DSM 5 Multiple Personality Disorder

What are dissociative disorders?

Dissociative disorders are a group of mental health conditions characterized by a disconnection or lack of continuity between thoughts, memories, surroundings, actions, and identity. People with these disorders escape reality in ways that are involuntary and unhealthy, leading to problems with functioning in everyday life.

Dissociative identity disorder (DID)

DID, formerly known as multiple personality disorder, involves the presence of two or more distinct personality states or identities in a single individual, leading to a disrupted sense of self. These identities may have their own names, ages, histories, and characteristics. DID is often a result of severe trauma during early childhood, typically extreme, repetitive physical, sexual, or emotional abuse.

In some cases, individuals may experience partial dissociative identity disorder with less distinct personality states.

Dissociative amnesia

Dissociative amnesia is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. The amnesia may be localized to a specific event or time period, or it may be more generalized.

Depersonalization/derealization disorder

This is a form of dissociative disorder that involves persistent or recurrent feelings of detachment or estrangement from one's self (depersonalization) or the surrounding environment (derealization). Individuals may feel as though they are observing their lives from outside their bodies or that the world around them is unreal.

The causes of dissociative disorders is not fully understood, but they are believed to be linked to trauma, stress, and disruptions in normal memory and consciousness processes. Neurobiological studies suggest that changes in brain function and structure may also play a role in the development of these disorders.

What is multiple personality disorder?

Multiple personality disorder (MPD), now known as dissociative identity disorder (DID) in the DSM-5, was last included in the DSM-IV under its original name. The change in terminology reflects a shift in understanding of the disorder, emphasizing the dissociative aspect rather than the presence of multiple personalities.

Causes

The primary cause of DID is believed to be severe and prolonged trauma experienced during early childhood, usually extreme, repetitive physical, sexual, or emotional abuse. This trauma leads to a disconnection of thoughts, memories, and identity as a coping mechanism (Chametzky, 2022). Other factors that may contribute to the development of DID include genetic predisposition and environmental influences (Mitra & Jain, 2021).

Interestingly enough, the causes of DID can contribute to the development of other disorders such as borderline personality disorder.

Symptoms

Symptoms of DID include the presence of two or more distinct identities or personality states, each with its own pattern of perceiving and interacting with the world (Drescher, 2022). Individuals may experience amnesia or gaps in memory, particularly for traumatic events. Other symptoms can include depression, anxiety, dissociative fugue states, and suicidal tendencies.

These symptoms can be observed by others or reported by the individual, and they often lead to significant impairment in social and occupational functioning.

How to diagnose multiple personality disorder?

To diagnose dissociative identity disorder, a psychiatrist or psychologist does a thorough evaluation. The diagnostic process often includes:

• A comprehensive clinical interview to gather a detailed personal history, including symptoms, trauma history, and family history.
• Psychological testing, including structured interviews and questionnaires designed to assess dissociative symptoms and other mental health conditions.
• A review of medical records and consultations with previous healthcare providers to rule out medical conditions that might mimic DID symptoms.
• Observations of behavior and interactions over time to identify distinct personality states and patterns of dissociation.

What is the DSM-5?

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is a widely used manual for diagnosing mental disorders, published by the American Psychiatric Association. It provides standardized criteria for mental health professionals to diagnose and classify mental disorders, including DID. The DSM-5 is considered a reliable tool for diagnosis, but mental health professionals must use their clinical judgment and consider the individual's unique circumstances.

What are the DSM-5 criteria for multiple personality disorder?

While the term "multiple personality disorder" is no longer used in the DSM-5, the criteria for Dissociative Identity Disorder, which replaced MPD, are as follows:

• Presence of two or more distinct personality states or identities, each with its own pattern of perceiving, relating to, and thinking about the environment and self.
• Recurrent gaps in memory for everyday events, important personal information, or traumatic events, inconsistent with ordinary forgetting.
• Significant distress or impairment in social, occupational, or other important areas of functioning.
• The disturbance is not a normal part of a broadly accepted cultural or religious practice.
• The symptoms are not attributable to the physiological effects of a substance or another medical condition.

Differential diagnosis

Distinguishing DID from other disorders is crucial for accurate diagnosis and treatment. Conditions that may have similarities with DID include:

• Other specified dissociative disorders
• Major depressive disorder
• Bipolar disorders
• Post-traumatic stress disorder
• Psychotic disorders
• Substance/medication-induced disorders
• Personality disorders
• Conversion disorder
• Seizure disorders
• Factitious disorder and malingering

Differences between DSM-IV and DSM-5 criteria

In the transition from DSM-IV to DSM-5, several changes were made to the criteria for dissociative identity disorder (DID). Text modifications throughout the criteria clarify the nature and course of identity disruptions, providing a more detailed understanding of the disorder

First, Criterion A has been expanded to include not only classic dissociative identity presentations but also possession-form phenomena and functional neurological symptoms, allowing for a broader range of manifestations of the disorder. Additionally, Criterion A now specifies that transitions in identity may be observable by others or self-reported, clarifying that external observation of the identity shifts is not a requirement for diagnosis.

Furthermore, Criterion B has been updated to indicate that individuals with DID may experience recurrent gaps in recall for everyday events, not just for traumatic experiences, thereby broadening the understanding of the memory disturbances associated with DID.

How is multiple personality disorder treated?

MPD is now known as DID, so we will focus on ways to treat DID. Dissociative identity disorder treatment involves a multifaceted approach that addresses the complex symptoms and underlying causes of the disorder. Here are some common treatment methods:

• Psychotherapy: Psychotherapy is the primary treatment for DID and involves various techniques such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and eye movement desensitization and reprocessing (EMDR). The goal is to integrate the distinct personality states into a cohesive identity and address traumatic memories and experiences.
• Medication: While there are no medications specifically approved for DID, certain medications may be prescribed to manage co-occurring symptoms such as depression, anxiety, or sleep disturbances.
• Family therapy: Involving family members in the treatment process can provide support and understanding, helping to create a stable environment for the individual with DID.
• Hypnotherapy: Hypnosis may be used to access and work through traumatic memories, promote integration of personality states, and improve communication between them.
• Art and creative therapies: Engaging in creative activities such as art, music, or writing can provide an outlet for expression and help individuals explore their identities and experiences.
• Support groups: Joining a support group can provide individuals with DID a sense of community and an opportunity to share experiences and coping strategies with others who understand their condition.

It's important to note that treating dissociative identity disorder is often long-term and requires the collaboration of a mental health professional experienced in dissociative disorders. The therapist and patient work together to set goals, develop a treatment plan, and monitor progress over time.

Research on DID

Recent research on DID has explored various treatment approaches and examined the underlying neurobiological mechanisms of the disorder.

A groundbreaking study published in 2023 by Bachrach et al. highlighted the potential of Schema Therapy (ST) as an evidence-based treatment for DID. A patient with DID showed significant improvement after undergoing 220 sessions of ST, including direct trauma processing through Imagery Rescripting (ImRs). The patient experienced a reduction in PTSD symptoms, dissociative symptoms, and suicidal behaviors, indicating that ST might be a viable treatment option for DID.

Another important study by Lebois et al. in 2022 published in Neuropsychopharmacology shed light on brain activity related to dissociative symptoms in individuals with DID. The research identified specific brain networks that communicate differently when people experience various dissociative symptoms, highlighting unique brain signatures associated with different types of dissociation.

The findings from these studies underscore the importance of assessing dissociation in clinical care, particularly to reduce gender-related health disparities. As research continues to evolve, it is hoped that more evidence-based treatments will be developed to improve the lives of individuals with DID.

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References

American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th-TR). American Psychiatric Association.

Bachrach, N., Rijkeboer, M. M., Arntz, A., & Huntjens, R. J. C. (2023). Schema therapy for dissociative identity disorder: A case report. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1151872

Chametzky, B. (2022). Discovering and uncovering: A new perspective on dissociative identity disorder | grounded theory review. Grounded Theory Review, 21(1). https://groundedtheoryreview.com/2022/06/25/discovering-and-uncovering-a-new-perspective-on-dissociative-identity-disorder/

Drescher, J. (2022, October). What are dissociative disorders? Psychiatry.org; American Psychiatric Association. https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociative-disorders

Lebois, L. A. M., Kumar, P., Palermo, C. A., Lambros, A. M., O’Connor, L., Wolff, J. D., Baker, J. T., Gruber, S. A., Lewis-Schroeder, N., Ressler, K. J., Robinson, M. A., Winternitz, S., Nickerson, L. D., & Kaufman, M. L. (2022). Deconstructing dissociation: A triple network model of trauma-related dissociation and its subtypes. Neuropsychopharmacology, 47(13), 2261–2270. https://doi.org/10.1038/s41386-022-01468-1

Mitra, P., & Jain, A. (2021). Dissociative identity disorder. In StatPearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK568768/