent developments such as the Clinic for Dissociative Studies in London, which was established in the late 1990s, the NHS appears to have no clear treatment pathway. Talking therapies remain unavailable in some areas, or only brief treatment is funded.

3 Dissociative Identity Disorder: Improving Treatment Outcomes. HCPJ. 14 (1), The International Society for the Study of Trauma and Dissociation (ISSTD) publishes the best available treatment guidelines 2, recommending three treatment stages, each repeated many times: 1. Establishing safety, stabilization, and symptom reduction; 2. Confronting, working through, and integrating traumatic memories; and 3. Identity integration and rehabilitation. For example, if working through traumatic memories causes significant increases in symptoms, the stabilisation phase should be returned to before continuing. Therapists working with DID should consider: Discussing treatment goals. Counter-transference with the main identity; viewing the others as less real is countertherapeutic 2. How to tolerate significant uncertainty in the therapeutic process and the client s narrative. Their ability to contain severe distress, and the risk of secondary traumatisation. Needs of complex cases: additional supervision, clients at significant risk of selfharm/suicide attempts 2,14, crisis contact/clear boundaries 13 and clear limits to support available, additional training/professional development, flexible ways of working. Safety: physical contact may be interpreted as a threat, triggering protective identities. Long-term availability; abandonment from previous therapists is common. Spring 15 provides an overview of the treatment of DID. Prognosis Bremner and Marmar 16 describe prognosis based on three groups, adapted below: 1 High-functioning DID, with little comorbidity of personality disorders/learning difficulties: a good prognosis. 2 Patients with complicated dissociative disorders and comorbid personality disorders/learning difficulties typically make slower progress. They may not achieve full integration of identities (if integration is their goal). 3. Patients who are unable to use the therapeutic relationship to achieve some selfsoothing and to appraise their contributions to their problems. These patients have a poor prognosis, responding best to symptom stabilisation and crisis management 17. The authors state that they think long-term prognosis is influenced by the duration and severity of the trauma, the capacity to use attachment figures for self-soothing, the propensity to re-enact the trauma in adult life, and the nature and severity of comorbid psychiatric conditions. They also point to the patient s capacity to attend to stimuli without cognitive or affective distortion, intellectual endowment, and the degree of primary identity as patient of victim. 16 Whilst the groups provide useful indicators, some people may fall outside the descriptors; there is also no consideration of whether a person can move between groups during treatment as this prediction is based on the first treatment stage only. Baars and colleagues 17 surveyed therapists to enable them to develop prognostic models for the stabilisation stage of treatment. The factors most indicative of a poor prognosis in DID are adapted below under each cluster name: 1 Lack of motivation eg strong investment in secondary gain from having DID; lack of motivation to lead a normal life. 2 Serious Axis I comorbidity (especially schizophrenia, organic mental disorder, psychotic disorder).

4 Dissociative Identity Disorder: Improving Treatment Outcomes. HCPJ. 14 (1), Serious Axis II comorbidity (personality disorders) (especially antisocial and paranoid personality disorders). 4 Lack of healthy relationships eg current ongoing abusive relationships, the current abuse, suicide or murder of a family member, hindrance of therapy by therapist and/or mental health care staff. 5 Lack of healthy therapeutic relationships, eg severely impaired ability to build a therapeutic relationship, poor closeness of fit between patient and therapist, severely impaired ability to abide by treatment rules, lack of responsibility for own share in the therapeutic process, little cooperation between therapist and dissociative parts of the personality. 6 Poor attachment eg strongly involved in antisocial behaviour, severe attachment problems. 7 Self-destruction, e.g. strongly involved in self-destructiveness*. 8 Lack of other internal and external resources eg amnesia for ongoing abuse (as victim and/or perpetrator), severe resistance against constructive communication among dissociative parts of the personality, severe inability to distinguish between past and present. *self-destruction has the lowest rating of the factors listed Improving outcomes The key factors can be used to create specific treatment goals and increase client involvement in the therapeutic process. Suggestions for improving treatment outcomes (from a multiple of sources) include: Building a strong therapeutic alliance, including empathising and developing trust with abusive, hostile or sabotaging identities and managing the conflicting views/priorities. Encouraging healthy relationships outside therapy. Encouraging the client to build a range of external supports, and liaising with other professionals (with client agreement). Using psychoeducation 2 to improve motivation, internal trust and empowerment. Improving cooperation and communication between dissociative parts of the personality. Forming safety plans and developing healthy coping skills. Clear boundaries for contact, encouraging self-reliance and independence Encouraging/maintaining a life outside illness. Learning from and working in partnership with the client. In recent years, the treatment of dissociative disorders has changed dramatically for those diagnosed. Working with DID is demanding for both therapists and clients, but prognosis is now significantly better for many client groups. REFERENCES 1 Steinberg M, Schnall M. The stranger in the mirror: dissociation - the hidden epidemic. New York: Cliff Street Books; International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation. 2011; 12(2) Spiegel D, Loewenstein RJ, Lewis-Fernandez R, Sar V, Simeon D, Vermetten E, Cardena E, Dell, PF. Dissociative disorders in DSM-5. Depression and anxiety. 2011; 28: Dell PF. Dissociation and the dissociative disorders: DSM-V and beyond. New York: Routledge; 2009.

5 Dissociative Identity Disorder: Improving Treatment Outcomes. HCPJ. 14 (1), Dorahy MJ, Lewis CA. Dissociative identity disorder in Northern Ireland: a survey of attitudes and experience among clinical psychologists and psychiatrists. Journal of Nervous and Mental Diseases. 2002; 190(10): Steinberg M. Interviewer's guide to the structured clinical interview for DSM-IV dissociative disorders (SCID-D). Washington DC; American Psychiatric Press; Carlson EB, Putnam FW. (1993). An update on the dissociative experiences scale. Dissociation. 1993; 6: Ross CA, Heber S, Norton GR, Anderson D, Barchet P. The dissociative disorders interview schedule: a structured interview. Dissociation. 1989; 2(3): Chu JA. Rebuilding shattered lives: Treating complex PTSD and dissociative disorders. New Jersey: John Wiley & Sons; Miller A. Healing the unimaginable: treating ritual abuse and mind control. London: Karnac Books; Kluft RP, Fine G. Clinical perspectives on multiple personality disorder. Washington, DC: American Psychiatric Press; Brand BL. What we know and what we need to learn about the treatment of dissociative disorders. Journal of Trauma & Dissociation. 2012; 13(4): Spring C. A brief guide to working with dissociative identity disorder. Healthcare Counselling and Psychotherapy Journal. 2011; Bremner JD, Marmar, CR. Trauma, memory, and dissociation. Washington DC: American Psychiatric Press Inc; Baars EW, van der Hart O, Nijenhuis ERS, Chu JA, Gerrit G, Draijer N. Predicting stabilizing treatment outcomes for complex posttraumatic stress disorder and dissociative identity disorder: an expertise-based prognostic model. Journal of Trauma & Dissociation. 2010; 12(1):67-87.

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE. Personality Disorder: the clinical management of borderline personality disorder

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Personality Disorder: the clinical management of borderline personality disorder 1.1 Short title Borderline personality disorder