He Dissociative Personality Identity Disorder (DIDP) It is a complex disorder that has been very little studied and that represents a challenge for clinical professionals. The complexity lies partly in the difficulty of identifying it. For this reason, many cases are lost in anonymity.
Dissociative Personality Identity Disorder: what is it?
One of the first challenges that TIDP patients face in therapy is that they often receive incomplete or simply wrong diagnoses. Incomplete in the sense that they may be relevant with respect to some of the alter egoswhile inadequate in the context of multiplicity.
Many people with Dissociative Personality Identity Disorder never go to psychological or psychiatric consultation. And when they do, they are often misdiagnosed. This makes it impossible for them to receive the help they need.
What is TIDP?
Among the specialists of this disorder, there is Valerie Sinasonpsychoanalyst and director of the Clinic for Dissociation Studies. She is the editor of the book “Attachment Trauma and Multiplicity” and in the introduction to it, she comments:
“Over the last decade I have counseled and treated children and adults, especially women, who have Dissociative Personality Identity Disorder (DIPD). There is a very significant bias regarding the sex of people who suffer from this condition. Male children Victims of abuse are more likely to externalize their trauma, even though both sexes use externalizing responses. Most of the children and adults I have evaluated have been misdiagnosed as schizophrenic, borderline, with an antisocial or psychotic disorder… Despite the fact that antipsychotic medication had little or no effect on them, that the voices they heard came from within and not outside, and that they did not exhibit a disorder of thinking about time and place except when they were In a state of trance, despite all this, mental health professionals did not perceive flaws in the diagnosis. In view of professional confusion and denial at the social level, some patients have managed to hide their multiplicity when it has been revealed to them. accused of making it up. In response to the key question concerning the small number of children who present severe dissociative states, some patients confirmed negative responses to their childhood confessions that led them to hide their symptoms. These children were told that they would grow out of it and that it was a phenomenon of imaginary friends” (2002 p. 5).
The purpose of the concept of dissociation: refers to the process of encapsulating or separating the memory or emotion that is directly associated with the trauma from the I conscious. Dissociation is a creative way to keep something unacceptable out of sight. Dissociative Personality Identity Disorder is a way that the internal system creates to protect secrets and continually learns to adapt to the environment. It is a survival mechanism. Likewise, it favors and maintains attachment with the abuser. It allows, on a mental level, some conflicting emotions to be kept in separate compartments.
More specifically, the dissociation entails a wide variety of behaviors that represent lapses in the cognitive and psychological process. The three main types of dissociative behavior that have been recognized are: amnesia, absorption and depersonalization.
Causes
North et al. (1983; cited by Sinason p. 10) found that this condition was not only linked to a high percentage of childhood sexual abuse, but also to an occurrence between 24 and 67% of sexual abuse in adult life, and between 60 and 81% of suicide attempts.
It is clear that TIDP is an important aspect of the cluster of trauma-induced conditions. In the USA, in a sample of 100 patients with TIDP, it was found that 97% of them had experienced significant trauma in childhood and almost half of them had witnessed the violent death of someone close to them. (Putman et al. 1986; cited by Sinason p. 11)
Until very recently, it has been extremely difficult to document childhood cases of TIDP. Although there are those who argue that this does not mean that they do not exist. The same occurs with adolescent cases and it is only the adult TIDP cases that receive support from the scientific community.
Richard Kluft believed his efforts to trace TIDP’s natural history had little success. His attempts to find children’s cases were an “unmitigated fiasco.” He described the case of an 8-year-old boy who seemed to manifest “a series of developed personality states” after witnessing a situation in which someone almost drowned in water, and having suffered physical abuse. However, he realized with other colleagues that his field of vision was too narrow. He noted that Gagan and MacMahon (1984, cited by Bentovim, A. p. 21) described a notion of an incipient multiple personality disorder in children; They raised the possibility of a broader spectrum of dissociative phenomenology that children could manifest.
The DSM-V criteria They specify that TIDP manifests itself with:
Guidelines for diagnosis and treatment
Regardless of the diagnosis, if dissociation is present, it is important to explore what role it plays in the patient’s life. Dissociation is a defense mechanism.
It is important for the therapist to discriminate dissociation and to talk about defense mechanisms as parts of a process. The therapist can then accompany the patient in exploring the reasons why he may be using this mechanism as a defense. If the therapist addresses the topic of dissociation as soon as there is some indication of it, the diagnosis will come more easily. Using the Dissociative Experiences Scale (DES) or the Somatoform Dissociation Questionnaire (SDQ-20) can help determine the degree and role dissociation plays in the person’s life. (Haddock, DB, 2001, p.72)
The International Society for the Study of Dissociation (ISSD) has developed general guidelines for the diagnosis and treatment of TIDP. He states that the basis for a diagnosis is a mental status examination that focuses on questions related to dissociative symptoms. The ISSD recommends the use of dissociative screening instruments, such as the DES, the Dissociative Disorders Interview Schedule (DDIS), and the Structured Clinical Interview for DSM-IV Dissociative Disorders.
The DDIS, developed by Ross, is a highly structured interview that covers topics related to the TIDP diagnosis, as well as other psychological disorders. It is useful in terms of differential diagnosis and provides the therapist with the mean of the scores in each subsection, based on a sample of TIDP patients who completed the inventory. The SCID-DR, developed by Marlene Steinberg, is another highly structured interview instrument used to diagnose dissociation.
An important aspect of Steinberg’s work involves the five core dissociative symptoms that must be present to diagnose a person with TIDP or TIDPNE (non-specific). These symptoms are: dissociative amnesia, depersonalization, derealization, identity confusion and identity alteration.
TIDP is experienced by the dissociator as identity confusion (while the non-dissociator typically experiences life in a more integrated way). The TIDP experience is comprised of the dissociator frequently feeling disconnected from the world around him, as if he were living in a dream at times. The SCID-DR helps the clinician identify specific aspects of this history.
In any case, the therapist’s basic components related to the diagnostic process include, but are not limited to, the following:
A comprehensive history
An initial interview that can last between 1 and 3 sessions.
A special emphasis on issues related to family of origin, as well as psychiatric and physical history. The therapist must pay attention to memory gaps or inconsistencies found in the patient’s stories.
direct observation
It is helpful to make notes regarding any amnesia and avoidance occurring in the session. It is also necessary to appreciate changes in facial features or voice quality, in case it seems out of context to the situation or what is being discussed at the time. Noticing a state of extreme sleepiness or confusion that interferes with the patient’s ability to follow the therapist during the session (Bray Haddock, Deborah, 2001; pp. 74-77)
Review of dissociative experiences
If it is suspected that there may be dissociation, a review tool such as the DES, the DDIS, the SDQ-20 or the SCID-R could be used to collect more information.
Note symptoms related to amnesia, depersonalization, derealization, identity confusion, and identity disturbance before diagnosing TIDP or TIDPNE.
Differential diagnosis to rule out specific disorders
You can start by considering the previous diagnoses. That is, taking into account the number of diagnoses, how many times the patient has received treatment, objectives achieved in previous treatments. Previous diagnoses are considered but not used unless they currently meet DSM criteria.
Then you have to compare the DSM criteria with each disorder that has dissociation as part of its composition and diagnosing TIDP only after observing the change of alter egos.
Find out if there is the presence of substance abuse and eating disorders. If dissociation is suspected, using a screening tool such as the CD or ED can provide further insight into the function of the dissociation process.
Confirmation of diagnosis
If the dissociation is confirmed, once again comparing the DSM criteria in terms of possible diagnoses and the diagnosis of TIDP, only after observing the change of alter egos. Until then, the most appropriate diagnosis will be Non-Specific Dissociative Personality Identity Disorder (PSID) or Post-Traumatic Stress Syndrome (PSS).
