Investigating Cognitive Inhibition in Dissociative Identity Disorder Compared to Depression,Posttraumatic Stress Disorder and Psychosis

ABSTRACT

Cognitive inhibition refers to the mental capacity to suppress distracting stimuli that compete with target stimuli for processing resources. Using neutral word stimuli in a flanker task, a recent study suggested that dissociative identity disorder (DID) is characterized by weakened cognitive inhibitory functioning (Dorahy, Irwin, & Middleton, 2002). The current study used single digit stimuli in the flanker task and tested cognitive inhibitory ability in samples with DID, depression, posttraumatic stress disorder and psychosis. The DID, depressed and PTSD groups displayed no evidence of weakened cognitive inhibitory functioning. Consistent with previous research, however, the psychosis sample displayed a reduced capacity to engage in cognitive inhibition. Cognitive inhibitory ability was not related to measures of dissociation, childhood traumatic experience or schizotypy. Results are discussed in terms of the positive symptoms of schizophrenia and the nature of stimuli used in the flanker task.     

SCL-90-R Norms for Dissociative Identity Disorder

ABSTRACT

Norms for dissociative identity disorder (DID) have been provided for a variety of structured interviews, self-report measures and computer-scored instruments. The SCL-90-R is a widely used self-report measure of general psychopathology, but prior to this report norms for DID were not available. The authors provide scores on the SCL-90-R for 101 participants with DID at baseline, and for 36 of the participants on two-year follow-up.     

Assessment of Genuine and Simulated Dissociative Identity Disorder on the Structured Interview of Reported Symptoms

ABSTRACT

Little is known about how to detect malingered dissociative identity disorder (DID). This study presents preliminary data from an ongoing study about the performance of DID patients on the Structured Interview of Reported Symptoms (SIRS, Rogers, Bagby, & Dickens, 1992), considered to be a “gold standard” structured interview in forensic psychology to detect feigning of psychological symptoms. Test responses from 20 dissociative identity disorder (DID) patients are compared to those of 43 well informed and motivated DID simulators. Both the simulators and DID patients endorsed such a high number of symptoms that their average overall scores would typically be interpreted as indicative of feigning. The simulators' mean scores were significantly higher than those of the DID patients on only four out of 13 scales. These results provide preliminary evidence that well informed and motivated simulators are able to fairly successfully simulate DID patients and avoid detection on the SIRS. Furthermore, many DID patients may be at risk for being inaccurately labeled as feigning on the SIRS.     

Discriminating Dissociative Identity Disorder from Schizophrenia and Feigned Dissociation on Psychological Tests and Structured Interview

ABSTRACT

Objective: The purpose of this study was to evaluate the relative efficacy of a number of psychological tests and interviews in discriminating dissociative identity disorder (DID) from feigned dissociation and schizophrenia.

Method: Three measures of dissociation (SCID-D, DES, SDQ-5) two personality measures (MMPI-2, Millon-III) and a brief measure of hypnotic susceptibility (Spiegel & Spiegel's Eye-Roll Sign) were assessed for their ability to differentiate these diagnostic groups.

Results: Results indicate that the SCID-D was clearly the most efficacious instrument in discriminating DID from schizophrenia and from feigned dissociation. The DES-Taxon and the SDQ-5 were adequate in screening pathological dissociation from schizophrenia but were less discriminative of feigned dissociation. The commonly used personality inventories were unable to detect feigned dissociation and the DID group tended to have higher elevations on scales measuring psychotic symptoms than did the schizophrenic group. The Eye-Roll Sign discriminated feigned dissociation from those with dissociative disorders.

Conclusions: Structured interviews such as the SCID-D, although resource consuming, are essential in comprehensive assessment of dissociative disorders. Comprehensive assessment of psychotic disorders should include some measure of dissociation.     

Developmental Needs Meeting Strategy: A New Treatment Approach Applied to Dissociative Identity Disorder

ABSTRACT

This article describes the use of the Developmental Needs Meeting Strategy (DNMS) for the treatment of dissociative identity disorder (DID). The DNMS is an ego state therapy which guides a client's own internal resources to meet developmental needs that were not met in childhood. After 17 months of DNMS treatment, a client with DID reported a near total elimination in frequency and severity of symptoms of depression, anxiety and suicidal thoughts, her Trauma Symptom Inventory scores indicated no trauma-related symptoms, and her Multidimensional Inventory of Dissociation scores indicated she no longer met the diagnostic criteria for DID. She was functioning well without any medication. Further research concerning this treatment strategy is warranted.     

Memory Fragmentation in Dissociative Identity Disorder

ABSTRACT

This study examined the quality of self-reported memories of traumatic experiences in participants with dissociative identity disorder (DID) and compared them with their memories of non-traumatic, but emotionally significant life experiences. Systematic interview data were gathered from 30 DID patients in The Netherlands. All participants reported a history of severe childhood abuse; 93.3% reported some period of amnesia for the index traumatic event, and 33.3% reported periods of amnesia for significant non-traumatic childhood experiences. All participants who had been amnestic for their trauma reported that their memories were initially retrieved in the form of somatosensory flashbacks. This suggests that, like PTSD patients, DID patients at least initially recall their trauma not as a narrative, but as somatosensory re-experiencing. Surprisingly, however, DID participants also recalled emotionally charged non-traumatic life events with significant somatosensory components, a phenomenon that has not been previously reported. This finding raises important issues regarding basic memory processing abnormalities in DID patients.     

Cognitive Inhibition in Dissociative Identity Disorder (DID): Developing an Understanding of Working Memory Function in DID

ABSTRACT

The current study examined cognitive inhibition, a mechanism of working memory, in dissociative identity disorder (DID). A negative priming procedure was used to assess inhibitory functioning in DID patients, as well as in a general population sample and a psychiatric comparison sample. Results from the first study show a significant interaction between group and experimental condition; the general population sample showed an independently non-significant trend towards negative priming while the two psychiatric groups showed no evidence of negative priming. Using different stimuli and a new priming procedure, Study 2 essentially replicated the findings of Study 1 with the control sample displaying significant negative priming and the two psychiatric samples producing no negative priming. High dissociativity was significantly related to reduced negative priming in Study 2. Findings suggest a relationship between DID and weakened inhibitory functioning and are discussed with reference to the negative priming and dissociation literatures.     

Dissociative Identity Disorder Among Adolescents: Prevalence in a University Psychiatric Outpatient Unit

The aim of this study was to determine the prevalence of dissociative identity disorder (DID) and other dissociative disorders among adolescent psychiatric outpatients. A total of 116 consecutive outpatients between 11 and 17 years of age who were admitted to the child and adolescent psychiatry clinic of a university hospital for the 1st time were evaluated using the Adolescent Dissociative Experiences Scale, adolescent version of the Child Symptom Inventory-4, Childhood Trauma Questionnaire, and McMaster Family Assessment Device. All patients were invited for an interview with the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) administered by 2 senior psychiatrists in a blind fashion. There was excellent interrater reliability between the 2 clinicians on SCID-D diagnoses and scores. Among 73 participants, 33 (45.2%) had a dissociative disorder: 12 (16.4%) had DID, and 21 (28.8%) had dissociative disorder not otherwise specified. There was no difference in gender distribution, childhood trauma, or family dysfunction scores between the dissociative and nondissociative groups. Childhood emotional abuse and family dysfunction correlated with self-reported dissociation. Of the dissociative adolescents, 93.9% had an additional psychiatric disorder. Among them, only separation anxiety disorder was significantly more prevalent than in controls. Although originally designed for adults, the SCID-D is promising for diagnosing dissociative disorders in adolescents, its modest congruence with self-rated dissociation and lack of relationship between diagnosis and childhood trauma and family dysfunction suggest that the prevalence rates obtained with this instrument originally designed for adults must be replicated. The introduction of diagnostic criteria for adolescent DID in revised versions of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, would refine the assessment of dissociative disorders in this age group.     

Comparing the symptoms and mechanisms of “dissociation” in dissociative identity disorder and borderline personality disorder

A total of 75 patients were diagnosed with the Structured Clinical Interview for DSM–IV Dissociative Disorders–Revised as having dissociative identity disorder (DID), and 100 patients were diagnosed with the Structured Interview for DSM–IV Personality as having borderline personality disorder (BPD). Both groups were administered the Multidimensional Inventory of Dissociation (MID). DID patients had significantly higher MID scores than BPD patients, different distributions of MID scores, and different MID subscale profiles in 3 ranges of MID scores (0–15, 15–30, 30–45). The core MID symptoms—exhibited at all ranges of MID scores—for DID patients (the presence of alters, identity confusion, and memory problems) and BPD patients (flashbacks, identity confusion, and memory problems) were ostensibly similar but were considered to be mostly produced by different underlying processes. Multiple regression analyses showed that the core MID symptoms of DID patients had different predictors than did the core MID symptoms of BPD patients. Alter identities seemed to generate most—but not all—dissociative phenomena in DID patients, whereas only the 24% highest scoring BPD patients (MID ≥45) seemed to manifest alter-driven dissociative experiences. Most BPD dissociative experiences appeared to be due to 5 other mechanisms: (a) BPD-specific, stress-driven, rapid shifts of self-state; (b and c) nondefensive disruptions of the framework of perceptual organization with or without an accompanying BPD-specific, dissociation-like disintegration of affective/neurocognitive functioning; (d) a defensive distancing or detachment from distress (i.e., simple depersonalization); and (e) Allen, Console, and Lewis’s (1999) severe absorptive detachment.     

Why the Diagnostic Criteria for Dissociative Identity Disorder Should Be Changed

Abstract

This paper examines the psy chi at ricdiagnosis of dissociative identity disorder (DID)inlightofthedevelopmentsinpsychi at ricclassification that have guided the last four re vi sions of the Diagnostic and Sta tis ti calMan ualforMen talDis or ders (DSM) (Amer i can Psychiatric Association, 1980, 1987, 1994, 2000). The author argues that multiple per son al ity 's pas sage from DSM-III, through DSM-III-R, to its current form as DID in DSM-IV-TR has left the di ag no sis out of step with the state of the art of psy chi atric classification. Ten dis advantages of the Diagnostic and Sta tis ti calMan ual of Men talDis or ders, Fourth Edi tion- Text Revision (DSM-IV-TR) cri te riafor DID are iden ti fied. The DSM-IV-TR cri te ria for DID: (1) are out of step with the state of the art of psy chi at ric clas si fi cation; (2) are not based on taxometric anal y sis of the symp toms of DID; (3) in correctly im ply that DID is a closed con cept; (4) have poor con tent valid ity; (5) throw away im portantinformation; (6) dis courage taxonomic research; (7) have poor reliability and cause frequent misdiagnoses; (8) are not “user-friendly”; (9) are un nee es sar ily con tro versial; and (10) along with pre vi ous ver sions of the DSM, have pro duced an artifactually low base-rate of DID for the past 20 years. In an effort to remedy these disadvantages, a re liable, user-friendly, polythetic set of diagnostic criteria for “Major Dissociative Disorder” is proposed for DSM-V. Using these polythetic cri te ria, the dissociative dis or ders (presently con cep tu al ized as Dissociative Am ne sia, Dissociative Fugue, DID, Depersonalization Disorder, and Dissociative Disorder Not Otherwise Spec ified) can be re struc tured into an eas ily un der stood and more re liable set of di ag nos tic en ti ties. This al ter nate nosology of the dissociative disorders consists of Sim pie Dissociative Dis or der (with at least three). sub types), Gen er al ized Dissociative Dis or der, Major Dissociative Disorder (with two subtypes), and Dissociative Disorder Not Otherwise Specified.     

The Treatment of Dissociative Identity Disorder with Cognitive Analytic Therapy: Experimental Evidence of Sudden Gains

ABSTRACT

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with DID. The methodology employed an A/B single case experimental design with six-months continuous follow-up in seven experimental measures. A and B represent the assessment of seven dissociative experimental variables under two conditions: baseline (A) and treatment (B). Treatment consisted of 24 sessions of CAT with four follow-up sessions, which is standard within the CAT model for personality disorder patients. A battery of measures of general psychological functioning was also completed at assessment, termination, and follow-up. During treatment the intensity of a range of dissociative symptoms was observed to be reduced, with sudden gains evident due to specific CAT interventions in specific dissociative symptoms. The long-term effectiveness of the intervention was established by the illustration of either continued stability or continued improvement in experimental variables across the follow-up period. Analysis of the general measures illustrates clinically significant change across a variety of robust psychometric measures. The study illustrates the utility of single-case approaches with dissociative disorders and the potential for utilizing CAT generally with such presentations.     

Differential Diagnosis between Anomalous Experiences and Dissociation Disorder Using the Dissociative Disorders Interview Schedule (DDIS)

Background. It is important to understand the most diverse cultural aspects related to religiosity. Scientifically, it is important to understand religious manifestations and their relation to health, and to differentiate them from psychopathological manifestations. Objective. To evaluate the mental health of a group of mediums and compare it with that of a control group from the same religious context who do not manifest mediumship, using the Dissociative Disorders Interview Schedule (DDIS). Methods. This was a cross-sectional study, evaluating 47 mediums (Group 1) and comparing them with 22 non-medium volunteers from the same religious context (Group 2) using the DDIS questionnaire. All results were matched with historical data from patients with dissociative identity disorder (DID) who answered the DDIS. Results. Scores obtained from the DDIS were similar in both groups. The number of positive symptoms was comparable in a wide range of analyzed areas, involving but not being restricted to somatization disorder, major depressive episode, borderline personality disorder, extrasensory/paranormal experiences, physical/sexual abuse and five dissociative disorders. There were considerable differences when we compared these results with historical data from patients with DID. Conclusion. In agreement with the extant literature, these results showed that mediumship can be considered a non-pathological form of dissociative phenomena.     

Evidence for phase-based psychotherapy as a treatment for dissociative identity disorder comorbid with major depressive disorder and alcohol dependence

We report on the treatment and successful outcome of a 58-year-old Native American male with a history of complex trauma presenting with dissociative identity disorder (DID) and major depressive disorder. The treatment included a trauma-informed phase-based psychotherapy as recommended by the International Society for the Study of Trauma and Dissociation for treating DID. We assessed symptoms at baseline and at three additional time points over the course of 14 months. We utilized the Reliable Change Index to examine statistically significant change in symptoms over the course of treatment. Significant symptom improvements were realized posttreatment across all measured domains of functioning, including dissociative symptoms, alcohol abuse, depression, anxiety, and emotion regulation skills. Moreover, the client no longer met criteria for DID, major depressive disorder, or alcohol abuse. Results are discussed in terms of the effectiveness of trauma-focused, phase-based treatment for DID for cases of complex trauma with comorbid disorders.     

The Detection of Dissociative Identity Disorder by Northern Irish Clinical Psychologists and Psychiatrists: A Clinical Vignettes Study

ABSTRACT

A sample of Northern Irish clinical psychologists (N = 27) and psychiatrists (N = 29) completed three clinical vignettes designed to assess the detection of dissociative identity disorder. Data suggested that psychiatrists and clinical psychologists were better able to detect dissociative identity disorder when discriminating and characteristic symptoms were present. However, the majority of clinicians still failed to diagnose dissociative identity disorder as the most likely condition in a clear-cut case.     

Drug-Induced Dissociative States of a Sleep Terror Patient

ABSTRACT

Frightening negative hallucinations as a side effect of fencamfamine (a central nervous system stimulant), aggressive behavior and amnesia due to interactions between metoprolol (a beta adrenergic blocking agent) and alcohol, chronic and severe sleep terrors and conversion disorder are described in a middle-aged man with high social status and no personality disorder. Rare mental side effects should draw attention to the possibility of a latent dissociative disorder. The relationship between beta-blocker induced disturbing dreams, dissociative disorders and sleep terrors is discussed.     

Ganser Syndrome,Organic Dementia and Hypnosis–A Case Study

ABSTRACT

Ganser Syndrome is a rare and controversial disorder, a form of pseudodementia, which has often been associated with prison environments. It is classified under dissociative disorder, not otherwise specified in the DSM-IV, and as a dissociative disorder with its own code in the ICD-10. In the literature, it has also been described as a psychotic illness, a factitious disorder, a histrionic disorder, and an organic illness. Despite special interest in dissociative disorders, we have diagnosed only one case of Ganser Syndrome during six years in Mental Hospital for Prisoners (that houses) with about 300 treatment periods per year of 3,000 male prisoners from a base population of five million people. While dissociative symptoms were clear, the patient also suffered from progressing organic dementia. Antipsychotic medication had no beneficial effect, but hypnosis clearly ameliorated the patient's symptoms. We conclude that Ganser Syndrome is rare, and may co-occur with organic dementia. The positive effect of hypnosis, apparently here described for the first time, may confirm the dissociative nature of the syndrome.     

Ten-Year Follow-Up Study of Patients with Dissociative Identity Disorder

Abstract

Lit tie fol low-up data has been pub lished on in di vid u als with dissociative iden tity dis or der (DID). In this study, DID was di agnosed in 25 pa tients by two sea soned dissociative dis or der clinician/researchers be ginning in 1986. The initial evaluationin cludedacomprehensive med i cal and psy chi at ric eval u a tion and Min ne sota Multiphasic Per sonal ity In ven tory (MMPI). A ten-year fol low-up eval u a tion in eluded the Dissociative Experi ences Scale, Ci vil ian Mis sis sippi PTSD Scale, Beck Inventory for De pres sion, Life Ex pe ri ences Sur vey, the MMPI Hypochondriasis scale, and a dissociative dis or ders fol low-up ques tion naire. The pa tients were also asked to write a nar ra tive about their life and treatment since intake. Twelve patients provided follow-up data. Of these twelve, six ul ti mately achieved full in te gra tion of their per son al ity states, although two of them subsequently dissociated into alter personality states again. The two teen-aged pa tients achieved full in te gra tion within two years, while the older pa tients took con sid er ably Ion ger. Of the patients who elected to con tinue in treat ment for their dissociative dis or der and who con tinued to dis so ci ate into al ter per son al ity states, all have experienced major symptomatic improvement in both dissociative and non-dissociative symptomatology. Of the two therapy dropouts, both con tinue to have dissociative symp toms at fol low-up. We con elude that treatmentforDIDfollowingtreatmentguidelinespromulgated by the International Societyforthe Study of Dis so ciation brings about symptomatic im prove merit in both dissociative and non-dissociative symp toms. Ig noring symp toms of dis so ci a tion, as has been ad vo cated by some, resuits in no im prove ment.     

Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative?

Proponents of the iatrogenic model of the etiology of dissociative identity disorder (DID) have expressed concern that treatment focused on direct engagement and interaction with dissociated self-states harms DID patients. However, empirical data have shown that this type of DID treatment is beneficial. Analyzing data from the prospective Treatment of Patients With Dissociative Disorders (TOP DD) Study, we test empirically whether DID treatment is associated with clinically adverse manifestations of dissociated self-states: acting so differently that one feels like different people, hearing voices, and dissociative amnesia. We show that, over the course of the study, there were significant decreases in feeling like different people and hearing voices. These results indicate that this form of DID treatment does not lead to symptomatic worsening in these dimensions, as predicted by the iatrogenic model. Indeed, treatment provided by TOP DD therapists reduced, rather than increased, the extent to which patients experienced manifestations of pathological dissociation. Because severe symptomatology and impairment are associated with DID, iatrogenic harm may come from depriving DID patients of treatment that targets DID symptomatology.     

Development of the Hebrew-Multidimensional Inventory of Dissociation (H-MID): A Valid and Reliable Measure of Pathological Dissociation

ABSTRACT

The Multidimensional Inventory of Dissociation (MID; Dell, 2004b) has 168 dissociation items and 50 validity items. The MID assesses 14 major facets of dissociation, 23 symptoms of dissociation, and has 5 validity scales. The MID operationalizes (a) the subjective/phenomenological domain of dissociation, and (b) 23 hypothesized symptoms of dissociative identity disorder (DID). This article describes the development of a Hebrew version of the MID (H-MID). In a sample of clinical and nonclinical research participants, the H-MID had strong internal consistency, temporal stability, and strong structural, convergent, discriminant, and construct validity. In addition, mean H-MID scores demonstrated incremental validity over the Hebrew Dissociative Experiences Scale (H-DES) by predicting an additional 17% of the variance in weighted trauma scores on the Traumatic Experiences Questionnaire (TEQ). Factor analysis of the H-MID extracted a single factor: dissociation. Both the MID and the subjective/phenomenological concept of pathological dissociation appear to have applicability not only in North America, but also in a heterogeneous Middle Eastern culture.     

Psychotherapy of an Adolescent with Dissociative Identity Disorder

Abstract

A female adolescent with dissociative identity disorder was assessed using structured interviews and the Rorschach test before and after one year of individual psychotherapy. In addition to improvement in several comorbid psychiatric disorders, according to the structured evaluation, criteria for neither dissociative identity disorder nor borderline personality disorder were met at the second evaluation. The main differences on the Rorschach assessments before and after integration were in the development of form-dominated color and human movement responses and a diminution in the externally focused coping style. The differences were interpreted as improvement in aggressiveness, impulsivity, anxiety, and better identification with social environment. This case study suggests that the Rorschach test can be used to evaluate the change of patients with dissociative identity disorder in psychotherapy.