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.     

Dissociation and Schizophrenia

Abstract

Comorbidity of psychotic and dissociative disorders often is not reported. This 38 year-old female with a history of schizophrenic symptoms displayed evidence of dissociative identity disorder (DID) during admission to an inpatient psychiatric unit. The case illustrates how the presence of a dissociative disorder may influence the presentation of a co-morbid psychosis. The historical association and differential diagnosis between DID and schizophrenia is described. Implications of various treatment approaches for patients exhibiting dissociation in the context of psychosis are discussed.     

Dissociation and psychosis in dissociative identity disorder and schizophrenia

Dissociative symptoms, first-rank symptoms of schizophrenia, and delusions were assessed in 40 schizophrenia patients and 40 dissociative identity disorder (DID) patients with the Multidimensional Inventory of Dissociation (MID). Schizophrenia patients were diagnosed with the Structured Clinical Interview for the DSM-IV Axis I Disorders; DID patients were diagnosed with the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised. DID patients obtained significantly (a) higher dissociation scores; (b) higher passive-influence scores (first-rank symptoms); and (c) higher scores on scales that measure child voices, angry voices, persecutory voices, voices arguing, and voices commenting. Schizophrenia patients obtained significantly higher delusion scores than did DID patients. What is odd is that the dissociation scores of schizophrenia patients were unrelated to their reports of childhood maltreatment. Multiple regression analyses indicated that 81% of the variance in DID patients' dissociation scores was predicted by the MID's Ego-Alien Experiences Scale, whereas 92% of the variance in schizophrenia patients' dissociation scores was predicted by the MID's Voices Scale. We propose that schizophrenia patients' responses to the MID do not index the same pathology as do the responses of DID patients. We argue that neither phenomenological definitions of dissociation nor the current generation of dissociation instruments (which are uniformly phenomenological in nature) can distinguish between the dissociative phenomena of DID and what we suspect are just the dissociation-like phenomena of schizophrenia.     

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.     

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.     

Inter-identity amnesia in dissociative identity disorder: a simulated memory impairment?

BACKGROUND: Although included in the current edition of the DSM, there does not seem to be consensus among mental health professionals regarding the diagnostic status and scientific validity of dissociative identity disorder (DID). This study was aimed at the detection of simulation of inter-identity amnesia in DID. METHOD: A sample of 22 DID patients was included, together with a matched control sample of subjects instructed to simulate inter-identity amnesia, a guessor group that had no knowledge of the stimulus material and a normal control group. A multiple-choice recognition test was included. The rate of incorrect answers was determined. Moreover, the specific simulation strategy used was examined by providing subjects with a range of choices that varied in extent of disagreement with the correct answer and determining whether plausible or implausible answer alternatives were selected. RESULTS: On the recognition test DID patients selected incorrect answers above chance like simulators. Patients thus seem to use their knowledge of the correct answer in determining their given answer. They were not characterized by a well-thought-out simulating behaviour style, as indicated by the differences in selection of specific answer alternatives found between patients and simulators. CONCLUSIONS: DID patients were found not to be characterized by an actual memory retrieval inability, in contrast to their subjective reports. Instead, it is suggested that DID may more accurately be considered a disorder characterized by meta-memory problems, holding incorrect beliefs about their own memory functioning.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Dissociation and Schizophrenia

ABSTRACT

The authors administered the Dissociative Experiences Scale (DES), the Dissociative Disorders Interview Schedule (DDIS), the Scale for the Assessment of Positive Symptoms, and the Scale for Assessment of Negative Symptoms to 60 participants with schizophrenia. Participants were divided into two groups: those with scores below 10 on the DES and no dissociative disorder on the DDIS; and those with scores above 25 on the DES and/or a dissociative disorder on the DDIS. The dissociative participants had more severe trauma histories, more comorbidity and higher scores for both positive and negative symptoms. The authors interpret their findings as evidence in support of a trauma-dissociation subgroup within schizophrenia.     

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.     

The responses of dissociative patients on the thematic apperception test.

This study compared the responses of dissociative inpatients and general inpatient psychiatric controls on the Thematic Apperception Test (TAT; Murray, 1943). We found the stories of dissociative participants to be characterized by a greater interpersonal distance and more trauma and dissociation responses than those of the controls. No significant differences were found regarding total number of emotional references, although references to positive emotions were almost nonexistent for the dissociative group. A post hoc analysis of the data found the testing behaviors of dissociative participants to be characterized by switching, trance states, intrainterview amnesias, and affectively loaded card rejections. Questions were raised regarding the relevancy of the findings to clinical practice and how they might explain some of the controversies surrounding the diagnosis of dissociative identity disorder (DID).     

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.     

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.     

Reliability and Validity of the Turkish Version of the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D): A Preliminary Study

A total of 34 consecutive patients with dissociative identity disorder or dissociative disorder not otherwise specified were evaluated using the Turkish version of the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D). They were compared with a matched control group composed of 34 patients who had a nondissociative psychiatric disorder. Interrater reliability was evaluated by 3 clinicians who assessed videotaped interviews conducted with 5 dissociative and 5 nondissociative patients. All subjects who were previously diagnosed by clinicians as having a dissociative disorder were identified as positive, and all subjects who were previously diagnosed as not having a dissociative disorder were identified as negative. The scores of the main symptom clusters and the total score of the SCID-D differentiated dissociative patients from the nondissociative group. There were strong correlations between the SCID-D and the Dissociative Experiences Scale total and subscale scores. These results are promising for the validity and reliability of the Turkish version of the SCID-D. However, as the present study was conducted on a predominantly female sample with very severe dissociation, these findings should not be generalized to male patients, to dissociative disorders other than dissociative identity disorder, or to broader clinical or nonclinical populations.     

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.