Lecture 7 Dissociative Identity Disorder 2024 PDF

30/08/2024 Reading (suggested) PERSONALITY & ITS Bailey, T. D., & Brand, B. L. (2017). Traumatic DISORDERS PSYU/X3336 dissociation: Theory,...

30/08/2024 Reading (suggested) PERSONALITY & ITS Bailey, T. D., & Brand, B. L. (2017). Traumatic DISORDERS PSYU/X3336 dissociation: Theory, research, & Lecture 7: Dissociative Identity treatment. Clinical Psychology: Science & Disorder & culture Practice, 24, 170-185 Spiegel, et al. (2013). Dissociative disorders in DSM-5. Annual Review of Clinical Psychology, 9, 299-326 A/Prof Simon Boag email: [email protected] 1 2 Readings (for interest) Outline Dalenberg, CJ et al. (2012). Evaluation of the 1. Introduction: Dissociation & DID evidence for the trauma & fantasy models of 2. Is DID real? dissociation. Psychological Bulletin, 138, 550-589 3. Theories of DID Lynn, SJ et al. (2014). The trauma model of Trauma model dissociation: Inconvenient truths & stubborn Sociocognitive/Fantasy model of DID fictions. Comment on Dalenberg et al. 4. DID & culture Psychological Bulletin, 140, 896-910 Possession states & DID Dalenberg, CJ et al. (2014). Reality versus fantasy: Reply to Lynn et al. Psychological Bulletin, 140, 911-920 3 4 Learning objectives 1. Introduction Describe the features of Dissociative Identity How plausible is the concept of multiple Disorder (DID) personalities within a single person (Dissociative Identity Disorder)? Describe & critically evaluate both the trauma Believers, non-believers & agnostics & sociocognitive/fantasy models of DID Actual ‘personalities’ or cultural/therapeutic artefacts? Role playing? etc. Critically evaluate the relevance of possession states for both the trauma & sociocognitive/fantasy models of DID 5 6 1  30/08/2024 Dissociative phenomena Dissociation = disconnection/separation Common-to-rare types of dissociation eg. Daydreaming ↔ DID “… instead of attending to a boring speaker, your eyes glaze over & your mind shifts to a favourite activity, such as sailing, creating a fantasy about the given event” (Bowins, 2004) 7 8 28-year old male final year medical student. He was declared Dissociative phenomena missing for 10 days prior to presentation because his whereabouts was unknown. He later arrived at his brother’s Depersonalisation: “experiences of unreality house, a distance of about 634km from where he lived & schooled. The patient had no knowledge of how he made the or detachment from one’s self” journey that takes approximately 8 hours by road. He equally Derealisation: “experiences of unreality or could not remember where he slept the night he left, how he detachment from one’s surroundings” raised money for the journey or the buses & routes he took. The patient denied all memory of events for the 2 days from Dissociative amnesia when he left to the time he suddenly realized he was at his Dissociative fugue (amnesia + travel) brother’s house, 634km away. The brother, however, reported Dissociative Identity Disorder that the patient appeared unkempt, looked exhausted but was fully conscious & alert on arrival at his house without any assistance. Prior to this episode, the patient had been under severe economic & academic pressures Igwe, M. N. (2013). Dissociative fugue symptoms in a 28-year-old male Nigerian medical student: a case report. Journal of Medical Case Report, 7, 9 143-146 10 Dissociative Identity Disorder MPD → DID Formerly known as Multiple Personality DSM-III (1980): Recognition of MPD as a stand- Disorder (MPD) alone condition “… the presence of two or more personality Existence of “two or more distinct or identity states that recurrently take control personalities” over the body” (Pica, 1999) DSM-IV (1994): Dissociative Identity Disorder “The core phenomenon is switches of “The presence of two or more distinct executive control b/w different dissociated identities or personality states (each with its identities with varying degrees of amnesia own relatively enduring pattern of perceiving, b/w identities” (Ross, 2011) relating to, & thinking about the environment & the self”) 11 12 2  30/08/2024 Dissociative Identity Disorder DID prevalence DSM-5 (2013) The 12-month prevalence of DID is c.1.5% 13 14 DID: DSM-5 Phenomenology Adults: F > M more common in clinical ‘Host’ personality: typically the ‘person’ who settings (not in childhood); males tend to deny presents for treatment, bears the legal name symptoms & trauma history & suffers time-loss & psychological complaints Major depression co-occurrence common Alters or sub-personalities: childlike personalities, protectors, helpers-advisors, >70% DID attempt suicide, multiple attempts guardians, inner persecutors, deviant/criminal, common, other self-injurious behaviour avengers, defenders Complicated by dissociative amnesia Typical DID: 2-15 alters Misdiagnosis with Bipolar Disorder common Polyfragmented DID: 100-1000+ personalities/fragments 15 16 Personalities & personality fragments DID & amnesia “… personality fragments are easily distinguished Dissociative amnesia (Criterion B) manifests in: from full-blown personalities, because the 1) gaps in any aspect of autobiographical fragments lack a life history &/or do not have a memory (eg. getting married) wide range of mood or affect. Complete 2) lapses in memory of recent events or well- personalities have both a history & a range of affect, as well as a consistent, ongoing style of learned skills (eg. how to cook or drive) speech & motor behaviour. New fragments may 3) discovery of possessions that the individual appear during therapy, but they typically appear has no recollection of ever owning only for limited time & purposes, they do not pose Each personality may have unique memories a problem for the progress of therapy, for they are Any personality may or may not be aware of easily reintegrated” the other personalities (Braun, 1984) 17 18 3  30/08/2024 Case histories 2. Is DID real? Evidence Sybil: Developed 16 separate Different allergic responses (Braun, 1983) personalities as a response to sustained Different responses to the same medication childhood abuse from her schizophrenic (Kluft, 1984) mother Different handedness (Kluft, 1996) Billy Milligan: 24 distinct personalities Severe childhood trauma Hand-writing differences b/w alters Lewis, et al (1997). Objective documentation of child abuse & First (successful) use of MPD for insanity dissociation in 12 murderers with dissociative identity disorder. American defense (rape/armed robberies) Journal of Psychiatry, 154, 1703-1710 Rogue alters committed the crimes Optical variability amongst alters Miller et al (1991). Optical differences in multiple personality disorder: A without the others knowing about it second look. The Journal of Nervous & Mental Disease, 179, 132-135 19 20 DID evidence: psychogenic DID: brain imaging evidence blindness Totally blind woman diagnosed with DID Functional brain imaging (PET & fMRI) Blindness initially attributed to craniocerebral differences b/w DID & controls (Reinders et al, trauma but change after therapy 2003, 2006; Sar et al, 2007; Schlumpf et al, 2013) Absent visual evoked potentials (VEP) in the Differences not found when simulating blind identity versus normal VEP in the seeing identities (Reinders et al, 2012) identity Reinders, AATS, et al (2003) One brain, two selves. NeuroImage, 20, 2119–2125 Reinders, AATS, et al (2006) Psychobiological characteristics of dissociative Strasburger, H., & Waldvogel, B. (2015). Sight & blindness in the same identity disorder: A symptom provocation study. Biological Psychiatry, person: Gating in the visual system. PsyCh Journal, 4, 178-185 60, 730–740 Bhuvaneswar, C., & Spiegel, D. (2013). An eye for an I: A 35-year-old Sar, V. et al (2007). Frontal & occipital perfusion changes in dissociative identity disorder. Psychiatry Research: Neuroimaging, 156, 217-223. woman with fluctuating oculomotor deficits & dissociative identity Schlumpf, Y. et al (2013). Dissociative part-dependent biopsychosocial disorder. International Journal of Clinical & Experimental reactions to backward masked angry & neutral faces: An fMRI study of Hypnosis, 61, 351–370 dissociative identity disorder. NeuroImage: Clinical, 3, 54-64 21 22 DID & neuroanatomy Blihar et al. (2020): systematic review (10 MRI DID vs healthy controls studies); DID: ↓ hippocampal volumes (memory consolidation); ↓ amygdala (defenses); ↓ parietal structures (personal awareness) Brain markers can potentially diagnose DID(?) Reinders et al. (2019): MRI study (32 DID vs 43 healthy controls) ML pattern classifiers 72-74% accurate Reinders AATS, et al (2012) Fact or factitious? Blihar, et al. (2020). A systematic review of the neuroanatomy of dissociative identity disorder. European Journal of Trauma & Dissociation, 4, 100148 A psychobiological study of authentic & simulated dissociative identity states. PLoS One, 7, e39279 Reinders et al. (2019). Aiding the diagnosis of dissociative identity disorder: pattern 23 recognition study of brain biomarkers. The British Journal of Psychiatry, 215, 536-544 24 4  30/08/2024 3. Theories of DID: trauma model DID causes: DSM 5 Trauma leads to DID via various Traumatisation: In the context of family & biopsychosocial mediators & moderators attachment pathology, early life trauma (e.g., neglect & physical, sexual, & emotional abuse, usually before ages 5–6 years) “Individuals with the disorder typically report multiple types of interpersonal maltreatment during childhood & adulthood” 25 26 DID & complex trauma DID & complex trauma Majority of cases report incest or brutal sexual Dalenberg et al (2012): evidence supports view abuse often by a psychotic adult that complex trauma causes DID eg. physical damage to the genitals (eg. with icepick), locking children in closet for days, “Every study that has systematically examined aetiology has found that antecedent severe, torture of children’s pets chronic childhood trauma is present in the DID as an initially adaptive defensive histories of almost all individuals with DID” (Dorahy et al, 2014) response: mental splitting/dissociation Neurobiological evidence suggests DID is a Number of alters associated with severe form of PTSD (Reinders & Veltman, 2021) severity/duration of abuse Dorahy, et al (2014). Dissociative identity disorder: An empirical overview. Australian & (Goodwin & Sachs, 1996) New Zealand Journal of Psychiatry, 48, 402-417 Reinders & Veltman (2021). Dissociative identity disorder: out of the shadows at 27 last? The British Journal of Psychiatry, 219, 413-414 28 Structural theory of Dissociation Structural theory of Dissociation (van der Hart et al., 2006) (van der Hart et al., 2006) Based on Janet’s theory & later study of acutely traumatised World War I combat soldiers (Myers, 1940) Personality system splits into: Trauma-avoidant Apparently Normal Part (ANP) or ANPs: Daily-life action system(s) Trauma-fixated Emotional Part (EP) or EPs: Fight-defense action system(s) “Each part includes at least a rudimentary sense of an experiencing “I”” (Steele et al., 2009) 29 30 5  30/08/2024 Theories of DID: sociocognitive/fantasy model Importance of social learning/expectancies Trauma can be present but unnecessary DID a disorder of self-understanding DID results from: Iatrogenic factors: inadvertent therapist cues (eg. suggestive questioning about alters, hypnosis for memory recovery) Media influences (eg. television & film portrayals of DID) Sociocultural expectations regarding the presumed clinical features of DID 31 32 Theories of DID: sociocognitive/fantasy model DID occurs “when people with coexisting or ambiguous psychological symptoms are exposed to suggestive procedures (e.g., repeated questioning about memories & personality “parts,” leading questions, hypnosis, … media influences (e.g., film & television), & broader sociocultural expectations (e.g., “dissociation is associated with abuse,” people possess “multiple personalities”) regarding the presumed clinical features of DID” (Lynn et al, 2012) 33 34 Role of trauma? "We remain open to the possibility that trauma may play a nonspecific causal role in dissociation, largely because the FM [fantasy model] is compatible with the view that a variety of stressors, including not only highly aversive events but also isolation & loneliness..., can foster the propensity to fantasize, disrupt sleep, & increase vulnerability to suggestive influences...” (Lynn et al. 2014) 35 36 6  30/08/2024 https://www.youtube.com/watch?v=cjemK803l2M [MA warning] “Individuals who feign dissociative identity disorder do not report the subtle symptoms of intrusion characteristic of the disorder; instead they tend to overreport well-publicized symptoms of the disorder, such as dissociative amnesia, while underreporting less-publicized comorbid symptoms, such as depression… Individuals who feign dissociative identity disorder tend to be relatively undisturbed by or may even seem to enjoy “having” the disorder. In contrast, individuals with genuine dissociative identity disorder tend to be ashamed of & overwhelmed by their symptoms & to underreport their symptoms or deny their condition…” (DSM-5) DEPARTMENT OF PSYCHOLOGY 37 38 Changes in DID over time Changes in DID over time “Since the 19th century … the Phenomenology changes number of personalities per 19th century cases: transitional sleep patient has jumped from 2 or 3 Modern DID: fast switching to often more than 20 & sometimes into the hundreds” Changes in alters (Spanos, 1994) 19th C.: human alters DSM-III: Allowed up to 100 alter 20th C.: different sex, race, species to host personalities eg. cat, dog, panther, gorilla, lobster, snake Kluft (1988): 2 cases with more Demon, angel, God, Hitler, alien than 4000 personalities or Robot, tree, river, lake, mountain personality fragments 39 40 Is DID plausible? “Why did the perhaps half-plausible 19th- century concept so floridly metamorphose into the totally implausible 20th-century concept” (Piper & Merskey, 2004) 41 OFFICE I FACULTY I DEPARTMENT 42 7  30/08/2024 4. DID & culture Cultural manifestations? Review of DID cases (2000-2010): Western bias? v. few DID cases in India, Japan, “Most cases of DID emerged from a small Oman, China, Iran, etc. number of countries & clinicians. In addition, documented cases occurring outside Different cultural manifestations? treatment were almost non-existent” (Boysen & Van Bergen, 2013) “In African, Asian, & other non-Western countries … DID usually takes the form of 80% cases found in North America pathological possession experiences which are more congruent with a conception of self as not Boysen, G. A. & VanBergen, A. (2013). A review of published separate or individual” (Dorahy, et al, 2014) research on adult dissociative identity disorder: 2000-2010. J. Nerv. Ment. Dis. 201, 5-11 43 44 Different cultural manifestations of Possession states & DID DID? “In certain (e.g., mainstream Western) cultures, “The majority of studied societies & cultures [DID] is consonant with a fragmentation of have conditions in which another entity is internal identities; in other (e.g., non-Western) understood to have taken over the body of an cultures it may accord with external spiritual entities that take control of the individual” inflicted individual, ie., possession states” (Kluft, 1996) (Dorahy, et al, 2014) Evidence for the reality of DID? cf. DSM-5 DEPARTMENT OF PSYCHOLOGY 45 OFFICE I FACULTY I DEPARTMENT 46 Criticism of using possession states as evidence for DID Most traditional societies hold possession beliefs but: Different rates per society, different M/F rates, different displays of possession “… possession phenomena underscore the rule-governed & social nature of multiple identity displays” (Spanos, 1994) 47 DEPARTMENT OF PSYCHOLOGY 48 8  30/08/2024 Spanos (1994) Discussion DID: Real or unreal? Note: Even if DID shown to be a sociohistorical product this does not rule out genuine (trauma) cases of DID No doubt that traumatisation occurs No doubt that personality disturbances exist Trauma x Culture interaction (Dorahy et al 2014) Culture might shape expression of DID Not all possession states indicate DID, but DID may take form of possession after 49 trauma 50 Trauma x culture interaction “Understanding the aetiology of DID requires the amalgamation of several exposure, coping & developmental factors. Thanks… These include traumatic experiences, family dynamics, child development, attachment … & the role culture plays in constructing ‘alternate’ selves (i.e. embodied representations of the metaphor of ‘a different person’ [or spiritual being]) with separate attributes & specific memories for trauma” (Dorahy et al., 2014) 51 52 9