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A disorder characterized by two or more identities or personalities that alternatively take over the person's behavior.Amnesia involving an inability to recall important personal information relating to some of the identities is present. Amnesia is not uniform in all personalities; what is not known by one personality may be known by another. Some personalities may appear to know and interact with other personalities in an elaborate inner world. For example, some personalities of which personality A is unaware may be aware of personality A and know what it does, as if observing its behavior. Others may be unaware of personality A or may be aware of personality A but lack co-consciousness (the simultaneous awareness of events by more than one personality) with personality A.

Dissociative identity disorder is serious and chronic and may lead to disability and incapacity. It is associated with a high incidence of suicide attempts and is believed to be more likely to end in suicide than any other mental disorder.

Several studies show that previously undiagnosed dissociative identity disorder is present in 3 to 4% of acute psychiatric inpatients and in a sizable minority of patients in psychoactive substance abuse treatment settings. It appears to be rather common, being diagnosed more frequently in recent years because of enhanced awareness of it, improved diagnostic methods, and increased awareness of childhood mistreatment and its consequences. Although some experts believe that increased reports of this disorder reflect the influence of physicians on suggestible patients, no firm evidence substantiates this view.

Etiology
Dissociative identity disorder is attributed to the interaction of several factors: overwhelming stress, dissociative capacity (including the ability to uncouple one's memories, perceptions, or identity from conscious awareness), the enlistment of steps in normal developmental processes as defenses, and, during childhood, the lack of sufficient nurturing and compassion in response to hurtful experiences or lack of protection against further overwhelming experiences. Children are not born with a sense of a unified identity--it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have blended into a relatively unified identity remain separate. North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of dissociative disorder. Although these data establish childhood abuse as a major cause among North American patients (in some cultures, the consequences of war and disaster play a larger role), they do not mean that all such patients were abused or that all the abuses reported by patients with dissociative identity disorder really happened. Some aspects of some reported abuse experiences may prove to be inaccurate. Also, some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other very stressful events. For example, a patient who required many hospitalizations and operations during childhood may have been severely overwhelmed but not abused.

Human development requires that children be able to integrate complicated and different types of information and experiences successfully. As children achieve cohesive, complex appreciations of themselves and others, they go through phases in which different perceptions and emotions are kept segregated. Each developmental phase may be used to generate different selves. Not every child who experiences abuse or major loss or trauma has the capacity to develop multiple personalities. Patients with dissociative identity disorder can be easily hypnotized. This capacity, closely related to the capacity to dissociate, is thought to be a factor in the development of the disorder. However, most children who have these capacities also have normal adaptive mechanisms, and most are sufficiently protected and soothed by adults to prevent development of dissociative identity disorder.

Symptoms and Signs
Patients often have a remarkable array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic and mood psychoses, and seizure disorders. Most have symptoms of depression, manifestations of anxiety (sweating, rapid pulse, palpitations), phobias, panic attacks, physical symptoms, sexual dysfunction, eating disorders, and posttraumatic stress. Suicidal preoccupations and attempts are common, as are episodes of self-mutilation. Many have abused psychoactive substances at some time.

The switching of personalities and the amnesic barriers between them frequently result in chaotic lives. Because the personalities often interact with each other, patients with dissociative identity disorder often report hearing inner conversations and the voices of other personalities, which often comment on or address the patient. The voices are experienced as hallucinations.

Several symptoms are characteristic of dissociative identity disorder: fluctuating symptom pictures; fluctuating levels of function, from highly effective to disabled; severe headaches or other bodily pain; time distortions, time lapse, and amnesia; and depersonalization and derealization. Depersonalization refers to feeling unreal, removed from one's self, and detached from one's physical and mental processes. The patient feels like an observer of his life and may actually see himself as if he were watching a movie. Derealization refers to experiencing familiar persons and surroundings as if they were unfamiliar and strange or unreal.

Persons with dissociative identity disorder are often told of things they have done but do not remember and of notable changes in their behavior. They may discover objects, productions, or handwriting that they cannot account for or recognize; they may refer to themselves in the first person plural (we) or in the third person (he, she, they); and they may have amnesia for events that occurred between ages 6 and 11. Amnesia for earlier events is normal and widespread.

Because dissociative identity disorder tends to resemble other psychiatric disorders, patients typically give histories of having had three or more different psychiatric diagnoses and of prior treatment failure. As a group, they are very concerned with issues of control, both self-control and control of others.

Diagnosis
The diagnosis requires medical and psychiatric evaluation, including specific questions about dissociative phenomena. Under some circumstances, the psychiatrist may use prolonged interviews, hypnosis, or drug-facilitated interviews and may ask the patient to keep a journal between visits. All of these measures encourage a shift of personality states during the evaluation. Specially designed questionnaires can help identify patients with dissociative identity disorder.

The psychiatrist may attempt to contact and elicit other personalities by asking to speak to the part of the mind involved in behaviors for which the patient had amnesia or that were experienced in a depersonalized or derealized fashion.

Prognosis
Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and posttraumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of other serious psychiatric disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration. Sometimes therapy helps a patient with a poorer prognosis make rapid strides toward recovery.

Treatment
Symptoms wax and wane spontaneously, but dissociative identity disorder does not resolve spontaneously. Drugs help manage specific symptoms but do not affect the disorder itself. All successful treatments that aim to achieve integration involve psychotherapy that specifically addresses the dissociative identity disorder. Some patients are unable or unwilling to pursue integration. For them, treatment aims to facilitate cooperation and collaboration among the personalities and to reduce symptoms. This treatment is often arduous and painful, and many crises tend to arise as a result of the personalities' actions and the patient's despair when dealing with traumatic memories. One or more periods of psychiatric hospitalization may be necessary to help some patients through difficult times and during the processing of particularly painful memories. Hypnosis is often used to help access the personalities, facilitate communication between them, and stabilize and interpret them. Hypnosis is also used to discuss traumatic memories and diffuse their impact. Eye movement desensitization and reprocessing (EMDR), applied cautiously, is a useful adjunct. EMDR tries to process traumatic memories and to replace negative thoughts about self that are associated with these memories with positive ones.

Generally, two or more psychotherapy sessions per week for 3 to >= 6 years are necessary to integrate the personalities or to achieve harmonious interaction among them that allows normal functioning without symptoms. Integration of the personalities is the most desirable outcome.

Psychotherapy has three main phases. In the first phase, the priority is safety, stabilization, and strengthening of the patient in anticipation of the difficult work of processing traumatic material and dealing with problematic personalities. The personality system is explored and mapped to plan the remainder of the treatment. In the second phase, the patient is helped to process the painful episodes of his past and to mourn the losses and other negative consequences of the trauma. As the reasons for the patient's remaining dissociations are addressed, therapy can move to the final phase, in which the patient's selves and relationships and social functioning can be reconnected, integrated, and rehabilitated. Some integration occurs spontaneously, but much must be encouraged by conversing with and arranging the unification of the personalities or must be facilitated with imagery and hypnotic suggestion. After integration, patients continue treatment to deal with some issues that have not been resolved. After postintegration treatment appears complete, visits to the therapist are tapered but are rarely completely terminated. Patients come to think of the psychiatrist as someone who can help them deal with psychologic issues, just as they periodically need assistance from a primary care physician.

Source: Sara Lambert

The average number of alter selves within a multiple system is thirteen, but some multiples have many times more than that. A few years ago, those with twenty-plus selves were known as "super-multiples". These days, however, therapists are being graced with the presence of more of their clients' selves. The number now required to be considered "extra" in the multiple stakes is 100-plus, and it is know by the more clinical term "poly-fragmented MPD(DID)."

This increase is probably more a reflection of increasing knowledge about MPD than of multiples actually becoming more split. Pioneer MPD therapists were not as skilled as they are today in recognizing switching and other dissociative phenomena. Furthermore, MPD has been seen for most of this century as a rare and bizarre psychiatric illness and clinicians have tried to get rid of alter selves and cure the disturbance. These days, multiplicity is generally recognized as a natural, creative defense against extreme trauma, and this enables therapists to honor the multiple system and allow it to unfold completely. Consequently, therapists are going beneath the top layer of selves to find huge systems in some clients. In addition to their size, these poly-fragmented systems are more intricate than standard MPD in terms of structure and in their greater degree of sequestration of information.

Many multiple systems have layers of selves and memory, but poly-fragmented systems take this to the extreme. Layering is where, beneath one self or group of selves, lies another group, and beneath that another, and so on. The sub-layers may lie dormant until the issues of the above layer have been resolved.

Usually, this layering has to do with organization of traumatic material. For poly-fragmented systems, however, there may also be layering for the purpose of self-preservation. For example, a multiple may have a self called Jane, and beneath her are other, identical, Janes, who declare they are the same person, and yet are secretly independent. This creates the same kind of effect as those trick mirrors in old adventure movies, where the hero is reflected repeatedly inside the mirror and the baddie doesn't know who the real target is. Similarly, layers of identical selves can act as decoys and, even if one or many Janes are destroyed (by the abusers or the therapist), Jane still exists within.

Poly-fragmented systems also have complex group formations. Often the members of one group know about each other but are unaware of the existence of other groups. For example, a multiple may have a group of selves who suffered incest, another group abused by a cult, another who were bullied at school, and another who go about the daily life with no memory of abuse. When a member of one group is "out", the members of the other groups lie dormant. In this way, a multiple can be in therapy for years, working on incest issues, and then suddenly begin getting memories of other abuse, of which she previously had no knowledge, as a different internal group becomes active.

Poly-fragmented systems also contain sub-systems, where some alter selves are a result of splitting off from another self, who was split from the original self - in other words, the alter self of a multiple may herself be multiple. So Anne may have a shy and traumatized teenager self called Petra, who herself has alter selves Poppy (who expresses Petra's carefree side) and Patrick (who cries the tears Petra never dares to show).

Additionally, the general fragmentation of information in these systems is greater. Various selves each have a small piece of one incident, whereas in standard MPD one self experienced the entire incident. So when a child is beaten by her father, one alter self takes the beating against her body, another feels the pain, another cries, another loves her father, another hates him, and another watches dispassionately, recording the information. Because the picture is broken into so many small pieces, regaining complete awareness of what happened is very difficult, even impossible. Often, the best the poly-fragmented multiple can achieve is knowing that, at some time in her past, she felt the pain of a fist smashing into her body, even though she does not know where, when or how. Fortunately, having the complete picture is not necessary for healing.

Poly-fragmented MPD has been strongly linked to ritual abuse. This is because ritual cults practice extreme, mind-boggling abuse purposefully designed to shatter the self. It is also because many cults are aware of the dissociative process and deliberately invoke it in children by way of hypnosis, drugging, over stimulation and/or sensory deprivation. They then create cult-loyal selves in the children and secure them, using specific codes and triggers, from the children's conscious awareness. For example, Anne may have a cult-loyal alter who only comes out when she hears a certain word connected with a certain sequence of tones. As these are never part of Anne's daily life, and as she automatically switches into the cult-loyal alter when she hears them, she stays ignorant of the fact that this alter is within her. As she grows up, however, breaking away from the cult influence and beginning therapy, the security codes start to weaken. They are not being reinforced by the cult and, at the same time, face pressure from Anne's growing self-awareness. It is important to always remember that, even though these alters were triggered and molded by the cult, they are the creation of the survivor. They belong to her, not the cult, and ultimately it is she who has sovereignty over them.

Poly-fragmentation can be a daunting picture for therapist and client alike. They may never be able to map the intertwined relationships or get to know all the alters. But this doesn't mean treatment is impossible. Although poly-fragmented systems seem chaotic and hopelessly dense, they are in fact the same mechanism as standard MPD. Therefore, they can be treated in the same way. Therapists report that multiples with large complex systems integrate with the same success as those with only a handful of selves. Most poly-fragmented systems comprise mainly fragments, rather than fully-developed "personalities", and these are easier and less painful to integrate. The most common method for bringing together a complex system is to integrate groups into one self who stands as a representative for the group issues, then integrate the various selves into one single person.

Copyright © Sara Lambert
Originally published in Team Spirit
Reprinted With Permission