OTHER DISORDERS

Dissociative Identity Disorder

Kill Me Heal Me, Psycho, Split and The Fight Club – what do these shows have in common?

They all feature protagonists who have Dissociative Personality Disorder (DID), popularly known as the condition with multiple personalities. While DID might form the central storyline in these shows, the question is – do they portray DID accurately? They have gotten some aspects of DID right – the protagonists are shown to have multiple personalities and have experienced childhood trauma. However, the accuracy of DID portrayals still leaves much to be desired. Characters are often portrayed to be violent and aggressive people, or that their condition is exaggerated to achieve comedic effect.  

Contrary to what these shows portray, not all individuals with DID lapse into violence or aggression when switching personalities. Neither is DID a laughing matter – individuals with DID often report feeling nervous when personality switches occur, which occurs when they try to blend in with others. This is also done to minimize the attention they get, as well as acting as an attempt to reduce harm. 

To be diagnosed with Dissociative Identity Disorder, the following criteria must be present:  

1. Disruption of identity characterized by two or more distinct personality states (some cultures describe this as an experience of possession).

Ψ The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

Ψ This can manifest in various ways, though they are all related to discontinuities of experience that can affect any aspect of an individual’s functioning. Some individuals might report the feeling that they have suddenly become depersonalized observers of their “own” speech and actions, though they feel powerless to stop this. Some might also report perceptions of voices (e.g a child’s voice, crying) – there are instances where voices are experienced as perplexing, independent thought streams over which the individual has no control over. Some individuals might also report that their bodies feel different – they might feel that their body is different from what is seen (e.g a child’s body, a body of the opposite gender).

2. Recurrent gaps in the recall of everyday events, important information, and/or traumatic events that are inconsistent with ordinary forgetting (aka recurrent dissociative amnesia)  

Causes 

Given the severe consequences that result from DID, much research has been conducted to uncover the causes of DID. While existing research is mixed, current results highlight two theories that can explain DID – the trauma theory and socio-cognitive theory.  

The trauma theory proposes that DID is a result of attempts to cope with an overwhelming sense of hopelessness and powerlessness that arises from repeated traumatic abuse when one is in their childhood. As they might lack other resources or routes of escape, the child may dissociate and escape into a fantasy to cope with the pain, such that they become someone else or imagine that the abuse is happening to someone else instead. This then helps them to manage the pain and negative emotions that arises due to the abuse. Positive reinforcement then occurs, where they will do the same when abuse occurs again. If the child is fantasy-prone, and continues to be this way over time, the child may unknowingly create different selves at different time points, resulting in dissociated identities over time.  

On the other hand, the socio-cognitive theory proposes that DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities. This can occur due to two reasons – one being that clinicians have inadvertently suggested, legitimized and reinforced these identities, and the other being that these different identities align with the individual’s own personal goals. Unlike the trauma theory, the socio-cognitive theory postulates that DID occurs with little or no awareness, such that it is not intentionally engineered by the individual involved.

Therapy

Given that most existing therapeutic approaches assume that DID is brought about by abuse or other traumatic events (e.g war, death of a loved one), a trauma-informed approach is often adopted in therapy, where clients are asked to process the trauma and learn healthy coping mechanisms as well, with the goal being that distinct personalities are integrated into one.  

In the 1st stage of therapy, to achieve safety and stabilization, clients are taught adaptive coping skills to manage overwhelming symptoms. To facilitate this, a therapeutic alliance will also be developed in the process. However, one thing to take note - developing a trusting relationship with a therapist might take some time and effort as some individuals might have experienced abuse under the hands of their family/caretakers. After therapeutic alliance has been developed and the client’s condition has stabilized, trauma processing then occurs. This can be done via various therapy modalities, such as cognitive-behavioral therapy, eye movement desensitization and reprocessing (EMDR). Psychodynamic and insight-oriented therapy might be utilized as well, with these modalities focused on uncovering and working through the trauma and other conflicts that are thought to have led to the disorder.    

In some instances, Dialectical Behavioral Therapy can act as a complement to therapy, specially the modules on mindfulness, distress tolerance and emotional regulation. Mindfulness can help decrease dissociation and improve grounding skills among clients, whereas distress tolerance and emotion regulation modules can be helpful in reducing impulsive behaviors.

Prognosis  

The prognosis of DID can be limited at times, as there is often considerable resistance to the therapeutic process by clients – dissociation is considered as a protective shield for some of them when they are faced with abuse or traumatic events. In addition, while integration of separate, distinct alters into one unified personality might be the end goal of therapy, it is not uncommon for only partial integration to be achieved.  

Nevertheless, therapy has been shown to produce symptom improvement and subsequent improvements in functioning. With appropriate intervention, many individuals with DID show marked improvement in occupational and personal functioning. Long-term supportive intervention may also slowly improve individuals’ abilities to manage their symptoms, therefore reducing the need for more restrictive levels of care.  

Support  

As therapy for DID might take a long period of time, what would help them in their journey is receiving love and support from their loved ones. Here are some things that you can do to support your loved ones as they go through therapy: