Dissociative identity disorder
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2008-07-11T16:40:13Z
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/* See also */
{{distinguish|Dissocial personality disorder}}
{{Infobox_Disease |
Name = {{PAGENAME}} |
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DiseasesDB = |
ICD10 = {{ICD10|F|44|8|f|40}} |
ICD9 = {{ICD9|300.14}} |
ICDO = |
OMIM = |
MedlinePlus = |
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eMedicineTopic = |
MeshID = D009105 |
}}
'''Dissociative Identity Disorder''', as defined by the [[American Psychiatric Association]]'s [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM), is a psychiatric [[diagnosis]] that describes a condition in which a single person displays multiple distinct [[Personal identity (philosophy)|identities]] or [[personality|personalities]], each with its own pattern of perceiving and interacting with the environment.<ref name=dsm>{{cite book | last = American Psychiatric Association | authorlink = American Psychiatric Association | title = Diagnostic and Statistical Manual of Mental Disorders DSM-IV TR (Text Revision) | url = http://books.google.com/books?id=3SQrtpnHb9MC&pg=PA527&lpg=PA535&sig=25ML_7zbvvLZl6ySYCF4DomqeRU | accessdate = 2007-12-27 | date = 2000-06 | publisher = American Psychiatric Publishing, Inc. | location = Arlington, VA, USA | isbn = 978-0890420249 | doi = 10.1176/appi.books.9780890423349 | pages = 527-30}}</ref> The diagnosis requires that at least two personalities routinely take control of the individual's behavior with an associated [[memory loss]] that goes beyond normal forgetfulness; in addition, symptoms cannot be due to [[substance abuse]] or medical condition. Earlier versions of the DSM named the condition '''multiple personality disorder''' (MPD), and the term is still used by the [[ICD-10]]. There is controversy around the existence, the possible causes, the prevalence across cultures, and the [[epidemiology]] of the condition.
==Controversy==
{{main|Multiple personality controversy}}
DID is a [[Multiple personality controversy|controversial]] diagnosis and condition, with much of the literature on DID being generated and published in North America, to the extent that it was regarded as a phenomenon confined to that continent.<ref name="pmid2006691">{{cite journal |author=Boon S, Draijer N |title=Diagnosing dissociative disorders in The Netherlands: a pilot study with the Structured Clinical Interview for DSM-III-R Dissociative Disorders |journal=The American journal of psychiatry |volume=148 |issue=4 |pages=458–62 |year=1991 |pmid=2006691 |doi=}}</ref><ref name="pmid7794202">{{cite journal |author=Atchison M, McFarlane AC |title=A review of dissociation and dissociative disorders |journal=The Australian and New Zealand journal of psychiatry |volume=28 |issue=4 |pages=591–9 |year=1994 |pmid=7794202 | doi = 10.3109/00048679409080782 <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid15503730">{{cite journal |author=Piper A, Merskey H |title=The persistence of folly: a critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept |journal=Canadian journal of psychiatry. Revue canadienne de psychiatrie |volume=49 |issue=9 |pages=592–600 |year=2004 |pmid=15503730 |doi=| url = http://ww1.cpa-apc.org:8080/Publications/Archives/CJP/2004/september/piper.pdf | format = pdf}}</ref> Even within North American psychiatrists, there is a lack of consensus regarding the validity of DID,<ref name="pmid9989574">{{cite journal |author=Pope HG, Oliva PS, Hudson JI, Bodkin JA, Gruber AJ |title=Attitudes toward DSM-IV dissociative disorders diagnoses among board-certified American psychiatrists |journal=The American journal of psychiatry |volume=156 |issue=2 |pages=321–3 |year=1999 |pmid=9989574 |doi=}}</ref><ref name="pmid11441778">{{cite journal |author=Lalonde JK, Hudson JI, Gigante RA, Pope HG |title=Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses |journal=Canadian journal of psychiatry. Revue canadienne de psychiatrie |volume=46 |issue=5 |pages=407–12 |year=2001 |pmid=11441778 |doi=}}</ref> with some researchers considering it a [[culture bound syndrome|culture bound]], [[Iatrogenesis|iatrogenic]] condition<ref name="pmid15503730" /><ref name="pmid15560314">{{cite journal |author=Piper A, Merskey H |title=The persistence of folly: critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder |journal=Canadian journal of psychiatry. Revue canadienne de psychiatrie |volume=49 |issue=10 |pages=678–83 |year=2004 |pmid=15560314 |doi= | url = http://ww1.cpa-apc.org:8080/Publications/Archives/CJP/2004/october/piper.pdf | format = pdf}}</ref> though this idea is neither confirmed nor has been accepted by many researchers in the field. <ref name = Brown/><ref name=Gleaves/><ref name=Ross/><ref name=Kluft1989/><ref name=Braun1989/><ref name=Kluft2003/> The [[Diagnostic and Statistical Manual of Mental Disorders|DSM]] is explicit about the controversy over the condition, identifying both the objective evidence of [[physical abuse|physical]] and [[sexual abuse]] in the history of individuals diagnosed with DID and that individuals accused of abuse are motivated to deny or distort past actions, but also points out that childhood memories may be distorted, and that individuals with DID are highly [[Hypnosis|hypnotizable]] and unusually vulnerable to [[suggestion]].<ref name = dsm/> Practitioners who accept DID as a valid disorder have produced an extensive amount of literature, and research originating outside North America has appeared in recent years that documents the [[epidemiology]] of the condition in a far greater variety of countries and cultures. Scientific interest in DID peaked in the mid 1990s, then sharply declined, and may now not have widespread scientific acceptance.<ref>{{cite journal |author=Pope HG, Barry S, Bodkin A, Hudson JI |title=Tracking scientific interest in the dissociative disorders: a study of scientific publication output 1984-2003 |journal=Psychother Psychosom |volume=75 |issue=1 |pages=19–24 |year=2006 |pmid=16361871 |doi=10.1159/000089223 |url=}}</ref>
== Classification ==
Some believe that DID should be re-classified as a trauma disorder.<ref name=Pearson1991/>
== Signs and symptoms ==
Individuals with DID demonstrate a variety of symptoms with wide fluctuations across time; functioning can vary from severe impairment in daily functioning to normal or high abilities. Symptoms can include:<ref name = merckdoc>{{cite web | url = http://www.merck.com/mmpe/sec15/ch197/ch197e.html | title = Dissociative Identity Disorder, doctor's reference | publisher = Merck.com | accessdate = 2007-12-07 | date = 2005-11-01 }}</ref>
* multiple mannerisms, attitudes and beliefs that are dissimilar to each other
* [[headache]]s and other body [[pain]]s
* distortion or loss of subjective [[time]]
* [[depersonalization]]
* [[amnesia]]
* [[Depression (mood)|depression]]
Patients may experience an extremely broad array of other symptoms that resemble [[epilepsy]], [[schizophrenia]], [[Anxiety disorder|anxiety]], [[Mood disorders]], [[Posttraumatic stress disorder|posttraumatic stress]], [[Personality disorder|personality]], and [[Eating disorder|eating disorders]].<ref name = merckdoc/>
== Causes ==
The causes of dissociative identity disorder have not been identified, but are theoretically linked with the interaction of overwhelming [[stress (medicine)|stress]], traumatic antecedents,<ref name=Pearson1991>{{cite journal | author = Pearson, M.L. | year = 1991 |journal=Dissociation |volume=10 |issue=1 |pages=58–62: | title =Childhood trauma, adult trauma, and dissociation | url = https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1837/1/Diss_10_1_9_OCR.pdf |accessdate = 2008-06-01}}</ref> insufficient childhood nurturing, and an innate ability to [[Dissociation (psychology)|dissociate]] memories or experiences from [[consciousness]].<ref name = merckdoc/> Prolonged [[child abuse|childhood abuse]] is frequently a factor, with a very high percentage of patients reporting documented abuse<ref name=Kluft2003>{{cite journal |last=Kluft |first=RP |year=2003 |month= |title=Current Issues in Dissociative Identity Disorder |journal=Bridging Eastern and Western Psychiatry |volume=1 |issue=1 |pages=71–87 |id= |url=http://www.psyter.org/allegati/180/Kluft.pdf |accessdate= 2008-05-09 |quote= }}</ref><ref name=merckpat>{{cite web | url = http://www.merck.com/mmhe/sec07/ch106/ch106d.html | title = Dissociative Identity Disorder, patient's reference | publisher = Merck.com | accessdate = 2007-12-07 | date = 2003-02-01 }}</ref> often confirmed by objective evidence.<ref name=dsm/>
Others believe DID is created [[Iatrogenesis|iatrogenic]]ally by therapists using certain treatment techniques with suggestible patients,<ref name="pmid15503730"/><ref name="pmid15560314"/><ref name = merckpat/><ref>{{cite web | url = http://www.skepdic.com/mpd.html | title = Multiple personality disorder (dissociative identity disorder) | date = 2007-12-03 | accessdate = 2008-01-22 | last = Carroll | first = RT | authorlink = Robert Todd Carroll | work = [[Skeptic’s Dictionary]] }}</ref> though this idea is neither confirmed nor universally accepted.<ref name = Brown>{{cite journal |last= Brown |first= D |coauthors= Frischholz E, Scheflin A. |year= 1999 |title= Iatrogenic dissociative identity disorder - an evaluation of the scientific evidence |journal= The Journal of Psychiatry and Law |volume= XXVII No. 3-4 |issue= Fall-Winter 1999 |pages= 549–637}}</ref><ref name=Gleaves>{{cite journal |last=Gleaves |first=D. |year=1996 |month=July |title=The sociocognitive model of dissociative identity disorder: a reexamination of the evidence |journal=Psychological Bulletin |volume=120 |issue=1 |pages=42–59 |pmid = 8711016 |doi=10.1037/0033-2909.120.1.42 }}</ref><ref name=Ross>{{cite journal |last=Ross |first=C. |coauthors=Norton, G. & Fraser, G. |year=1989 |title=Evidence against the iatrogenesis of multiple personality disorder |journal=Dissociation |volume=2 |issue=2 |pages=61–65 |url=https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1424/1/Diss_2_2_2_OCR.pdf |accessdate=2008-02-10}}</ref><ref name=Kluft1989>{{cite journal | author = Kluft, R.P. | year = 1989 | title =Iatrongenic creation of new alter personalities |journal=Dissociation |volume=2 |issue=2 |pages=83–91 |url =https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1428/1/Diss_2_2_6_OCR.pdf | accessdate =2008-04-21}}</ref><ref name=Braun1989>{{cite journal | author = Braun, B.G. | year = 1989
| title = Dissociation: Vol. 2, No. 2, p. 066-069: Iatrophilia and Iatrophobia in the diagnosis and treatment of MPD | url = https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1425/1/Diss_2_2_3_OCR.pdf
| accessdate = 2008-05-04}}</ref><ref name=Kluft2003/>
== Pathophysiology==
Reviews of the literature have discussed the findings of various [[Pathophysiology|psychophysiologic]] investigations of DID.<ref name="pmid6371727">{{cite journal |author=Putnam FW |title=The psychophysiologic investigation of multiple personality disorder. A review |journal=Psychiatr. Clin. North Am. |volume=7 |issue=1 |pages=31–9 |year=1984 |pmid=6371727 |doi=}}</ref><ref name="pmid1442640">{{cite journal |author=Miller SD, Triggiano PJ |title=The psychophysiological investigation of multiple personality disorder: review and update |journal=The American journal of clinical hypnosis |volume=35 |issue=1 |pages=47–61 |year=1992 |pmid=1442640 |doi=}}</ref> Many of the investigations include testing and observation in the one person but with different alters. Different alter states have shown distinct [[physiology|physiological]] markers<ref name="pmid2333357">{{cite journal |author=Putnam FW, Zahn TP, Post RM |title=Differential autonomic nervous system activity in multiple personality disorder |journal=Psychiatry research |volume=31 |issue=3 |pages=251–60 |year=1990 |pmid=2333357| doi = 10.1016/0165-1781(90)90094-L <!--Retrieved from CrossRef by DOI bot-->}}</ref> and some [[EEG]] studies have shown distinct differences between alters in some subjects,<ref name="pmid2225470">{{cite journal |author=Hughes JR, Kuhlman DT, Fichtner CG, Gruenfeld MJ |title=Brain mapping in a case of multiple personality |journal=Clinical EEG (electroencephalography) |volume=21 |issue=4 |pages=200–9 |year=1990 |pmid=2225470 |doi=}}</ref><ref name="pmid16929711">{{cite journal |author=Lapointe AR, Crayton JW, DeVito R, Fichtner CG, Konopka LM |title=Similar or disparate brain patterns? The intra-personal EEG variability of three women with multiple personality disorder |journal=Clinical EEG and neuroscience : official journal of the EEG and Clinical Neuroscience Society (ENCS) |volume=37 |issue=3 |pages=235–42 |year=2006 |pmid=16929711 |doi=}}</ref> while other subjects' patterns were consistent across alters.<ref name="pmid6427406">{{cite journal |author=Cocores JA, Bender AL, McBride E |title=Multiple personality, seizure disorder, and the electroencephalogram |journal=J. Nerv. Ment. Dis. |volume=172 |issue=7 |pages=436–8 |year=1984 |pmid=6427406 |doi=}}</ref> Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of persons with multiple personalities and those of persons with single personalities.<ref name="pmid7165480">{{cite journal |author=Coons PM, Milstein V, Marley C |title=EEG studies of two multiple personalities and a control |journal=Arch. Gen. Psychiatry |volume=39 |issue=7 |pages=823–5 |year=1982 |pmid=7165480 |doi=}}</ref> Brain imaging studies have corroborated the transitions of identity in some DID sufferers.<ref>{{cite article |url=http://psychologytoday.com/conditions/did.html |title=Psychology Today's Diagnosis Dictionary Dissociative Identity Disorder (Multiple Personality Disorder)|publisher=Sussex Publishers LLC |location=New York, NY |year=2005 |month=October |accessdate= 2008-02-19}}</ref> One EEG study comparing DID with [[hysteria]] showed differences between the two diagnoses.<ref name="pmid2272862">{{cite journal |author=Flor-Henry P, Tomer R, Kumpula I, Koles ZJ, Yeudall LT |title=Neurophysiological and neuropsychological study of two cases of multiple personality syndrome and comparison with chronic hysteria |journal=International journal of psychophysiology : official journal of the International Organization of Psychophysiology |volume=10 |issue=2 |pages=151–61 |year=1990 |pmid=2272862 |doi=}}</ref> A postulated link between [[epilepsy]] and DID has been disputed by a number of authors.<ref name="pmid2912820">{{cite journal |author=Ross CA, Heber S, Anderson G, ''et al'' |title=Differentiating multiple personality disorder and complex partial seizures |journal=General hospital psychiatry |volume=11 |issue=1 |pages=54–8 |year=1989 |pmid=2912820 |doi=}}</ref><ref name="pmid2725878">{{cite journal |author=Devinsky O, Putnam F, Grafman J, Bromfield E, Theodore WH |title=Dissociative states and epilepsy |journal=Neurology |volume=39 |issue=6 |pages=835–40 |year=1989 |pmid=2725878 |doi=}}</ref> Some [[Neuroimaging|brain imaging]] studies have shown differing [[cerebral blood flow]] with different alters,<ref name="pmid14683715">{{cite journal |author=Reinders AA, Nijenhuis ER, Paans AM, Korf J, Willemsen AT, den Boer JA |title=One brain, two selves |journal=Neuroimage |volume=20 |issue=4 |pages=2119–25 |year=2003 |pmid=14683715| doi = 10.1016/j.neuroimage.2003.08.021 <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid17008145">{{cite journal |author=Reinders AA, Nijenhuis ER, Quak J, ''et al'' |title=Psychobiological characteristics of dissociative identity disorder: a symptom provocation study |journal=Biol. Psychiatry |volume=60 |issue=7 |pages=730–40 |year=2006 |pmid=17008145 |doi=10.1016/j.biopsych.2005.12.019}}</ref><ref name="pmid3976929">{{cite journal |author=Mathew RJ, Jack RA, West WS |title=Regional cerebral blood flow in a patient with multiple personality |journal=The American journal of psychiatry |volume=142 |issue=4 |pages=504–5 |year=1985 |pmid=3976929 |doi=}}</ref> and distinct differences overall between subjects with DID and a healthy control group.<ref name="pmid17961993">{{cite journal |author=Sar V, Unal SN, Ozturk E |title=Frontal and occipital perfusion changes in dissociative identity disorder |journal=Psychiatry research |volume=156 |issue=3 |pages=217–23 |year=2007 |pmid=17961993| doi = 10.1016/j.pscychresns.2006.12.017 <!--Retrieved from CrossRef by DOI bot-->}}</ref> A different imaging study showed that findings of smaller [[hippocampus|hippocampal]] volumes in patients with a history of exposure to [[Stress (medicine)|traumatic stress]] and an accompanying stress-related psychiatric disorder were also demonstrated in DID.<ref name="pmid16585437">{{cite journal |author=Vermetten E, Schmahl C, Lindner S, Loewenstein RJ, Bremner JD |title=Hippocampal and amygdalar volumes in dissociative identity disorder |journal=The American journal of psychiatry |volume=163 |issue=4 |pages=630–6 |year=2006 |pmid=16585437 |doi=10.1176/appi.ajp.163.4.630}}</ref> This study also found smaller [[amygdala]] volumes. Studies have demonstrated various changes in visual parameters between alters.<ref name="pmid2760599">{{cite journal |author=Miller SD |title=Optical differences in cases of multiple personality disorder |journal=J. Nerv. Ment. Dis. |volume=177 |issue=8 |pages=480–6 |year=1989 |pmid=2760599 |doi=}}</ref><ref name="pmid1997659">{{cite journal |author=Miller SD, Blackburn T, Scholes G, White GL, Mamalis N |title=Optical differences in multiple personality disorder. A second look |journal=J. Nerv. Ment. Dis. |volume=179 |issue=3 |pages=132–5 |year=1991 |pmid=1997659 |doi=}}</ref><ref name="pmid8888853">{{cite journal |author=Birnbaum MH, Thomann K |title=Visual function in multiple personality disorder |journal=Journal of the American Optometric Association |volume=67 |issue=6 |pages=327–34 |year=1996 |pmid=8888853 |doi=}}</ref> One [[twin study]] showed hereditable factors were present in DID.<ref name="pmid9653418">{{cite journal |author=Jang KL, Paris J, Zweig-Frank H, Livesley WJ |title=Twin study of dissociative experience |journal=J. Nerv. Ment. Dis. |volume=186 |issue=6 |pages=345–51 |year=1998 |pmid=9653418| doi = 10.1097/00005053-199806000-00004 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
== Diagnosis ==
The diagnostic criteria in [[DSM-IV Codes#Dissociative Identity Disorder|DSM-IV Dissociative disorders]] section 300.14 require:
* 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.
* At least two of these identities or personality states recurrently take control of the person's behavior.
* [[amnesia|Inability to recall]] important personal information that is too extensive to be explained by ordinary forgetfulness.
* 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]]). In children, the symptoms are not attributable to imaginary playmates or other fantasy play.<ref name=dsm/> A [[Medical history|patient history]], [[x-ray]]s, [[blood test]]s, and other procedures can be used to eliminate symptoms being due to [[traumatic brain injury]], [[medication]], [[sleep deprivation]], or intoxicants, all of which can mimic symptoms of DID.<ref name="webmd"/>
Diagnosis should be performed by a [[psychiatrist]] or [[psychologist]] who may use specially designed interviews (such as the [[Structured Clinical Interview for DSM-IV#SCID-D|SCID-D]]) and personality assessment tools to evaluate a person for a [[dissociative disorder]].<ref name="webmd">{{cite web | url = http://www.webmd.com/content/article/118/112901.htm | title = Mental Health: Dissociative Identity Disorder (Multiple Personality Disorder) | publisher = Webmd.com | accessdate = 2007-12-10 }}</ref>
The [[psychiatric history]] of individuals diagnosed with DID frequently contain multiple previous diagnoses of various [[mental disorder]]s and [[treatment]] failures. The belief by some doctors that the diagnosis is fallacious may contribute to the frequency of its [[Medical error|misdiagnosis]].<ref name = merckdoc/> DID is frequently misdiagnosed as [[bipolar disorder]] due to mood changes between alter states being mistaken for the cyclical mood changes accompanying bipolarity. Another frequent misdiagnosis is [[psychotic disorder]] as dialogues between alters may be mistaken for [[Hallucination#Auditory hallucinations|auditory hallucinations]].<ref name = merckdoc/><ref name=dsm/>
== Screening ==
The [[Structured Clinical Interview for DSM-IV#SCID-D|SCID-D]]<ref name="pmid2293792">{{cite journal |author=Steinberg M, Rounsaville B, Cicchetti DV |title=The Structured Clinical Interview for DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument |journal=The American journal of psychiatry |volume=147 |issue=1 |pages=76–82 |year=1990 |pmid=2293792 |doi=}}</ref> may be used to make a diagnosis. This interview takes about 30 to 90 minutes depending on the subject's experiences.
The Dissociative Disorders Interview Schedule (DDIS)<ref name="pmid15941122">{{cite journal |author=Ross CA, Ellason JW |title=Discriminating among diagnostic categories using the Dissociative Disorders Interview Schedule |journal=Psychological reports |volume=96 |issue=2 |pages=445–53 |year=2005 |pmid=15941122| doi = 10.2466/PR0.96.2.445-453 <!--Retrieved from CrossRef by DOI bot-->}}</ref> is a highly structured interview which discriminates between various DSM-IV diagnoses. The DDIS can usually be administered in 30-45 minutes.
The Dissociative Experiences Scale (DES)<ref name="pmid3783140">{{cite journal |author=Bernstein EM, Putnam FW |title=Development, reliability, and validity of a dissociation scale |journal=J. Nerv. Ment. Dis. |volume=174 |issue=12 |pages=727–35 |year=1986 |pmid=3783140 |doi=}}</ref> is a simple, quick, and validated<ref name="pmid8317572">{{cite journal |author=Carlson EB, Putnam FW, Ross CA, ''et al'' |title=Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: a multicenter study |journal=The American journal of psychiatry |volume=150 |issue=7 |pages=1030–6 |year=1993 |pmid=8317572 |doi=}}</ref> questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20<ref name="pmid1853955">{{cite journal |author=Steinberg M, Rounsaville B, Cicchetti D |title=Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview |journal=The American journal of psychiatry |volume=148 |issue=8 |pages=1050–4 |year=1991 |pmid=1853955 |doi=}}</ref> and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D<ref name="pmid2293792">{{cite journal |author=Steinberg M, Rounsaville B, Cicchetti DV |title=The Structured Clinical Interview for DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument |journal=The American journal of psychiatry |volume=147 |issue=1 |pages=76–82 |year=1990 |pmid=2293792 |doi=}}</ref> diagnoses and a cutoff of 20 missed 25%.<ref name="pmid16585436">{{cite journal |author=Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D |title=Prevalence of dissociative disorders in psychiatric outpatients |journal=The American journal of psychiatry |volume=163 |issue=4 |pages=623–9 |year=2006 |pmid=16585436 |doi=10.1176/appi.ajp.163.4.623}} [http://ajp.psychiatryonline.org/cgi/content/full/163/4/623 Full Text]</ref> The reliability of the DES in non-clinical samples has been questioned.<ref name="pmid10696264">{{cite journal |author=Wright DB, Loftus EF |title=Measuring dissociation: comparison of alternative forms of the dissociative experiences scale |journal=The American journal of psychology |volume=112 |issue=4 |pages=497–519 |year=1999 |pmid=10696264| doi = 10.2307/1423648 <!--Retrieved from CrossRef by DOI bot-->}} [http://links.jstor.org/sici?sici=0002-9556(199924)112%3C497%3E2.0.CO Page 1]</ref> There is also a DES scale for children
and DES scale for adolescents.
One study found that old and new trauma may interact, causing higher DID item test scores.<ref name=Pearson1991/>
== Treatment ==
Treatment of DID may attempt to "reconnect" the identities of the disparate alters into a single functioning identity and/or may be symptomatic to relieve the distressing aspects of the condition and ensure the safety of the individual. Treatment methods may include [[psychotherapy]] and [[Psychiatric medication|medication]]s for [[Comorbidity|comorbid]] disorders.<ref name="webmd" /> Some [[Behaviour therapy|behavior therapists]] initially use behavioral treatments such as only responding to a single identity, and using more traditional therapy once a consistent response is established.<ref name=Kohlenberg1991>{{cite book | author = Kohlenberg, R.J. | coauthors = Tsai, M. | year = 1991 | title = Functional Analytic Psychotherapy: Creating Intense and Curative Therapeutic Relationships | publisher = Springer | isbn = 0306438577}}</ref> It has been stated that treatment recommendations that follow from models that do not believe in the [[psychological trauma|traumatic]] origins of DID might be harmful due to the fact that they ignore the posttraumatic [[symptomatology]] of people with DID.<ref name=Gleaves/>
== Prognosis ==
DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily [[Dissociation (psychology)|dissociative]] symptoms and features of [[posttraumatic stress disorder]] normally recover with treatment. Those with [[Comorbidity|comorbid]] [[Substance abuse|addictions]], [[Personality disorder|personality]], [[Mood disorder|mood]], or [[eating disorder]]s face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of [[symptom]] relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives.<ref name = merckdoc/>
== Epidemiology ==
The DSM does not provide an estimate, and suggests different explanations for the sharp rise in incidence of DID. Possible reasons suggested for the increase in incidence and prevalence of DID over time include the condition being misdiagnosed as [[schizophrenia]], [[bipolar]], or other such disorders in the past, and/or an increase in awareness of DID and [[child sexual abuse]] leading to earlier, more accurate diagnosis. Other clinicians believe that DID is an [[Iatrogenesis|iatrogenic]] condition overdiagnosed in highly suggestive individuals,<ref name=dsm/> though there is disagreement over the ability of the condition to be induced by hypnosis.<ref name = Brown/><ref name=Braun1989/> Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:
{| class="wikitable sortable"
!width="100"|Country
!width="100"|Prevalence
!width="200"|Source study
|-
|[[India]] || 0.015% || Adityanjee et al (1989)<ref name="pmid2589555">{{cite journal |author=Adityanjee, Raju GS, Khandelwal SK |title=Current status of multiple personality disorder in India |journal=The American journal of psychiatry |volume=146 |issue=12 |pages=1607–10 |year=1989 |pmid=2589555 |doi=}}</ref>
|-
|[[Switzerland]] || 0.05-0.1%|| Modestin (1992)<ref name="pmid1728191">{{cite journal |author=Modestin J |title=Multiple personality disorder in Switzerland |journal=The American journal of psychiatry |volume=149 |issue=1 |pages=88–92 |year=1992 |pmid=1728191 |doi=}}</ref>
|-
| [[China]] || 0.4% || Xiao et al (2006)<ref name="pmid16877651">{{cite journal |author=Xiao Z, Yan H, Wang Z, ''et al'' |title=Trauma and dissociation in China |journal=The American journal of psychiatry |volume=163 |issue=8 |pages=1388–91 |year=2006 |pmid=16877651 |doi=10.1176/appi.ajp.163.8.1388}}</ref>
|-
| [[Germany]] || 0.9% || Gast et al (2001)<ref name="pmid11339321">{{cite journal |author=Gast U, Rodewald F, Nickel V, Emrich HM |title=Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic |journal=J. Nerv. Ment. Dis. |volume=189 |issue=4 |pages=249–57 |year=2001 |pmid=11339321| doi = 10.1097/00005053-200104000-00007 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
|-
| The Netherlands || 2% || Friedl & Draijer (2000)<ref name="pmid10831486">{{cite journal |author=Friedl MC, Draijer N |title=Dissociative disorders in Dutch psychiatric inpatients |journal=The American journal of psychiatry |volume=157 |issue=6 |pages=1012–3 |year=2000 |pmid=10831486| doi = 10.1176/appi.ajp.157.6.1012 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
|-
| [[United States|U.S.]] || 10% || Bliss & Jeppsen (1985)<ref name="pmid3970252">{{cite journal |author=Bliss EL, Jeppsen EA |title=Prevalence of multiple personality among inpatients and outpatients |journal=The American journal of psychiatry |volume=142 |issue=2 |pages=250–1 |year=1985 |pmid=3970252 |doi=}}</ref>
|-
| U.S. || 6-8% || Ross et al (1992)<ref name="pmid1521791">{{cite journal |author=Ross CA, Anderson G, Fleisher WP, Norton GR |title=Dissociative experiences among psychiatric inpatients |journal=General hospital psychiatry |volume=14 |issue=5 |pages=350–4 |year=1992 |pmid=1521791 |doi=}}</ref>
|-
|U.S. || 6-10% || Foote et al. (2006)<ref name="pmid16585436">{{cite journal |author=Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D |title=Prevalence of dissociative disorders in psychiatric outpatients |journal=The American journal of psychiatry |volume=163 |issue=4 |pages=623–9 |year=2006 |pmid=16585436 |doi=10.1176/appi.ajp.163.4.623}}</ref>
|-
| [[Turkey]] || 14% || Sar et al (2007)<ref name="pmid17189745">{{cite journal |author=Sar V, Koyuncu A, Ozturk E, ''et al'' |title=Dissociative disorders in the psychiatric emergency ward |journal=General hospital psychiatry |volume=29 |issue=1 |pages=45–50 |year=2007 |pmid=17189745 |doi=10.1016/j.genhosppsych.2006.10.009}}</ref>
|}
Figures from the general population show less diversity:
{| class="wikitable sortable"
!width="100"|Country
!width="100"|Prevalence
!width="200"|Source study
|-
| [[Canada]] || 1% || Ross (1991)<ref name="pmid1946021">{{cite journal |author=Ross CA |title=Epidemiology of multiple personality disorder and dissociation |journal=Psychiatr. Clin. North Am. |volume=14 |issue=3 |pages=503–17 |year=1991 |pmid=1946021 |doi=}}</ref>
|-
| Turkey (male) || 0.4% || Akyuz et al (1999)<ref name="pmid10080263">{{cite journal |author=Akyüz G, Doğan O, Sar V, Yargiç LI, Tutkun H |title=Frequency of dissociative identity disorder in the general population in Turkey |journal=Comprehensive psychiatry |volume=40 |issue=2 |pages=151–9 |year=1999 |pmid=10080263| doi = 10.1016/S0010-440X(99)90120-7 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
|-
| Turkey (female) || 1.1% || Sar et al (2007)<ref name="pmid17157389">{{cite journal |author=Sar V, Akyüz G, Doğan O |title=Prevalence of dissociative disorders among women in the general population |journal=Psychiatry Res |volume=149 |issue=1-3 |pages=169–76 |year=2007 |pmid=17157389 |doi=10.1016/j.psychres.2006.01.005}}</ref>
|}
Dissociative identity disorder can be found in a sizable minority of patients in [[drug abuse]] treatment facilities.<ref name=merckpat/>
== History ==
An intense interest in [[spiritualism]], [[parapsychology]], and [[hypnosis]] continued throughout the 19th and early 20th centuries,<ref name="pmid7794202">{{cite journal |author=Atchison M, McFarlane AC |title=A review of dissociation and dissociative disorders |journal=The Australian and New Zealand journal of psychiatry |volume=28 |issue=4 |pages=591–9 |year=1994 |pmid=7794202 | doi = 10.3109/00048679409080782 <!--Retrieved from CrossRef by DOI bot-->}}</ref> running in parallel with [[John Locke]]'s views that there was an ''association'' of ideas requiring the coexistence of feelings with awareness of the feelings.<ref name="pmid12094818">{{cite journal |author=Rieber RW |title=The duality of the brain and the multiplicity of minds: can you have it both ways? |journal=History of psychiatry |volume=13 |issue=49 Pt 1 |pages=3–17 |year=2002 |pmid=12094818| doi = 10.1177/0957154X0201304901 <!--Retrieved from CrossRef by DOI bot-->10.1177/0957154X0201304901}}</ref> [[Hypnosis]], which was pioneered in the late 1700s by [[Franz Mesmer]] and [[Armand-Marie-Jacques_de_Chastenet%2C_Marques_of_Puys%C3%A9gur|Armand-Marie Jacques de Chastenet, Marques de Puységur]], challenged Locke's association of ideas. Hypnotists observed second personalities emerging during hypnosis and wondered how two minds could coexist.<ref name="pmid7794202" />
Early cases of what would now be diagnosed as DID appeared at this time and were treated by hypnosis.<ref name="pmid12094818"/><ref name="pmid2677129">{{cite journal |author=Carlson ET |title=Multiple personality and hypnosis: the first one hundred years |journal=Journal of the history of the behavioral sciences |volume=25 |issue=4 |pages=315–22 |year=1989 |pmid=2677129| doi = 10.1002/1520-6696(198910)25:4<315::AID-JHBS2300250402>3.0.CO;2-H}}</ref> The 19th century saw a number of increasingly sophisticatedly reported cases of multiple personalities which Rieber<ref name="pmid12094818">{{cite journal |author=Rieber RW |title=The duality of the brain and the multiplicity of minds: can you have it both ways? |journal=History of psychiatry |volume=13 |issue=49 Pt 1 |pages=3–17 |year=2002 |pmid=12094818| doi = 10.1177/0957154X0201304901 <!--Retrieved from CrossRef by DOI bot-->}}</ref> estimated would be close to 100. [[Epilepsy]] was seen as a factor in some cases<ref name="pmid12094818" /> and discussion of this connection continues into the present era.<ref name="pmid6427406">{{cite journal |author=Cocores JA, Bender AL, McBride E |title=Multiple personality, seizure disorder, and the electroencephalogram |journal=J. Nerv. Ment. Dis. |volume=172 |issue=7 |pages=436–8 |year=1984 |pmid=6427406 |doi=}}</ref><ref name="pmid2725878">{{cite journal |author=Devinsky O, Putnam F, Grafman J, Bromfield E, Theodore WH |title=Dissociative states and epilepsy |journal=Neurology |volume=39 |issue=6 |pages=835–40 |year=1989 |pmid=2725878 |doi=}}</ref>
By the late 19th century there was a general realization that emotionally traumatic experiences could cause long-term disorders which may manifest with a variety of symptoms.<ref name="Borch-Jacobsen M 2000">{{cite journal |author= Borch-Jacobsen M, Brick D |title= How to predict the past: from trauma to repression |journal= History of Psychiatry |volume=11 |issue= |pages=15–35 |year=2000|doi=10.1177/0957154X0001104102 }} </ref> Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. <ref name="putnam">{{cite book | last = Putnam | first = Frank W. | title = Diagnosis and Treatment of Multiple Personality Disorder | publisher = The Guilford Press | date = 1989 | location =New York | pages = 351 | isbn = 0-89862-177-1}}</ref> It was in this climate that [[Jean-Martin_Charcot|Jean-Martin Charcot]] introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, [[Pierre Janet]], took these ideas and went on to developed his own theories of dissociation.<ref name="pmid2686473">{{cite journal |author=van der Kolk BA, van der Hart O |title=Pierre Janet and the breakdown of adaptation in psychological trauma |journal=The American journal of psychiatry |volume=146 |issue=12 |pages=1530–40 |year=1989 |pmid=2686473 |doi=}}</ref>
In the early 20th century interest in dissociation and MPD waned for a number of reasons. After Charcot's death in 1893, many of his "hysterical" patients were exposed as frauds and Janet's association with Charcot tarnished his theories of dissociation.<ref name="pmid7794202" /> [[Sigmund Freud]] recanted his earlier emphasis on dissociation and childhood trauma.<ref name="pmid7794202" /> Freud, a man who actively promoted his ideas and enlisted the help of others, won out over the "lone wolf" Janet who did not train students in a teaching hospital.<ref name="pmid12094818" /> Psychologists found that science was hard to reconcile with a "[[soul]]" or an "[[unconscious]]".
In 1910, [[Eugen Bleuler]] introduced the term "schizophrenia" to replace "[[dementia praecox]]" and a review of the ''[[Index_medicus|Index Medicus]]'' from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia "caught on," especially in the United States.<ref name="pmid7004385">{{cite journal |author=Rosenbaum M |title=The role of the term schizophrenia in the decline of diagnoses of multiple personality |journal=Arch. Gen. Psychiatry |volume=37 |issue=12 |pages=1383–5 |year=1980 |pmid=7004385 |doi=}}</ref> A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of MPD was the decline of interest in dissociation as a laboratory and clinical phenomenon.<!-- Putnam -->
Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports.<!-- Putnam --> Bleuler also included multiple personality in his category of schizophrenia. It was found in the 1980's that MPD patients are often misdiagnosed as suffering from schizophrenia.<ref name="putnam"/>
The public, however, were exposed to psychological ideas which took their interest. [[Mary Shelley]]'s ''[[Frankenstein]]'', [[Robert Louis Stevenson]]'s ''[[Strange Case of Dr Jekyll and Mr Hyde]]'', and many [[short story|short stories]] by [[Edgar Allan Poe]], had a formidable impact.<ref name="pmid12094818" /> In 1957, the publication of the book ''[[The Three Faces of Eve]]'', and the popular movie which followed it, the American public's interest in multiple personality was revived. Multiple personality disorder began to emerge as a separate disorder in the 1970's when an initially small number of clinicians worked to re-establish MPD as a legitimate diagnosis.<ref name="putnam"/>
In 1974, the highly influential book ''[[Sybil (book)|Sybil]]'' was published and six years later the diagnosis of multiple personality disorder was included in the DSM. As media coverage spiked, diagnoses climbed. There were 200 reported cases of MPD from 1880 to 1979, and 20,000 from 1980 to 1990.<ref name="Adams 2003">{{cite web | last = Adams | first = C | year = 2003 | url = http://www.straightdope.com/columns/031003.html | title = Does multiple personality disorder really exist? | work = [[The Straight Dope]] | accessdate = 2008-01-22}}</ref> [[Joan Acocella]] reports that 40,000 cases were diagnosed from 1985 to 1995.<ref name="Accocella">{{cite book |author=Acocella, JR | authorlink = Joan Acocella |title=Creating hysteria: women and multiple personality disorder |publisher=Jossey-Bass Publishers |location=San Francisco |year=1999 |pages= |isbn=0-7879-4794-6 |oclc= |doi=}}</ref> The majority of diagnoses are made in North America, particularly the [[United States]], and in [[English language|English]]-speaking countries more generally<ref name="Spanos 2001">{{cite book |author=Spanos, Nicholas P. |title=Multiple Identities & False Memories: A Sociocognitive Perspective |publisher=American Psychological Association (APA) |location= |year= |pages= |isbn=1557983402 |oclc= |doi=}}</ref> with reports recently emerging from other countries.<ref name="pmid2589555"/><ref name="pmid1728191"/><ref name="pmid16877651"/><ref name="pmid11339321"/><ref name="pmid10831486"/><ref name="pmid17189745"/><ref name="pmid10080263"/>
One of the primary reasons for the ongoing recategorization of this condition is that there were once so few documented cases (research in 1944 showed only 76<ref name="Accocella"/>) of what was once referred to as multiple personality. Dissociation is recognized as a symptomatic presentation in response to [[Psychological trauma|trauma]], extreme emotional stress, and, as noted, in association with [[emotional dysregulation]] and [[borderline personality disorder]]<ref>{{cite journal |author=Marmer S, Fink D |title=Rethinking the comparison of Borderline Personality Disorder and multiple personality disorder |journal=Psychiatr Clin North Am |volume=17 |issue=4 |pages=743–71 |year=1994 |pmid=7877901}}</ref>. In one study, DID was found to be a genuine disorder with a constant set of core features.<ref name=Ross/>
The DSM-II used the term ''multiple personality disorder'', the DSM-III the diagnosis with the other four major [[Dissociative disorders|dissociative disorders]], and the [[Diagnostic and Statistical Manual of Mental Disorders|DSM-IV-TR]] categorizes it as dissociative identity disorder. The [[ICD-10]] continues to list the condition as multiple personality disorder.
== Cultural references ==
{{main|Dissociative identity disorder in fiction}} <!-- <---- Do not add to the list, add to the main list -->
==See also==
*[[Depersonalization]]
*[[Dissociative disorders]]
*[[Fugue state]]
*[[Psychogenic amnesia]]
*[[Truddi Chase]]
*[[Self-concept]]
*[[Blitzwing]]
==Notes==
{{reflist|3}}
<!-- == References ==-->
<!-- == Further reading or Bibliography (paper resources such as books, not web sites) ==-->
==Further reading==
*{{cite book | last =Goettmann | first =B. A. | coauthors = Greaves, B. G., Coons M. P. | title =Multiple personality and dissociation, 1791-1992: a complete bibliography | publisher =The Sidran Press | date =1994 | location =Lutherville, MD | pages =85 | url =http://boundless.uoregon.edu/cdm4/item_viewer.php?CISOROOT=/diss&CISOPTR=38 | isbn =0-9629164-5-5}}
==External links==
{{wiktionary|multiple personality}}
*{{DMOZ|/Health/Mental_Health/Disorders/Dissociative/Multiple_Personality/}}
*[http://www.isst-d.org/ International Society for the Study of Trauma and Dissociation]
[[Category:Dissociative disorders]]
[[ar:تعدد شخصية فصامي]]
[[de:Dissoziative Identitätsstörung]]
[[es:Trastorno de identidad disociativo]]
[[fr:Trouble dissociatif de l'identité]]
[[he:פיצול אישיות]]
[[id:Kepribadian yang terpecah]]
[[ja:解離性同一性障害]]
[[nl:Dissociatieve identiteitsstoornis]]
[[pl:Osobowość mnoga]]
[[pt:Transtorno dissociativo de identidade]]
[[ru:Множественная личность]]
[[fi:Dissosiatiivinen identiteettihäiriö]]
[[sv:Dissociativ identitetsstörning]]
[[ur:تفارقی شناختی اضطراب]]
[[zh:多重人格疾患]]