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UNDERGRADUATE SYLLABUS
SUBJECT: Psychology
PAPER: Abnormal Psychology
TOPIC: Dissociative and Somatoform Disorders
LESSON: Dissociative Disorders – Part 2
Dissociative Disorders – Part-2
Dissociative Identity Disorder
Perhaps the most bizarre of the dissociative disorders is dissociative identity
disorder (DID), formerly known as multiple personality disorder. In this dramatic
disorder pattern, the personality breaks up into 2 or more distinct identities or
personality states, each well integrated and well developed, which then take
turns controlling the person's behavior. Amnesia is part of the pattern. At least
one of the different identities is amnesic for the experiences of the other or
others (Dorahy, 2001). Each identity may appear to have a different personal
history, self image and name, though there are some identities that are only
partially distinct and independent from other identities. The first case of DID to
receive extensive professional attention-the case of Miss Beauchamp, who may
have had as many as 17 identities-was reported by Morton Prince in 1905. Ever
since, this disorder has held a certain fascination for the public, as shown by the
immense popularity of Thigpen and Cleckley's The Three Faces of Eve (1957), both
book and movie, and by the best-seller Sybil (Schreiber, 1974), about a girl with
16 personality states.
In Dissociative Identity Disorder, a distinction is usually made between the host,
the personality state, corresponding to who the person was before the onset of
the disorder, and the alters, the later-developing identities. The personality that is
most frequently encountered and carries the person’s real name is the host
identity. The alter identities may differ in striking ways involving gender, age,
handedness, handwriting, and so on. For example one alter may be carefree, funloving and sexually provocative and another alter quiet, studious, serious, and
prudish. Needs and behaviors inhibited in the host identity are usually liberally
displayed by one or more alter identities.
There are many different configurations of host and alters (Putnam, 1997). In the
simplest pattern, called alternating personality, 2 identities take turns controlling
behavior, each having amnesia for the thoughts and actions of the other. In a
slightly more complex pattern, the alter knows about the host, but the host
doesn't know about the alter (Dorahy, 2001). While the host is directing the
person's behavior the alter, fully aware of the thoughts and actions of the host,
continues to operate covertly and to make its presence felt now and then. In such
cases, the alter is said to be coconscious (Prince, 1905) with the host. When the
coconscious alters finally surfaces, it can discuss in detail the interesting problems
of the host. Meanwhile, the host only gradually becomes aware of the existence.
of the alter, usually by encountering the evidence of his or her activities. In one
case (Osgood, Luria, Jeans, Smith., 1976), the host, “Gina," first learned of the
existence of her alter, “Mary Sunshine," when she began waking up in the
morning to find cups with leftover hot chocolate in the kitchen sink. Gina did not
drink hot chocolate. But even, this is an atypically simple pattern. Most DID
patients have far more than one alter-surveys have even found an average of 13
per patient (Putnam, 1997; Putnam, Guroff, Silberman, Barban, & Post., 1986)and the host and alters often have complex patterns of coconsciousness. One
identity may know about another, but not about a third; that third identity may
be in league with a fourth and a fifth, but not with the sixth and seventh; and so
on. The transition from one personality to another is called a switch. Usually the
switch is instantaneous (unlike the dramatic effect shown in movies). Physical
transformations may occur during switches ex: posture, facial expressions,
patterns of facial wrinkling, and even physical disabilities may emerge. In one
study, changes in handedness occurred in 37% of the cases. (Putnam, Guroff,
Silberman, & Barban, & Post., 1986).
The presence of more than one identity and significant amnesia for what the alter
identities have experienced are not the only symptoms of Dissociative Identity
Disorder. Other symptoms include depression, self-mutilation, and frequent
suicidal ideation and attempts. People with DID often show moodiness and erratic
behaviour, headaches, hallucinations, substance abuse, post-traumatic
symptoms, and other amnesic and fugue symptoms. (APA, 2000; Maldonado,
Butler, & Spiegel., 2002).
Types of Personalities
Many cases of DID involve identities that are 'polar opposites: one conformist,
reserved, "nice" personality and one rebellious, aggressive, "naughty" personality,
In surveys of dissociative identity patients by two teams of researchers, at least 50
percent of the patients reported drug abuse by an alternate identity; 20 percent
claimed that an alternate identity had been involved in a sexual assault on
another person; and 29 percent reported that one of their alternates was
homicidal (Putnam, Guroff, Silberman, & Barban, & Post ., 1986;
Ross, Miller,
Reagor, et al., 1990). Dissociative identity patients may do violence to themselves
when one identity tries to kill another. Such "internal homicide" attempts were
reported by more than half the people.
But "good versus bad" is not the only pattern. It is possible that, one identity
encapsulates a traumatic memory, while another reflects a former abuser. In
other cases, the personality states' may divide up the emotional life, one dealing
with anger, another handling sadness, and so on.
The disorder usually starts in childhood, although most patients are in their
twenties or thirties at the time of their diagnosis (Ross, 1997). Approximately
three to nine times more females than males are diagnosed as having the
disorder, and females tend to have a larger number of alters than do males (APA,
2000).
Causes: In the Putnam survey, 97 out of 100 patients reported some significant
trauma in childhood. The most common was sexual abuse, reported by 83
percent of the patients; in 68 percent of the patients, this sexual abuse involved
incest. Three fourths of the patients also claimed to have suffered repeated
physical abuse in childhood, and almost half reported having witnessed a violent
death, usually of a parent or sibling, during their early years. The nearly
unanimous testimonies of abuse suggest that dissociative identity disorder may
be a stratagem that terrified children use to distance themselves from the
realities of their lives (Atchison & McFarlane, 1994). In support of this view, most
patients report that the disorder began in childhood, at a time of severe trauma.
(In the Putnam survey, 89 percent reported onset before the age of 12).
On the other hand, there is the criticism that rejects many cases as false cases.
Increasingly over years, even firm defenders of the DID diagnosis have become
more concerned about false cases. For example, Ross (1997) estimates that a
quarter of the DID cases in the dissociative disorders unit that he directs are
either faked or iatrogenic (induced by therapy). That the central feature of DID,
the presentation of multiple identities, is usually not observable before treatment
and that this essential feature becomes visible during treatment are major
reasons why some critics have argued that DID is, at least in part, induced by
therapy (Spanos, 1996; Lilienfeld, Lynn, Kirsch, et al., 1999). According to auto
hypnotic model, people who are suggestible may be able to use dissociation as a
defense against extreme trauma (Putnam, 1991). Indeed, a survey of boardcertified American psychiatrists found little consensus regarding the diagnostic
status and scientist validity of DID (Pope, Oliva, Hudson, et al., 1999).
Dissociative Disorders: Theory and Therapy
1. The Psychodynamic Perspective: Defense Against Anxiety
Dissociation as Defense Freud, believed that when many basic human wishes
were in direct conflict with either reality or the superego, the result of this conflict
is painful anxiety. To protect the mind against the anxiety, the ego represses the
wish and mounts defenses against it. The dissociative disorders are simply
extreme and maladaptive defenses. Dissociative amnesia, for example, is
regarded by Freudian theorists as a simple case of repression. Fugue and
dissociative identity disorder are more complicated, in that the person also acts
out the repressed wish directly or symbolically. Thus the fugue patient goes off
and has adventures. The person with dissociative identity disorder becomes a
different, "forbidden" self-while the ego maintains amnesia for the episode, thus
protecting the mind against the strictures of the superego.
Treating Dissociation Psychodynamic therapy is the most common treatment for
the dissociative disorders. When trauma is involved, or thought to be involved,
the treatment generally proceeds in three stages. Stage 1 involves settling the
patient down: establishing an atmosphere of trust and helping the patient to gain
some mastery over the dissociative
symptoms. Then, in stage 2, the traumatic memory is recovered and grieved over.
Stage 3 is devoted to the reintegration of the traumatic memory, so that the
patient no longer has to use dissociation to wall it off (Herman, 1992; Kluft, 1999).
In amnesia, fugue, and DID, the traditional method of bringing forth the lost
material has been hypnosis. (Barbiturates and benzodiazepines may achieve the
same effect). A disadvantage of hypnosis is that in some cases it seems to bring
on or exacerbate dissociative symptoms (Destun & Kuiper, 1996; Powell & Gee,
1999). Another concern is that the memory retrieval may be re-traumatizing
particularly when it takes the form of abreaction (the intense re-experiencing of
the event) and unnecessarily prolonged, plunging the patient again and again into
a state of emotional crisis. Some therapists now avoid abreactions (Ross, 1997).
Kluft (1999) has proposed a technique called fractionated abreaction, in which the
memory is retrieved only gradually, in small parts, while the therapist encourages
mastery and discourages surrender to emotion.
2. The Behavioral Perspective: Dissociation as a Social Rule
Learning to Dissociate The behaviorists have conceptualized the dissociative
disorders as a form of learned coping response, with the production of symptoms
in order to obtain rewards or relief from stress. According to the behaviorists, the
dissociative disorders, like many other psychological disorders, are the result of a
person's adopting a social role that is reinforced by its consequences (Seltzer,
1994). In amnesia, fugue, and dissociative identity disorder, the rewarding
consequence is protection from stressful events. It is important for the student
here to note the similarity between this interpretation and the psychodynamic
view. In both cases, the focus is on motivation, and the motivation is escape. The
difference is that in the psychodynamic view the process is unconscious, whereas
in the behavioral view dissociative behavior is maintained by reinforcement.
Non-reinforcement According to behavioral and socio-cultural theory, the way to
treat dissociative symptoms is to stop reinforcing them (Spanos, 1996).
3. The Cognitive Perspective: Memory Dysfunction
Cognitive theorists view the dissociative syndromes as fundamentally disorders of
memory (Dorahy, 2001). In each case, what has been dissociated is all or part of
the patient's autobiography. As we have seen in the preceding sections, the
patient's skills (procedural memory) and general knowledge (semantic memory)
are usually intact. What is partially impaired is the patient's episodic memory or
record of personal experience. Patients may still show evidence that they have
implicit memory of their past. What they don't have is explicit memory for the
dissociated material, the ability to retrieve it into consciousness.
Improving Memory Retrieval To date, there has been little work on cognitive
therapy for dissociative disorders. Nevertheless, many therapists use cognitive
techniques in treating patients with dissociative disorders (Brand, 2001). For
example, in the case of Jane Doewhere the personal details were not
remembered, the therapist appealed to her implicit memory by asking her to
punch in telephone numbers at random. The method worked and when the
numbers were punched at random, there was a number where her family
members responded.
4. Integrated approach
Some treatments for DID, such as tactical-integration therapy, combine cognitivebehavioral and psychodynamic approaches (Fine, 1999). In this therapy, the first
stage of treatment focuses on the cognitive distortions and dysfunctional beliefs
arising from past traumas among the various alters. These trauma-based cognitive
biases are challenged with typical cognitive techniques, such as hypothesis testing
and reattribution training. The second stage is more psychodynamic and involves
fractionated abreaction and mastery of emotion.
5. The Neuroscience Perspective: Brain Dysfunction
According to neuroscience researchers, some so called dissociative disorders may
be neurological disorders. According to one theory (Sivec &Lynn, 1995), the
dissociative syndromes may be a by-product of undiagnosed epilepsy. This theory
may apply to certain dissociative conditions, but it is unlikely to explain DID, in
which the symptoms are far more elaborate than the dissociative experiences
reported by epileptic patients.
A second hypothesis has to do with the hippocampus, a part of the limbic system.
When a memory needs to be retrieved, it is apparently the hippocampus that
brings the memory elements back together and integrates them. But stress can
derail this process. In autopsies of monkeys and in MRI scans of human beings, it
has been shown that stress can lead to structural changes in the hippocampus,
including the atrophy of cells. Stress can also trigger the release of
neurotransmitters that are highly concentrated in the hippocampus-a process
that is thought to interfere with the encoding and retrieval of memories.
Finally, it has been suggested that, at least in depersonalization disorder, there
may be some abnormality in serotonin functioning.
6. Drug Treatment
Little in the way of biological treatment has been developed for the dissociative
disorders. The barbiturate sodium amytal or the benzodiazepine lorazepam can
be used as alternatives to hypnosis to aid in the recovery of memories, although
the reliability of such memories is no better than with hypnosis. As researchers
gain more knowledge about stress-induced changes in memory function, it is
hoped that they will be able to develop medications for the dissociative disorders.