Running head: DID
Dissociative Identity Disorder: A Case Study
A Research Paper
Presented to
The Faculty of the Department of Psychology
East Carolina University
In Partial fulfillment
of the Requirements for the Degree of the Substance Abuse and Clinical Counseling program
by
Eric K. Mason
March 2008
Dissociative Identity Disorder: A Case Study
Introduction
In the following paper, I will present a young woman who I believe is suffering from Dissociative Identity Disorder (DID). In addition, I will give a description of DID, its etiology, and its epidemiology. Lastly, I will present information which I believe supports the diagnosis of DID.
DID is, perhaps, the most misunderstood and controversial of all mental disorders. It is both fascinating and tragic at the same time. Perhaps, no disorder has garnered more attention from the media or more disdain from the skeptics.
There is no denying that those with DID experience a myriad of symptoms, and have a very high rate of co-occurring mental disorders. Furthermore, one cannot easily refute that most people presenting with symptoms of DID have suffered physical and/or sexual abuse, as well as other traumatic experiences as children. Although it is generally believed that DID is a rare mental disorder, one study indicates that it has a lifetime prevalence of 1% in the general population (Millon, Blaney, & Davis, 1999).
The young woman described below exhibits many symptoms of DID. I believe she may have a history that would predispose her to develop DID. In addition, she has experienced factors known to precipitate the onset of DID.
The Client/Patient
The Client/Patient is an 18-year-old female from Germany. She has been living in the U.S. for the last three years. Her mother died four years ago (cause of death unknown). Client witnessed mother's death. Client's mother was never very involved in her life. She was raised by her grandmother. She has no prior history of mental illness or any other medical problems.
The client appeared under nourished at the time of the interview. Client fainted during the clinical interview when her hand was placed in cold water. Otherwise, she exhibited good physical strength for her size. Client had a pleasant disposition, is responsive, and seems oriented to time and place.
Client was brought in by her father and grandmother. Father and grandmother complained that client steals and lies, frequently. For example, father reported that she will take money from his pocket and then deny that she had done so. Father stated that client stole a pocketknife from her teacher. Client claimed that she did not steal it, but rather found it. Father and grandmother claimed that client steals money to buy candy from the store. Client will often assert that it was another little girl who actually bought the candy.
Client often behaves like a child much younger than 18. Father reported that client came to him stating that she wanted to be loved and be his baby like the other little girl. Client went on to say "I'm a good girl now, ain't I? I don't steal anymore, do I?" Father said she had a peculiar look on her face during this time. Father claimed that the client will change behaviors frequently. For example, client once ran away and claimed that she was whipped excessively at home. However, on other occasions, as stated above, client will seek out father's love and affection.
Although father claimed that she is not whipped excessively, he does admit to whipping her when she returned home after she ran away. I am not convinced that the client is not physically abused. Family did not seem to be very fond of client. For example, client’s grandmother called her "a terrible little liar."
Client is frequently interested in things that one would associate with a young child, not an 18-year-old. For example, she reported stealing money from teacher in order to buy candy, ice cream, and rollerskates. Client appeared more gullible than one would expect for an 18-year-old. For example, client stole items and called people "wicked" names when told to by a boy (15) who lives on her street.
During the interview the client talked about her interaction with the aforementioned boy and another girl (11). Client described how the boy tried to get the other girl to go into the bushes with him. Client said that she did not know what this meant, and that the other girl would not tell her. Client said that the boy will say bad names to her and try to get her to steal, but that he is nice to the other girl. Later in the interview, however, client talked about how the boy tries to get her to go out into the bushes with her (after having said that he never tried to get her to do that). Client also stated that the boy had knocked down the other girl and tried to take her clothes off (after having said that he was nice to her). Client went on to say that the other girl told her lots of bad names that that boy taught her (after having stated that the girl does not say bad words).
From the interview provided, I get the impression that the interviewer is having a conversation with two different people. It appears as though the client switches from herself to "the other girl," about whom she was talking. The other girl then appears to be talking about the "client." I believe this is why the girl contradicts herself, as described above. Furthermore, I believe this is why the client (18) buys candy, ice cream, and rollerskates (interests more characteristic of an 11-year-old) with the money she steals. This may also explain why she claims not to remember stealing certain items. It is my opinion that the client is suffering from Dissociative Identity Disorder (DID). The so-called other girl (11) is actually an alternate personality/identity.
Diagnosis
300.14 Dissociative Identity Disorder
Diagnostic Criteria:
- 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 person's 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 (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play (American Psychiatric Association, 2000).
Dissociative Identity Disorder (DID)
DID, formerly multiple personality disorder, is characterized by the presence of two more distinct personalities residing in an individual (American Psychiatric Association, 2000). “The quiet, careful guy at the lab who is a ‘wild man’ at parties may look to others like a multiple personality, but he sees these ways of being as different aspects of his identity and does not suffer from Dissociative identity disorder” (Maxmen & Ward, 1995). According to the DSM-IV-TR, DID "reflects a failure to integrate various aspects of identity, memory, and consciousness" (American Psychiatric Association, 2000).
The different personalities or identities may vary in age, sex, personal history, and temperament. They usually have different names, as well. The various identities may not have knowledge of one another. They may emerge (i.e., take control of the person) gradually or within seconds. When a new identity takes control, the person’s facial expression may change or rapid eye blinking may occur (American Psychiatric Association, 2000).
Those who have witnessed a person with DID alternate or transition between personalities may report that it is “spooky” or strange to witness, as the newly emerged identity may speak and walk differently. The person’s facial expression may change so dramatically, the person may become unrecognizable to those witnessing the “transformation.” For some, it is an unnerving experience to say the least (Maxmen & Ward, 1995).
People with DID experience frequent gaps in memory. They may disavow behavior witnessed by others. Psychosocial stresses may precipitate the onset of DID (American Psychiatric Association, 2000).
Individuals with DID often report a history of physical and/or sexual abuse (American Psychiatric Association, 2000). People with DID have learned to dissociate as a way to escape from a traumatic reality. Some argue that DID is a coping mechanism or simply a means of survival, as the trauma people with DID have experience is so psychologically and emotionally painful, it could easily lead to psychosis or suicide (Middleton, 2005). Even so, “untreated patients with DID have very high suicide rates, in the order of several thousandfold in excess of the American national average” (Middleton, 2005).
The abusers may deny or distort their abusive behavior, in an attempt to trivialize real abuse as proper punishment (Middleton, 2005). The psychological motivation of abusers time and again is
to evoke protectively in the child the unwanted negative images of the self—to make the abused one feel utterly helpless, humiliated, shamed, violated and abject—and to bring about a near annihilation of the true self of the abused (Middleton, 2005).
It is no wonder then that abuse leads to a damaged sense of self. Abuse perpetuated on children by a caregiver (as is usually the case) is especially traumatic. In order to maintain a bond with their abusive caregivers (as they remain dependent on the very people who abuse them), abused children may learn to block out or dissociate themselves from the abuse, as a means of coping with their emotionally and psychologically conflicting reality (Middleton, 2005).
Psychologically sound and healthy individuals may take the notion of selfhood for granted, but it is an essential aspect of healthy human functioning, without which one’s daily functioning would be severely hindered. Selfhood allows one to differentiate him- or herself from others and the environment. In other words, it serves as boundary between the self and the rest of the world. It serves as a guide for how one represents him- or herself to others and the environment, as well (Middleton, 2005).
Furthermore, a good sense of selfhood allows one to distinguish the past from the present, as well as the capacity to recall one’s life logically and relatively chronologically. Self-hood enables one to live for him- or herself independently and free of toxic, enmeshed relationships. This in turn, allows one to be at peace with him- or herself and to develop self-esteem, as well as an overall sense of wellbeing (which is an essential aspect of an emotionally and psychologically healthy individual (Middleton, 2005). Interestingly enough, Middleton points out that selfhood enables one to cope with traumatic experiences, so that he or she may move on with his or her life (2005).
People with DID lack a true sense of selfhood. They, therefore, lack many or most of the positive aspects of a well-defined sense of self. It is not surprising that people with DID have difficulties in nearly every aspect of their lives (e.g., vocational and financial difficulties, social and familial problems, legal troubles, substance abuse and other mental disorders, etc.) (Middleton, 2005).
Comorbidity is a significant problem of people living with DID. People with DID regularly have had or will develop other mental disorders at some point in their lifetimes. Common cooccuring disorders run the gamut from mood, anxiety, and psychotic disorders to substance abuse, somatoform, and eating disorders (Millon, et al., 1999). “Moreover, borderline personality disorder has been diagnosed in almost 70% of a series of clinically diagnosed DID subjects” (Millon, et al., 1999). Like DID, Borderline personality disorder (BPD) is frequently diagnosed in individuals with a traumatic/abusive childhood. Those dually diagnosed with DID and BPD are more likely to have been more severely abused than those diagnosed with only DID (Millon, et al., 1999).
Clinicians are frequently unaware that they’re treating a [person with DID], since these patients are tough to detect. One psychiatrist reported that seven years had passed before he realized his patient had this disorder. Few enter treatment complaining of multiple personalities, and if they come at all, it’s usually for depression (Maxmen & Ward, 1995).
In short, DID “rarely occurs as an isolated condition” (Millon, et al., 1999). In regards to DID, comorbidity is more often the rule than the exception. Differential diagnose is, therefore, extremely important when considering a diagnosis of DID (Millon, et al., 1999).
People with DID are prone to establishing abusive relationships with others (American Psychiatric Association, 2000). In addition to having real physical ailments (as they are prone to self-mutilation), they may exhibit psychosomatic symptoms (Middleton, 2005).
DID has been found in cultures throughout the world. For example, DID has been documented in Australia, India, New Zealand, North America, South America, Turkey, France, Belgium, Scotland, Scandinavia, England, Japan, the United States, and Germany. Although DID is found all over the world, in may be expressed differently depending on the cultural context. For example, in traditional cultures, alternate personalities often manifest as god, ghost, deceased family members, or nonhuman entities. The manifestation of such alternate personalities is in line with the cultural values of some traditional societies. Although psychopathology may be universal, it always occurs within the context of a culture. One cannot deny the interplay that occurs between culture and nearly every aspect of human life, including psychopathology (Shumaker & Ward, 2001).
DID appears to be more prevalent in individualistic cultures, such as the United States, Germany, and Finland, than collectivistic cultures. Most Western cultures are individualistic in nature, while Eastern cultures are more collectivistic (Shumaker & Ward, 2001). However, a recent study indicated that DID was on the rise in Japan. Between 1919 and 1990 there were only five documented cases of DID. A dramatic increase in DID occurred between 1991 and 1997, with 30 cases being documented (Uchinuma & Sekine, 2000).
In addition, DID is more prevalent in cultures that tend to be relatively more tolerant of child abuse (Middleton, 2005). Although Western cultures typically hold a harsh opinion of child abusers, they are generally not really severely punished. Rates remain high in the West, despite increasing efforts to improve detection and early intervention of physical, sexual, psychological, and emotional abuse of children (Steinberg, 2005).
DID is three to nine times more prevalent in females than males (American Psychiatric Association, 2000). However, this disparity narrows between the sexes among incarcerated individuals—reflecting the greater likelihood that prison inmates were abused as children. DID usually shows up during adolescents and rarely develops after the age of 40 (Maxmen & Ward, 1995). It tends to be chronic and recurrent. DID, “and the proliferation of new identities, often continues for life, making this condition the worst of the dissociative disorders” (Maxmen & Ward, 1995).
Justification for Diagnosis
I would like to point out that after making the initial diagnosis of DID, I would investigate further in order to gain more evidence to substantiate my claim. A fully detailed description of the methods for more thoroughly investigating DID is beyond the scope of this paper, but they include things like semi-structured diagnostic interviews (the Dissociative Disorders Interview Schedule) and screening tests, such as the Dissociative Experiences Scale. A diagnoses of DID is more or less done on an exclusionary basis, meaning that other seemingly similar disorders, such as schizophrenia (for which DID is frequently—albeit wrongly—diagnosed as), must be first systematically ruled out before it is given (Maxmen & Ward, 1995).
If I could not substantiate my claim relatively quickly, one option would be to defer the diagnosis of DID or, perhaps, give a diagnosis of Dissociative Disorder, Not Otherwise Specified (DDNOS). DDNOS is often used by clinicians as an initial diagnosis until they can more thoroughly substantiate a diagnosis of DID (Maxmen & Ward, 1995). That being said, I will now provide justification for why I believe that the young woman described above does, in fact, have DID.
This particular client exhibits many symptoms of DID. For example, the client disavows certain behaviors, apparently having no recollection of pervious events that were witnessed by others. She may claim to have found items that were known by others to have been stolen by her. The client will persistently deny that she stole the items, even in the face of proof that she did, in fact, steal the items.
In addition, the client has stolen money from her father in order to purchase candy. I find that stealing money to buy candy to be rather uncharacteristic of an 18-year-old. It seems to me that an 18-year-old would be more interested in stealing money to purchase more age-appropriate items. At times, the client has claimed that another little girl was actually responsible for purchasing the candy. The family is convinced that she is simply a pathological liar.
People with DID usually have no recollection of events that took place while an alternate personality or identity was in control. I believe that the client has an alternate identity, which takes on the persona of a little girl. I think that this alternate identity is responsible for the thefts witnesses by others. Furthermore, I think this explains why the client apparently buys candy with the money she steals, instead of more age-appropriate items.
Client’s father reported that her behaviors shift dramatically from time to time for no apparent reason. He stated that she once ran away and refused to come home. Upon returning, client told father that she wanted him to love her like he did the other girl. Furthermore, client’s father claimed that she has a strange look about her during these shifts in behavior.
When different identities emerge in people with DID, it usually proceeded by rapid blinking or a change in facial expressions. Witnesses often say that people with DID have an overall strange look about them when they are shifting from one identity to another. I believe that the client’s strange facial expression (described by the father), which co-occurred with a shift in her behavior, is actually the emergence of alternate identity. This would also explain the dramatic shifts in her behavior, as well as her request that her father love her like he does the other girl. I believe the other girl, of whom she spoke, is actually an alternate identity.
On one occasion, when the client ran away, she claimed that she was whipped excessively at home. The father denies that this is the case. However, one would expect him to deny it, as abusers usually do. Although the father claimed that he does not whip her, he admitted to whipping the client after she returned home from running away. This is an obvious contradiction, which, I believe, reveals that he does in fact whip her—perhaps, excessively. Obviously, this suspicion would have to be substantiated before I could make this claim with any level of real confidence.
It would appear that the client has not had an extremely stable childhood. Her mother and apparently her father were not very involved in her life growing up, as she was predominantly raised by her grandmother. It sounds as if the client’s grandmother does not hold her in high regard, as the grandmother commented that the client was “a terrible little liar.” Such a statement may indicate the presence of emotional or psychological abuse.
Furthermore, the client appeared undernourished at the time of the interview. This may be evidence of neglect and/or abuse at home. However, under normal circumstances one would expect an 18-year-old to be capable of attaining nourishment for herself by whatever means necessary (perhaps her alternate identities are stealing for this very reason), though the client’s circumstances appear to be by no means normal. The client’s undernourished appearance could be the result of an eating disorder, which co-occur with DID at a very high rate (Maxmen & Ward, 1995). Of course, these suspicions would have to be further substantiated, as well.
Approximately 90% of people suffering from DID were abused and/or experienced a traumatic childhood (Millon, et al., 1999). A history of abuse appears to be the overwhelmingly consistent feature of those with DID (Okugawa, 2005). Although I cannot yet make this claim unequivocally, I believe there is some reason to expect that the client at the very least experienced a difficult childhood, if not an abusive and/or traumatic one.
Further evidence for a diagnosis of DID appeared during the diagnostic interview. During the interview it seemed as if the clinician was having a conversation with two different people. Although the client appeared to be rambling and contradicting herself, I believe that the interviewer was actually witnessing the emergence of one of the client’s alternate identities.
Furthermore, during the interview, the client claimed not to be aware of the sexual innuendo of the boy who lives on her street. This is rather unusual for most 18-year-olds (especially considering she is of normal intelligence). I believe that when she made this claim, one of her alternate identities was in control, probably the little girl described above.
In regards to the little girl, the client makes reference to interactions between herself, the boy (described above), and the little girl. She seems to intermix and intertwine the actions of the little girl with herself. For example, in one instance stating that she (the client) said bad words and not the other girl, but in another instance say that the other girl said bad words and not her. Perhaps, in the second instance “the other girl” (the little girl) had emerged as the controlling identity and was actually speaking of the client as “the other girl.” This may explain the apparent contradictions the client made during the interview described above.
The client’s father reported that her strange behaviors did not begin until she moved to the United States from Germany, shortly after the death of her mother. The client reportedly witnessed the death of her mother (who “fell over dead next to her”). Psychosocial stressors have been shown to precipitate the onset of DID for those susceptible to the disorder. Moving, especially to a foreign country which speaks a different language and has different customs, is extremely stressful. Moving to a new country, in conjunction with witnessing the death of her mother, may have been enough to push her over the edge—leading to the development of a full-blown case of DID.
Other factors that support the diagnosis of DID are as follows: The client is female, under the age of 40, and comes from a Western culture with previously documented cases of DID. DID is much more prevalent (four to nine times) in females than males. There are few cases in which DID developed in individuals over the age of 40. The client is from Germany and lives in the U.S. They are both Western cultures where child abuse is more or less tolerated, and where DID has been documented relatively frequently.
Lastly, during the interview, when the client’s hand was placed in cold water, she fainted. This may be indicative of psychosomatic symptoms. According to Maxmen and Ward, psychosomatic symptoms are common in people with DID (1995).
Conclusion
DID, also known as multiple personality or split personality disorder, has a notorious and somewhat controversial history. DID has garnered attention from Hollywood, gaining pop culture status in movies like Sybil and Primal Fear. From time to time, DID shows up as the centerpiece in the defense of someone charged with a crime who, as a result of DID, claims to have no recollection of ever committing the crime. Such individuals contend that they are not to blame for the crime, as it was not “them” who committed, but rather one of their alternate identities. Certainly, this may be a legitimate claim for some, but I am just as certain that this defense is abused from time to time. Those who falsely claim to have DID in an attempt to avoid punishment, are surely--in part--responsible for the controversy surrounding this disorder (Kennett & Matthews, 2002).
Although some people may be skeptical of DID, the statistics may speak for themselves. Although relatively rare (when compared with other mental disorders, such as depression), DID is a widespread disorder occurring across the world and throughout history. One study of 1,008 adults living in North Carolina, fond that 10% of them have at least experienced some symptoms of a dissociative disorder at one time or another. Another study found the inpatient prevalence of DID to be between 1% and 10% (Steinberg, 2005).
To dissociate refers to the “splitting off” from normal consciousness. This “splitting off,” though it sounds dramatic, is actually very normal and routine in the human experience. For example, sleeping, meditation, daydreaming, or just “zoning out” are all common experiences which represent a “splitting off” from normal consciousness. Perhaps, one could argue that the experience of dissociation lies on a continuum, with daydreaming being the mildest and least disruptive form and DID being the most severe and malevolent. Although DID is a very extreme version of dissociation, dissociation, in its truest sense, may not be so unusual after all (Maxmen & Ward, 1995). “According to some philosophical and religious stances, to be human IS to live in a dissociated condition” (Krippner & Powers, 1997).
DID is both fascinating and tragically debilitating. While some disregard DID as a hoax or as a creation of those in the mental health field, the data shows that a similar clustering of symptoms surround those with DID across a wide spectrum of individuals (Kennett & Matthews, 2002) (Steinberg, 2005). To be sure, more research is needed in order to gain a more accurate and comprehensive understanding of DID.
Bibliography
Cohen, A. (2004). Dissociative identity disorder: Perspectives and alternatives. Ethical Human Psychology and Psychiatry, 6, 217-230.
Kennett, J., & Matthews, S. (2002). Identity, control and responsibility: The case of dissociative identity disorder. Philosophical Psychology, 15, 509-526.
Humphreys, C.L., et al. (2005). The assimilation of anger in a case of dissociative identity disorder. Counseling Psychology Quarterly, 18, 121-132.
Krippner, S., & Powers, S.M. (Eds.). (1997). Broken Images, Broken Selves: Dissociative Narratives in Clinical Practice. Washington: Brunner/Mazel, Inc.
Maxem, J. S., & Ward, N. G. (1995). Essential Psychopathology and Its Treatment. (2nd.). New York: W.W. Norton and Company.
Million, T., Blaney, P.H, & Davis, R.D. (Eds.). (1999). Oxford Textbook of Psychopathology. New York: Oxford University Press.
Okugawa, G., et al. (2005). Perospirone for treatment of dissociative identity disorder. Psychiatry and Clinical Neurosciences, 59, 624.
Schumaker, J.F., & Ward, T. (Eds.). (2001). Cultural Cognition and Psychopathology. Westport: Praeger Publishers.
Steinberg, M., et al. (2005). SCL-90 symptom patterns: Indicators of dissociative disorders. Bulletin of the Menninger Clinic, 69, 237-249.
Uchinuma, Y., & Sekine, Y. (2000). Dissociative identity disorder (DID) in Japan: A forensic case report and the recent increase in reports of DID. International Journal of Psychiatry in Clinical Practices, 4, 155-160.
Warwick, M. (2005). Owning the past, claiming the present: Perspectives on the treatment of dissociative patients. Australasian Psychiatry, 13, 40-49.
