MPD/DID - Education: MPD Overview

Multiple Personality Disorder Overview (TWC 1997)

Primary Symptomotology
Secondary Clinical Features/Correlated Patterns
Etiology
Treatment Modalities
References

The Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for Multiple Personality Disorder (MPD) was first established in 1980. The clinical criteria was:

DSM-III Criteria for Multiple Personality Disorder: (Ross, 1989)
A. The existence within the individual of two or most distinct personalities, each of which is dominant at a particular time.
B. The personality that is dominant at any particular time determines the individual's behavior.
C. Each individual personality is complex and integrated with its own unique behavior patterns and social relationships.
D. Two or more alter personalities must exhibit individually distinct and consistent alter personality-specific behavior on at least three occasions.
E. There is evidence of some type of amnesia or combinations of types of amnesia among alter personalities (e.g., one-way amnesia, mutual amnesia, etc.). the amnesia does not have to include all of the alters.

In 1987, the American Psychiatric Association revised the DSM III and changed the criteria to the following:

DSM-III-R Criteria for Multiple Personality Disorder: (Ross, 1989)
A. The existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring patterns of perceiving, relating to, and thinking about the environment and self).
B. At least two of these personalities or personality states recurrently take full control of the person's behavior.

The DSM IV, which was released in 1994, changed the name of Multiple Personality Disorder to Dissociative Identity Disorder (DID) and altered the criteria to:

DSM-IV Criteria for Dissociative Identity Disorder: (Ross, 1997)
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person's behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

Secondary Clinical Features/Correlated Patterns

The most commonly reported secondary clinical features of DID are childhood abuse, previous clinical history, self-destructive behaviors, comorbidity, and headaches. In a study done by Ross , sexual abuse was reported by 90.2% of the subjects, physical abuse by 82.4% subjects, and both were reported by 95.1% of the subjects. Over 50% said the abuse started before the age of five, and the average duration was ten years, with several perpetrators (Ross & Miller et al., 1991). Ross (1997) quotes that the average number of years spent in therapeutic treatment prior to diagnosis averages 6.8 years. He also states that the average number of previous diagnoses is 3.1 based on research compiled using Putnam's and his own research. Furthermore, Ross and Putnam's combined research shows that an average of 45% of the DID patients they interviewed had received a previous diagnosis of schizophrenia, 68.2% had previous schizophrenia or schizoaffective disorder diagnosis, and 74.3% had been previous diagnosis of a psychotic disorder. One of the reasons for the high levels of false-positive schizophrenic and schizoaffective disorder are the tests used for diagnosis. A study done by Ellason and Ross compared 108 DID patients with 240 schizophrenic patients with the Positive and Negative Syndrome Scale (PANSS), which was developed to differentiate schizophrenic subtypes. They found that the positive symptom scores were more severe in the DID group, while the negative symptom scores were more severe in the schizophrenic group. Consequently, depending on which end of the scale is being focused on by the diagnosing professional, misdiagnosis can occur for either diagnosis (1995). Schneiderian first rank symptoms are also used to diagnose schizophrenia, but research has shown that DID subjects present more Schneiderian symptoms than schizophrenics. A comparison of 1739 schizophrenics with 368 DID patients found that schizophrenics averaged 1.3 symptoms, while DID subjects averaged 4.9 (Ross & Miller et al., 1990). Self-destructive behaviors range from self-harm to completion of suicide. Ross (as cited in Ross, 1997) found that 92% of DID patients had recurrent suicidal thoughts, while 72.5% attempted suicide. Self inflicted injuries were reported by 23.5%, wrist slashing by 40.2%, and overdose by 56.9%. Some of the rates of comorbidity that Ross states for meeting lifetime criteria are: 98.1% for mood disorder, with most qualifying for depression; 79.2% for Post Traumatic Stress Disorder (PTSD); 65.4% for substance abuse; 41.4% somatization disorder; and 38.3% for an eating disorder (Ross, 1997, pp. 126-135). The final common feature found in DID patients is the experience of frequent and severe headaches, occurring in 78.7% of DID patients.

Ross (1997) summarizes this by listing what he refers to as "nonspecific diagnostic clues for DID:"

1. History of childhood sexual and/or physical abuse
2. Female sex {Ratio female/male is 9:1}
3. Age 20-40
4. Blank spells
5. Voices in the head or other Schneiderian symptoms
6. Meets or nearly meets DSM-IV criteria for borderline personality disorder
7. Previous unsuccessful treatment
8. Self-destructive behavior
9. No thought disorder (pp. 135).

Etiology

The most frequent precursor to DID is extreme physical, emotional, and sexual abuse in childhood, but survivors of other kinds of trauma in childhood (such as natural disasters, invasive medical procedures, war, and torture) have also reacted by developing DID.

Ross (1997) states that there seems to be four pathways to DID. The most common is the childhood abuse/trauma pathway. The second most common is childhood neglect. The third pathway, in decreasing percentage of cases, is the factitious pathway. In these cases there are often histories of abuse and trauma in childhood, but no past history of dissociation patterns before the onset of therapy. Furthermore, this group tends to have extremely extensive medical histories, rate low on hypnotizability, and "overscore" on the Dissociative Experiences Scale as if trying to fake DID symptoms (usually scoring 70-80, when the average DID score is 30-40). In addition, the personality type that seems to be prevalent is the antisocial personality. The last pathway that Ross has seen is the iatrogenic pathway. There is no history of dissociation prior to therapy, no extensive medical history, and no signs of neglect nor abuse or trauma in childhood. Often, these people fall into the dependent personality group, and "become" DID in therapy when the underlying problem is really PTSD, Bipolar Personality, or Dissociative Disorder not otherwise specified (Ross, 1997, pp. 61-73).

Treatment Modalities

Overall, there are general basic treatment patterns and modalities for DID patients. A study of 305 various mental health professionals showed that individual psychotherapy facilitated by hypnosis was uniformly endorsed as the primary treatment modality for DID clients. Adjunct drug therapies with antidepressants and antianxiety medications were also highly supported (Putnam & Loewenstein, 1993). Ellason and Ross studied the effects of integration after a two year period and found that integration provided the patient with significant improvements of scores on the self-defeating, borderline, anxiety, dysthymia, avoidant, passive-aggressive, and major depression scales of the Millon Clinical Multiaxial Inventory-II (1996).

Specific outlines for treatment for DID patients have been created by different leaders in the field. Braun created a list of 13 steps in treatment of DID patients in 1986:

1. Developing trust
2. Making and sharing the diagnosis
3. Communicating with each personality state
4. Contracting
5. Gathering history
6. Working with each personality state�s problems
7. Undertaking special procedures
8. Developing interpersonality communication
9. Achieving resolution/integration
10. Developing new behaviors and coping skills
11. Networking and using social support systems
12. Solidifying gains
13. Following up (Ross, 1997, pp. 267)

Ross offers a detailed treatment plan, which involves four phases, comprised of 38 individual steps. Great detail is given for each step in order to make the process clear for clinicians. The four phases, in Ross's words, are:

Initial: The assessment and planning phase of therapy. In the treatment of DID, it involves contracting alters, mapping the system, developing a treatment alliance.
Middle: The working phase of therapy. In the treatment of DID, it involves establishing interpersonality communication, breaking down the amnesic barriers, disclosing memories.
Late: The evaluation and consolidation of gains made in the middle phase of therapy and further reworking of conflicts. In treatment of DID, it involves preparation for and carrying out of the integration of alters.
Postintegration: The work following the resolution of the major abuse issues and memories, such as developing and applying new coping skills, adjusting to new feelings and memories. In treatment of DID, it involves grieving the loss of alters (1997, pp. 407-409).

Duncan (1994) follows the thought that DID is a dramatic form of PTSD and therefore has a large neurological aspect which needs to be identified and dealt with in treatment. He believes that the flight or fight response shifts to one of numbness versus "revivification" (which include flashbacks, hyperalertness, abreactions, excessive startle responses and hyperactivity). Duncan believes that working to correct these response patterns is a must in order to successfully stop the dependence upon severe dissociation as a coping skill. Furthermore, the therapist and the patient need to be aware of this cycle between "all and nothing" in order to fully understand what is happening internally so as not to confuse it with alter activity. (Duncan, 1994, pp. 103-109)

Ross discusses that different pathways of DID need to receive different treatment approaches in order to be successful. The outline listed above is used for the childhood abuse and trauma pathway. The difference in treatment for the childhood neglect DID is that the therapist takes a more macrolevel approach and does not enter into the system dynamics. The factitious pathway is treated with confrontation and directing the patient to deal with the real problems that have lead to the factitious disorder. For the iatrogenic pathway, Ross states that the therapy approach follows that of cult exit counseling (Ross, 1997, pp. 61-73).

References

Duncan, C. W. (1994). The Fractured Mirror: Healing multiple personality disorder. Deerfield Beach, Florida: Health Communications, Inc.

Ellason, Joan W., & Ross, Colin A. (1996). Millon Clinical Multiaxial Inventory-II follow up patients with dissociative identity disorder. Psychological Reports, 78, 707-716.

Ellason, Joan W., & Ross, Colin A. (1995) Positive and negative symptoms in dissociative identity disorder and schizophrenia: A comparative analysis. Journal of Nervous and Mental Disease, 183, 236-241.

Putnam. Frank W., & Loewenstein, Richard J. (1993). Treatment of multiple personality disorder: A survey of current practices. American Journal of Psychiatry, 150, 1048-1052.

Ross, Colin A. (1997). Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment. New York: John Wiley & Sons.

Ross, Colin A. (1989). Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. New York: John Wiley & Sons.

Ross, Colin A., & Miller, Scott D. et al. (1991). Abuse histories in 102 cases of multiple personality disorder. Canadian Journal of Psychiatry, 36, 97-101.

Ross, Colin A., & Miller, Scott D. et al. (1990). Schneiderian symptoms in multiple personality disorder and schizophrenia. Comprehensive Psychiatry, 31, 111-118.