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Trauma Treatment (MPD/DID)

A few definitions:

MPD - Multiple Personality Disorder
This was the term used in the preceding diagnostic manual (DSM-III).

DID - Dissociative Identity Disorder
This is the term used in the current diagnostic manual (DSM-IV).

There is considerable debate among professionals about what accurately defines the condition.

dissociation - rather than "associating" separate pieces into a unified whole, dissociation simply refers to splitting off some aspect of the person's awareness. Dissociation is a very normal phenomenon, occurring everyday for ordinary people. Look at a child's face when he/she is watching TV (wives tell me that many husbands look this way too!) They tend to sit rather motionless with a flat, glazed expression on their face. They have "dissociated" their awareness of other things going on around them. This kind of dissociation is referred to in the jargon as "normal" dissociation.

Dissociation can help a person concentrate. It can help a person ignore pain. (Just ask anyone who suddenly becomes aware of a full bladder at halftime!) In traumatic situations, it can help a person focus on what has to be done to survive. Dissociation can become a problem, however, when it has to be used repeatedly to deal with recurring trauma, such as childhood emotional, physical or sexual abuse. In such cases it can lead to the development of what is called an "alter" personality. When this happens, therapists speak of "pathological" dissociation. While it is an incredible coping strategy that I suspect helps keep such a child from going psychotic, it usually creates problems later when the child is no longer living in an abusive environment.  

alter (personality) - Current thinking has it that all children begin life with a very fluid sense of who they are. The delightful main character in the cartoon strip Calvin and Hobbes enjoys fantasizing about being other people or animals. Over time, most children weave together aspects of their play into a unified sense of who they are -- their personality. As adults we may play several roles (e.g., spouse, parent, colleague, tennis player), but we have a unified memory across time. When I am at the office being a psychologist I can remember what I did the night before as a parent.

In the face of repeat trauma, some children begin to formalize separate roles (alter personalities.) For example, a child may "split" into three selves (e.g., the child who goes to school, the child who deals with a sexually abusive relative, and the child who plays with family and friends). An important, amazingly adaptive part of this separation is the compartmentalization of memories. Alter personalities who hold memories of abuse keep them hidden from alters who deal with normal day-to-day activities. For those who deal with computers, think of it as being like a small group of  people on a network who each have only limited access to certain files stored on the mainframe.

core/birth personality - In the metaphor above, the "system administrator" is the person who has access to every file stored on the mainframe. The birth personality (or core) is thought to be the part of the child who organizes the system of alters. It is thought that only the birth personality can create an alter. 


Dissociative Disorders in the DSM-IV:

The Dissociative Disorders group of diagnoses includes:

  • Dissociative Amnesia
  • Dissociative Fugue
  • Dissociative Identity Disorder (DID). This is the new term for Multiple Personality Disorder (MPD).
  • Depersonalization Disorder
  • Dissociative Disorder Not Otherwise Specified (DDNOS)
There are 5 types of symptoms which can be present in the dissociative disorders:
  • Amnesia (I can't remember.)
  • Depersonalization (I don't feel real.)
  • Derealization (Things around me don't feel real.)
  • Identity Confusion - Associated features include mood changes, age regression/flashbacks, internal voices/dialogues
  • Identity Alteration (Significant shifts in self-perception.)
The diagnostic criteria for DID in the current manual (DSM-IV) are:
  • 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).
  • At least two of these identities or personality states recurrently take control of the personís behavior.
  • Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
  • 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.

The most common cause of DID, but not the only cause, is sexual abuse over an extended period of time beginning prior to the age of 7. In some cases, a single severe trauma can trigger the development of DID; for example, a child watching a parent being brutally murdered. If the trauma occurs much later than age 7, the way the child/teen copes with the trauma will be different. For example, major trauma which occurs to adults or teens may trigger Posttraumatic Stress Disorder (PTSD) such as occurs with rape victims, and was common among many Vietnam War soldiers. It is not necessary to identify the childhood trauma(s) to establish a diagnosis of DID. For treatment purposes, it usually becomes important to identify the traumatic event(s).


The experience of dissociation in DID:

When people refer to feeling "schizophrenic" because they feel like they have a "split personality", they are really referring to the experience of being DID, not schizophrenia. Schizophrenia involves a loss of contact with reality -- that is, being psychotic. DID does not typically involve a loss of contact with reality. Instead, it involves a careful partitioning of information and abilities. Over time, each "alter" (as in an "alternate personality", different from the original "birth" or "core" personality) further develops specific coping skills. As one DID patient described it, "I have several major characters, plus a number of bit players and extras." In order to deal with the intense emotions associated with being abused, the person discovers she can split off a part of herself to "hold" the memory of the event and the associated emotions. Thus one alter may hold the memories of a specific kind of abuse. Another alter may develop to handle the demands of school. A third may develop to protect younger alters and the birth personality from threatening situations. A fourth may be reserved for pure play activities.

The ability to partition off the traumatic events is what keeps the child from going crazy. This splitting off is what "dissociation" is all about. I suspect that those who are not able to do this are the ones who do become psychotic/schizophrenic in the face of such trauma, escaping from reality because reality is so impossible to deal with.

Dissociation by itself is very normal. Everyone dissociates in mild ways. Every mother who has watched a child or a husband watching TV has seen what dissociation can look like: the viewer has tuned out or dissociated from a part of what is going on around them Ė until halftime comes and they notice how full their bladders have become! Lamaze techniques involve a similar process of mild dissociation from the pain of the labor contractions. Used in this way, dissociation is a healthy coping strategy. 

The problem for adults who developed DID as children is that they misuse dissociation: they apply the strategy in situations where dissociation is not the best coping strategy. When an alter "comes out" to handle a stressful situation, the birth personality is often not aware of what happens in its absence: the alter deals with the situation and then goes back inside Ė leaving no post it note to explain, "While you were gone..." The birth personality often has no memory of what the alter did, or even of how much time is missing. This is what is referred to as an "amnestic barrier". The barrier was originally created to protect the birth personality from remembering the traumatic events. In later years it is used out of habit. As a result, while alters may have differing levels of awareness of other alters, the birth personality is, by definition, often unaware of their existence until the amnestic barrier begins to break down, typically in the personís late 20's or early 30's.

Adults (and children) with DID do not realize that their experience of the world is not shared by everyone else. For example, one of my patients was in college before she realized that other people could routinely remember what they did each day. She discovered this one Friday afternoon when, talking to a group of friends, one of them asked her what day it was. She answered, "Tuesday." She had no memory of Tuesday night, Wednesday or Thursday, and thus thought it was still Tuesday. She was amazed to discover that everyone standing there never had that problem.

Equally as puzzling is that many alters do not experience the passage of time. One alter may believe that it is still 1965, another may think it is 1972. 


Therapy for the adult (or child) who has a dissociative disorder:

Treatment involves teaching the birth personality how to cope with the situations that the alter personalities have developed the skills to handle. "Switching" from the birth personality to an alter occurs primarily when the birth personality feels unable to handle what is going on at the moment. When the birth personality is able to deal with the situation, switching will not take place because of stress. Switching may still occur because an alter wants time "out" to enjoy a preferred activity.

"Integration" of all the alter personalities into a unified whole used to be the final goal of treatment. There is now a difference of opinion on this point among professionals. Some view a kind of "peaceful co-existence" as a very acceptable alternative. In this scenario, the birth personality has developed the ability to remain "co-conscious" when an alter is "out". One might think of it as the difference between being in the driverís seat, sitting in the passenger seat, sitting in the back seat, or being locked in the trunk. Many others still see full integration as the best resolution. 

As recently as the 1970's DID was thought to be very rare. Since then the condition has been diagnosed much more frequently as therapists have learned how to recognize the symptoms. At least one Atlanta area psychiatric facility has an entire DID unit earlier this decade (before managed care!) Patients were typically in therapy for at least 7 years before the diagnosis was made. DID patients typically qualify for a variety of other diagnoses including Major Depression, Generalized Anxiety Disorder, and any of several Personality Disorders. The average age when the patient is first diagnosed with DID is in their late 20's or early 30's. More recently, the diagnosis is being made at earlier ages as more therapists have learned how to recognize the disorder. The treatment of DID in children and teens is much easier because the alters have not had as much time developing their own identities. By the time the patient is an adult, alters think integrating means they will literally have to die.

Many therapists who work with DID patients are careful to explain that the birth personality will be held accountable for the actions of all the alters. "I didnít know what I (i.e., one of the alters) was doing" is not an acceptable defense. The alters are taught early on in therapy that the birth personality will be held accountable for anything and everything that they do as alters. (This is not an easy point to get across since the alters initially do not think they share the body with anyone else. They each believe that every other alter and the birth personality have their own bodies.)


Hypnosis and memories in the treatment of DID

The last decade saw an incredible uproar in the field as different camps erupted about (a) whether it is possible to "repress" memories in the way that seems to occur in individuals diagnosed with a dissociative disorder (but note that repression and dissociation are believed to be different neurological processes; as such, DID is not about repression of memories); and (b) under what conditions, if any, it is possible to create false memories. While the debate continues, some excellent research on memory has emerged. For purposes of this discussion, the research has begun to make important distinctions between normal memory and traumatic memory. Some excellent studies have demonstrated that it is indeed possible for someone to completely dissociate a traumatic memory for years, only to have it re-emerge at a later time. Other studies have also demonstrated that it is possible to create false memories, though not as easily as some have feared. The message for therapists who work with trauma clients is to get good training to reduce the risks.

There are five kinds of memory which I find helpful to describe (drawn from the work by Lenore Terr, MD):

  1. True memory - An accurate recall of a real event

  2. True memory with false detail - in remembering a real event, the person may give one or more details which are not accurate. For example, a witness to a car accident may misremember the color of one of the cars. 
  3. In one famous case Dr. Terr researched, a man thought his entire home town knew about his childhood rape from newspaper reports of the court case. They didn't; his name had never been released as having been the victim. He also misremembered the time of year when it occurred and his actual age at the time. Dr. Terr found news reports which verified the correct age and time of year.

    Another more common example occurs when a parent misremembers an event involving one child when it actually happened to another child in the family. The event was a real event, but it happened to a different child.

  4. Absolutely false memory - The event which the person is describing never took place.  It is this kind of "memory" which some therapists have been accused of "implanting" because of leading questioning  or the use of suggestive hypnosis. 

  5. Lying - Just what it sounds like. The person knows the information is false but presents it as if it is true.

  6. False memory with true details -  For example, a person describes a rock concert he believes he once attended. The rock concert really took place and the man has accurate memories of the concert (perhaps from having seen film footage of the event), but he didn't actually attend it.

The concept of "state dependent memory" is a useful one to understand. Sometimes a person's memory of an event is stored in the brain in a way that it is indexed according to certain components of the original event. At a later time the memory may come into awareness because it is "triggered" by something which is linked to the original memory. For example, a certain after shave lotion used to trigger abuse memories for one of my clients. Another client used to be triggered if she sat at the desk in her bedroom with her back to the door. (She stopped getting anxious after she moved the desk to another wall.) For a more detailed explanation of how this works, read the article French Fries and Food Fights that contains a fascinating example of how easily such a state dependent memory can be triggered.

Because people tend to be more suggestible when in trance (hypnosis), and because people with a history of serious childhood trauma tend to be more suggestible than average, the rule of thumb is that therapists do not use hypnosis to help such a client attempt to remember childhood memories. This is particularly true in legal cases, because many courts will exclude testimony which has been “hypnotically refreshed.” Hypnosis has many excellent clinical applications, but retrieving memories of traumatic events is not one of them as a general rule. My experience has been that memories surface on their own in therapy when the client is ready to deal with them. There are other, non-hypnotic ways to test for memories of this type that are much safer. If this applies to you, ask me about how I approach this with clients.