DISSOCIATIVE IDENTITY DISORDER

        Dissociative identity disorder (DID) is a mental health condition. DID patients have two or more distinct identities. Dissociative identity disorder used to be called multiple personality disorder or split personality disorder. DID is one of several dissociative disorders. These disorders affect a person's ability to connect with reality. The diagnosis of DID has been controversial for many years, with many mental health professionals alternatively attributing the disorder to misdiagnosis, social contagion or simply hypnotic suggestion.

        At certain times, these personalities are in charge of their actions. Every identity has a unique personal history, character traits, and preferences. The alters in DID have 'their own identities, involving a centre of initiative and experience, they have a characteristic self-representation, which may be different from how the patient is generally seen or perceived, they have their own autobiographic memory, and distinguish what they understand to be their own actions and experiences from those done and experienced by other a' Watkins and Watkins and others distinguish the concept of alters from that of ego states.

CAUSES

        Other symptoms of dissociative identity disorder may include headache, amnesia, time loss, trances, and "out of body experiences." Some people with dissociative disorders have a tendency toward self-persecution, self-sabotage, and even violence (both self-inflicted and outwardly directed).

        A defence system that has gotten out of control manifests itself as the dissociative component. Dissociative identity disorder is assumed to result from a number of circumstances, some of which may include trauma that the disordered individual has experienced. It is believed that the dissociative feature is a coping technique; the person figuratively disconnects from or dissociates from a scenario or experience that is too traumatic, violent, or unpleasant to absorb with their conscious self.

PREVALENCE

        In the global population, dissociative disorders have an incidence of 1 to 5 percent. 1 to 1.5 percent of this population suffers from severe dissociative identity disorder. Prior to receiving a dissociative identity disorder diagnosis, patients may get care for anywhere between five and twelve and a half years. Non-suicidal self-injurious conduct and suicide attempts are more common in DID patients.

        Even if there hasn't been any overt physical or sexual abuse, dissociation can occur when there has been ongoing neglect or emotional abuse. Studies have shown that children may develop dissociative disorders in families when the parents are frightful and unpredictable.

DIAGNOSIS CRITERIA

• International Classification of Diseases 10

          Under ICD 10 dissociative identity disorder comes under dissociative disorders. F 44 Dissociation (Conversion) disorders-   the common theme shared by dissociative (or conversion) disorders is a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.

Diagnostic guidelines - For a definitive diagnosis the following should be present

a. The clinical features as specified for the individual disorders in F 44.-

b. No evidence of a physical disorder that might explain the symptoms

c. Evidence for psychological causation, in the form of clear association in time with stressful events and problems or disturbed relationships (even if denied by the individual).

F 44.81 Multiple personality disorder

        The essential feature is the apparent existence of two or more distinct personalities within an individual, with only one of them being evident at a time. Each personality is complete, with its own memories, behaviour, and preferences; these may be in marked contrast to the single premorbid personality.

• Diagnostic and Statistical Manual of Mental Disorders 5-

Diagnostic criteria-

a. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms maybe observed by others or reported by the individual.

b. Recurrent gaps in the recall of everyday events, important personal information, and or traumatic events that are inconsistent with ordinary forgetting.

c. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

d. The disturbance is not a normal part of a broadly accepted cultural or religious practice.

e. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behaviour during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

TREATMENT FOR DISSOCIATIVE IDENTITY DISORDER

        Due to their extreme sensitivity to issues of interpersonal trust and rejection, patients with DID frequently find it challenging to receive short-term care in a managed care setting. Patients with DID are typically seen by therapists as outpatients once or twice a week for years with the aim of fusing the personality states while keeping the full spectrum of experiences present in all of the alters.

Therapy focuses on:

1. Identifying and working through past trauma or abuse.

2. Managing sudden behavioural changes.

3. Merging separate identities into a single identity.

        Integrative functioning is the main goal of therapy. As a result, the DID patient should be seen as a complete adult who shares life's obligations with numerous identities. Changes in identity can happen at any time, frequently in response to changes in the patient's mental state or to demands placed on them by the environment. As a result, the therapist must constantly balance the opposing viewpoints of the alters. The therapist must assist the identities in becoming aware of one another, legitimising one another, negotiating with one another, and resolving problems because the identity in charge may be unaware of the others or disavow them.

        It is frequently advised to use a cognitive behavioural therapy (CBT) strategy that includes helping the patient develop more adaptive coping mechanisms than "switching" when they are upset. This can be improved by giving the patient instruction in relaxing techniques, proposing brief getaways from the environment, and assisting them in gaining control over their own and the outside world's cognitive distortions. The therapist makes an effort to set an appropriate example for relationships and for calm, deliberate responses to emergencies.

Author:

Sanya Sundaram, M.Phil. (Clinical Psychology) 1st year Trainee, under the supervision of Dr. Ranjita (Assistant Professor of Clinical Psychology at CIIMHANS,Chattisgarh).