Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision


From the Journal of Trauma and Dissociation

Diagnostic Criteria for DID The DSM–IV–TR (American Psychiatric Association, 2000a) lists the following diagnostic criteria for DID (300.14; p. 529): 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 Downloaded by [] at 09:20 21 October 2011 Journal of Trauma & Dissociation, 12:115–187, 2011 119 children, the symptoms are not attributable to imaginary playmates or other fantasy play. In recent years, there has been debate about the diagnostic criteria for DID. Dell (2001, 2009a) has suggested that the high level of abstraction of the current diagnostic criteria, and the corresponding lack of concrete clinical symptoms, sharply reduces their utility for the average clinician and that a set of frequently appearing dissociative signs and symptoms would more accurately capture the typical presentations of DID patients. Others have argued that the current criteria are sufficient (D. Spiegel, 2001). Still others have suggested that dissociative disorders should be reconceptualized as belonging to a spectrum of trauma disorders, thereby emphasizing their intimate association with overwhelming and traumatic circumstances (Davidson & Foa, 1993; Ross, 2007; Van der Hart, Nijenhuis, & Steele, 2006). Dissociation: Terminology and Definitions The American Psychiatric Association (2000a) and the World Health Organization (1992) have characterized the dissociative disorders but have not fully described the nature of dissociation itself. Thus, the DSM–IV–TR states that “the essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception” (American Psychiatric Association, 2000a, p. 519). There is some debate as to how broad or narrow the definition of dissociation should be. Putnam (1989) has described the process of dissociation as “a normal process that is initially used defensively by an individual to handle traumatic experiences [that] evolves over time into a maladaptive or pathological process” (p. 9). A number of authors (e.g., Cardeña, 1994; Holmes et al., 2005) have used the term descriptively to refer to failures to integrate information and self-attributions that should ordinarily be integrated, and to alterations of consciousness characterized by a sense of detachment from the self and/or the environment. A further subdivision is based on Pierre Janet’s distinction between dissociative negative (i.e., a diminution or abolishment of a psychological process) and positive (i.e., the creation or exaggeration of a psychological process) symptoms. Dell and O’Neil’s (2009) definition elaborated on the DSM–IV’s central concept of disruption: The essential manifestation of pathological dissociation is a partial or complete disruption of the normal integration of a person’s psychological functioning. . . . Specifically, dissociation can unexpectedly disrupt, alter, or intrude upon a person’s consciousness and experience of body, world, self, mind, agency, intentionality, thinking, believing, knowing, recognizing, remembering, feeling, wanting, speaking, acting, seeing, Downloaded by [] at 09:20 21 October 2011 120 International Society for the Study of Trauma and Dissociation hearing, smelling, tasting, touching, and so on. . . . [T]hese disruptions . . . are typically experienced by the person as startling, autonomous intrusions into his or her usual ways of responding or functioning. The most common dissociative intrusions include hearing voices, depersonalization, derealization, “made” thoughts, “made” urges, “made” desires, “made” emotions, and “made” actions. (p. xxi) Dissociative processes have various manifestations (Howell, 2005), many of them nonpathological. In particular, Dell (2009d) has argued that spontaneous, survival-related dissociation is part of a normal, evolutionselected, species-specific response; this dissociation is automatic and reflexive and is one part of a brief, time-limited, normal biological reaction that subsides as soon as the danger is over. The relationship between this dissociative response and the degree and nature of the dissociation seen in dissociative disorders is not yet adequately understood. Alternate Identities: Conceptual Issues and Physiological Manifestations The DID patient is a single person who experiences himself or herself as having separate alternate identities that have relative psychological autonomy from one another. At various times, these subjective identities may take executive control of the person’s body and behavior and/or influence his or her experience and behavior from “within.” Taken together, all of the alternate identities make up the identity or personality of the human being with DID. Alternate identities have been defined in a number of ways. For example, Putnam (1989) described them as “highly discrete states of consciousness organized around a prevailing affect, sense of self (including body image), with a limited repertoire of behaviors and a set of state dependent memories” (p. 103). R. P. Kluft (1988b) stated, A disaggregate self state (i.e., personality) is the mental address of a relatively stable and enduring particular pattern of selective mobilization of mental contents and functions, which may be behaviorally enacted with noteworthy role-taking and role-playing dimensions and sensitive to intrapsychic, interpersonal, and environmental stimuli. It is organized in and associated with a relatively stable . . . pattern of neuropsychophysiologic activation, and has crucial psychodynamic contents. It functions both as a recipient, processor, and storage center for perceptions, experiences, and the processing of such in connection with past events and thoughts, and/or present and anticipated ones as well. It has a sense of its own identity and ideation, and a capacity for initiating thought processes and action. (pp. 55) Downloaded by [] at 09:20 21 October 2011 Journal of Trauma & Dissociation, 12:115–187, 2011 121 Many terms have been developed to describe the DID patient’s subjective sense of self-states or identities. These include personality, personality state, self-state, disaggregate self-state, alter, alter personality, alternate identity, part, part of the mind, part of the self, dissociative part of the personality, and entity, among others (see Van der Hart & Dorahy, 2009). Because the DSM–IV–TR (American Psychiatric Association, 2000a) uses the term alternate identity, this term is used in the Guidelines for consistency. Clinicians should attend to the unique, personal language with which DID patients characterize their alternate identities. Patients commonly refer to themselves as having parts, parts inside, aspects, facets, ways of being, voices, multiples, selves, ages of me, people, persons, individuals, spirits, demons, others, and so on. It can be helpful to use the terms that patients use to refer to their identities unless the use of these terms is not in line with therapeutic recommendations and/or, in the clinician’s judgment, certain terms would reinforce a belief that the alternate identities are separate people or persons rather than a single human being with subjectively divided self-aspects.


Integrated Functioning as the Goal of Treatment Although the DID patient has the subjective experience of having separate identities, it is important for clinicians to keep in mind that the patient is not a collection of separate people sharing the same body. The DID patient should be seen as a whole adult person, with the identities sharing responsibility for daily life. Clinicians working with DID patients generally must hold the whole person (i.e., system of alternate identities) responsible for the behavior of any or all of the constituent identities, even in the presence of amnesia or the sense of lack of control or agency over behavior (see Radden, 1996). Treatment should move the patient toward better integrated functioning whenever possible. In the service of gradual integration, the therapist may, at times, acknowledge that the patient experiences the alternate identities as if they were separate. Nevertheless, a fundamental tenet of the psychotherapy of patients with DID is to bring about an increased degree of communication and coordination among the identities. In most DID patients, each identity seems to have its “own” first-person perspective and sense of its “own” self, as well as a perspective of other parts as being “not self.” The identity that is in control usually speaks in the first person and may disown other parts or be completely unaware of them. Switches among identities occur in response to changes in emotional state or to environmental demands, resulting in another identity emerging to assume control. Because different identities have different roles, experiences, emotions, memories, and beliefs, the therapist is constantly contending with their competing points of view. Helping the identities to be aware of one another as legitimate parts of the self and to negotiate and resolve their conflicts is at the very core of the therapeutic process. It is countertherapeutic for the therapist to treat any alternate identity as if it were more “real” or more important than any other. The therapist should not “play favorites” among the alternate identities or exclude apparently unlikable or disruptive ones from the therapy (although Downloaded by [] at 09:20 21 October 2011 Journal of Trauma & Dissociation, 12:115–187, 2011 133 such steps may be necessary for a limited period of time at some stages in the treatment of some patients to provide for the safety and stability of the patient or the safety of others). The therapist should foster the idea that all alternate identities represent adaptive attempts to cope or to master problems that the patient has faced. Thus, it is countertherapeutic to tell patients to ignore or “get rid” of identities (although it is acceptable to provide strategies for the patient to resist the influence of destructive identities, or to help control the emergence of certain identities at inappropriate circumstances or times). It is countertherapeutic to suggest that the patient create additional alternate identities, to name identities when they have no names (although the patient may choose names if he or she wishes), or to suggest that identities function in a more elaborated and autonomous way than they already are functioning. A desirable treatment outcome is a workable form of integration or harmony among alternate identities. Terms such as integration and fusion are sometimes used in a confusing way. Integration is a broad, longitudinal process referring to all work on dissociated mental processes throughout treatment. R. P. Kluft (1993a) defined integration as an ongoing process of undoing all aspects of dissociative dividedness that begins long before there is any reduction in the number or distinctness of the identities, persists through their fusion, and continues at a deeper level even after the identities have blended into one. It denotes an ongoing process in the tradition of psychoanalytic perspectives on structural change. (p. 109) Fusion refers to a point in time when two or more alternate identities experience themselves as joining together with a complete loss of subjective separateness. Final fusion refers to the point in time when the patient’s sense of self shifts from that of having multiple identities to that of being a unified self. Some members of the 2010 Guidelines Task Force have advocated for the use of the term unification to avoid the confusion of early fusions and final fusion. R. P. Kluft (1993a) has argued that the most stable treatment outcome is final fusion—complete integration, merger, and loss of separateness—of all identity states. However, even after undergoing considerable treatment, a considerable number of DID patients will not be able to achieve final fusion and/or will not see fusion as desirable. Many factors can contribute to patients being unable to achieve final fusion: chronic and serious situational stress; avoidance of unresolved, extremely painful life issues, including traumatic memories; lack of financial resources for treatment; comorbid medical disorders; advanced age; significant unremitting DSM Axis I and/or Axis II comorbidities; and/or significant narcissistic investment in the alternate Downloaded by [] at 09:20 21 October 2011 134 International Society for the Study of Trauma and Dissociation identities and/or DID itself; among others. Accordingly, a more realistic long-term outcome for some patients may be a cooperative arrangement sometimes called a “resolution”—that is, sufficiently integrated and coordinated functioning among alternate identities to promote optimal functioning. However, patients who achieve a cooperative arrangement rather than final fusion may be more vulnerable to later decompensation (into florid DID and/or PTSD) when sufficiently stressed. Even after final fusion, additional work to integrate the patient’s residual dissociated ways of thinking and experiencing may continue. For instance, the therapist and patient might need to work on fully integrating an ability that was previously held by one alternate identity, or the patient may need to learn what his or her new pain threshold is, or how to integrate all the dissociated ages into one chronological age, or how to regauge appropriate and healthy exercise or exertion levels for his or her age. Traumatic and stressful material also may need to be reworked from this new unified perspective. Treatment Outcome, Treatment Trajectories, and Cost Effectiveness

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