The Diagnosis and Assessment of Dissociative Identity Disorder
Neil Brick MA Ed. Author e-mail : email@example.com
Copyright 2003 – All rights reserved. No reproduction of any material without written permission from the author.
This paper will describe the methods and criteria used for diagnosing and assessing Dissociative Identity Disorder (DID). The symptoms and etiology of DID will be discussed. The use of client histories, different psychological tests and the test results of different test items will be discussed in terms of their applicability to a diagnosis, as well as their validity and reliability.
Differential diagnoses and their effect on the diagnosis of DID will be enumerated upon. The dissociative spectrum and ritual abuse will be discussed briefly, in order to help clarify the symptomology and etiology of DID.
Dissociative Identity Disorder is listed in the DSM-IV-TR under Dissociative Disorders. It is characterized by the presence of at least two distinct personality states or identities that repeatedly take control of a patient’s behavior. This is accompanied by the inability to recall important personal information, which is too extensive to be explained by normal forgetfulness. The disorder is characterized by identity fragmentation and not a proliferation of separate personalities. The diagnostic criteria for DID (300.14) are, two distinct identities or personality states, these states take recurrent control of the patient’s behavior, an inability to recall personal information too great to be accounted for by normal forgetfulness and the disorder is not due to the physiological effects of a substance or a general medical condition. In children, symptoms cannot be attributable to fantasy play or imaginary playmates. (Diagnostic and statistical manual of mental disorders, 2000)
Putnam writes about Multiple Personality Disorder (MPD), now called DID, and the way therapists can determine its diagnosis. He defines it as a chronic dissociative condition, not transient like psychogenic amnesia and fugues. A thorough history can help determine if a patient has had dissociative experiences. But other diagnostic interventions may be necessary. It may be difficult to get a clear chronology of life events. The host personality, which usually presents for treatment, may have the least access to early biographical information. MPD patients may describe their lack of memory as the result of having a poor memory. MPD patients may have developed compensatory behaviors to help them answer or avoid questions when they have memory gaps. Useful inquiries may include asking question about time loss or fugue-like experiences, depersonalization and derealization experiences (though these symptoms may be present in other disorders), questions about common life experiences, like being called a liar, large gaps in the continuousness of childhood memories, the occurrence of intrusive mental images, having dreamlike memories and having life skills that have unknown source, and questions about Schneiderian Primary Symptoms for schizophrenia, like hearing voices or feeling as if their body is controlled by an external force. (Putnam, 1989)
Manifestations of MPD may be displayed during interview interactions with patients. Two ways of detecting personality switching with patients are to notice the physical signs, which include facial and vocal changes. The second is to be alert for intrainterview amnesia, due to an alter personality’s emergence, admitting to and then denying symptoms. Other signs include a patient’s making references to themselves in the third person or the first person plural and an exaggerated startle reflex. (Putnam, 1989)
A diagnosis of MPD is more likely to be made after an extended period of observation. Diagnostic procedures include a mental status examination for appearance, speech, motor and thought processes, hallucinations, intellectual functioning, judgment and insight. Extended interviews for three hours may help, as it is difficult for MPD patients to keep from switching that long during the stress of an interview. The MMPI questions relating to blank spells and lack of knowledge of past actions show fairly high retest validity. The Rorschach test has a lot of diversified movement responses and labile and conflicting color responses. Physical examinations can help rule out other neurological disorders causing amnesia and may help detect self-mutilation scars. A diagnosis of MPD can only be made once a clinician has met a distinct alter state and not a transient ego-state phenomena. (Putnam, 1989)
It may be helpful to look at the spectrum of dissociation to further describe the observed symptomology of DID. Whitfield describes dissociation on a spectrum from healthy dissociation, like healthy trance states or defending against a painful experience to unhealthy dissociation, like PTSD, Dissociative Disorders and DID. Dissociation may be considered a useful survival defense mechanism. But once a patient leaves the abusive situations (as in a child leaving an abusive home), these dissociative symptoms may not be particularly useful. (Whitfield, 1995)
An understanding of the possible causal factors of DID may help with developing a diagnosis. Ross suggests four pathways that might lead to DID’s emergence. These include child abuse, child neglect, factitious and iatrogenic. Ross believes that some cases of DID occur as a result of incompetent and misguided treatments for other types of disorders, like bipolar, post-traumatic stress or other mixed syndromes containing dissociative elements. (Carson, Butcher & Mineka, 2000) Whitfield cites a Scheflin and Brown study that found in 30 malpractice lawsuits filed by retractors against former therapists for implanted false memories or DID, most had the diagnosis of DID and/or had recovered memories before the sued therapist had seen them. (Whitfield, 2001) Brown, Frischholz and Scheflin state that there is insufficient data to meet the minimal standard of scientific evidence that DID can be caused by suggestive influences in therapy. They believe that alter creation in some cases has been confused with alter shaping. (Brown, Frischholz & Scheflin, 1999) There is no convincing evidence of a genetic contribution to DID. Evidence is growing that DID is largely a kind of post-traumatic stress disorder. The reported percentages of child abuse (sexual or physical) in five DID patient studies run between 60 and 90%. (Carson, Butcher & Mineka, 2000)
The psychological testing of MPD patients was done by Erikson and Rapaport in the 1940′s. They both analyzed the Rorschach responses of two patients and found the test results reflecting tendencies toward introversion, “compulsive-obsessional” and intellectualization personality characteristics. Lovitt and Lefkof describe the use of Exner’s Comprehensive System to analyze the structural features for three MPD patients’ Rorschach responses. All the major personalities fluctuated in the way they responded to the inkblots. Single case studies of MPD patients using the Minnesota Multiphasic Personality Inventory (MMPI) show a wide variety of diagnostic configurations. Invalid profiles of MPD patients may result from extremely high scores on the F scale (validity), which measures a tendency to exaggerate problems and elevated scores on the Sc scale, which measures social alienation, bizarre feelings, isolation, thoughts of external influence, feelings of inadequacy, and peculiar bodily dysfunction. (Mangen, 1992)
The Dissociative Experiences Scale (DES) was used by Putnam and Bernstein to measure dissociation in normal and clinical populations. The test was found to have good split-half and test-retest reliability and it displayed construct and criterion-related validity. The Perception Alteration Scale (PAS) was drawn from items on the MMPI. Sander’s factor analysis of the scale showed three factors (modification of affect, control and cognition) accounted for almost half of the variance. The Questionnaire of Experiences of Dissociation (QED) was described by Riley as having good reliability and validity. Armstrong and Lowenstein discuss an approach to psychological testing that tries to follow “state” changes. MPD patients display patterns different from schizophrenic and borderline patients. These patients tended to present with more complicated defense structures than van der Kolk’s sample of war trauma veterans. (Mangen, 1992)
The first questionnaire used to screen for dissociative disorders was the General Amnesia Profile (GAP) developed by Wilbur and Caul in 1978. Several GAP-type items are included on the Dissociative Experiences Scale (DES). The DES inquires about dissociative experiences and symptoms, with subjects marking a line representing between 0% and 100% of the time. Two other structured diagnostic tests are the Structured Clinical Interview for DSM-IV disorders-Revised (SCID-D-R, created by Steinberg) and the Dissociative Disorders Interview Scale (DDIS, created by Ross). Studies have cross-validated the DDIS and the original SCID-D with the DES. The DDIS had 131 items covering dissociative disorders, major depression, somatization and BPD. Many items simply restate DSM criteria using a yes-no format. The SCID-D-R has 250 items and assesses five areas, amnesia, depersonalization, derealization, identity confusion and identity alteration. The severity of symptoms is graded on a 4-point scale. (Putnam, 1997)
Mangen used a battery of tests for the psychological evaluation of ritual abuse victims in satanic cult settings. Most of these patients were diagnosed with MPD. This battery includes the Weschler Adult Intelligence Scale – Revised (WAIS-R), the Rorschach Inkblot Test, a story telling test like the Thematic Apperception Test (TAT) a human figure drawing test, the Animal Choice Test and other brief projective tests. Testers should be open to the possibility that cult abuse exists, should be familiar with the symbols and customs of this kind of abuse and should know how testing effects the patient and should be aware of countertransference issues. The WAIS-R may show inconsistencies in performance. Certain tasks, such as repeating things in backward order, may be troublesome to some patients due to the similarity of this test to Satanic rituals. Rorschach card descriptions may entail memories of abusive rituals. An MPD patient’s TAT responses may entail memories of rituals or issues around a lack of trust of others. (Mangen, 1992)
Putnam suggests a phenomenological approach to pediatric dissociative disorders. This entails the study of symptoms and behaviors on their own and not from a theoretical point of view. Hornstein and Putnam examined 64 children having either MPD or DDNOS. The average child had received 1.4 to 4.0 diagnoses before the DD diagnosis. Symptoms include anxiety, affective, depression, affective lability, self-blame, withdrawal/hopelessness and low self-esteem. Serious suicidal ideation was present in more than half of the children. Almost half of those diagnosed MPD had made a suicide attempt and self-mutilation was common. Two-thirds of the children had conduct problems. Sexual behavior problems occurred in about half of the patients. Posttraumatic symptoms were present in three-quarters of the cases. Trance-like states occurred in almost all cases. Differential diagnosis of pathological dissociation in children includes ADHD, Conduct disorder, Rapid-cycling bipolar disorder, schizophrenia and other psychotic disorders, seizure disorder and Borderline personality disorder. (Putnam, 1997)
Information gathering for childhood dissociation should include getting all pertinent records and interviewing caretakers. A clinician should look for parenting difficulties, parental psychopathology and deficits in the ability to care for the child. Teachers can be good sources of information. Children should be interviewed with caretakers first to watch for clues during their interactions. Self-evaluative interview levels of validity depend on the age of the child. Signs of dissociative symptoms in children during an interview may be manifest in strong behavioral changes, blank stares, unresponsiveness, or continuous repetitive movements. Play or projective techniques and physical examinations may also provide partial useful information toward a diagnosis. (Putnam, 1997)
Diagnostic tests for pathological dissociation in youths include the Child Dissociative Checklist (CDC). It has twenty questions, each with a three-point scale. Scores more than 12 warrant additional evaluation. The CDC is a reliable and valid instrument. The Adolescent Dissociative Experiences Scale (A-DES) is a self-report scale that has 30 items with a 0-10 scale. It is a reliable and valid measure of pathological dissociation in adolescents. The Bellevue Diagnostic Interview for Children (BDID-C) uses television analogies to inquire about dissociative experiences (like switching). The BDID-C inquires about awareness, memory, hallucinations, imaginative experiences, aggression and temper, alterations in abilities, sexual experiences, identity disturbances and medical complaints. (Putnam, 1997)
Separate identities or alters can be co-conscious, where each alter can keep track of the other alters’ activities or amnestic or there can be combinations of these. Usually, DID is not easily detectable by other people. The popularized version of DID patients leading different lives represents only a small percentage of patients. Not all DID patients are alike. Frequent misdiagnosis of DID includes identifying secondary symptoms, like depression, physical ailments, chemical dependency and eating disorders, as the primary problem. Symptoms of unintegrated trauma are closely similar to and can be confused with certain personality or mental disorders. Common misdiagnoses include borderline personality, anxiety disorder, paranoid schizophrenic, attention deficit disorder, psychosis and clinical depression. These conditions may be present but are often secondary symptoms. Therapists need to learn the signs of unintegrated trauma or DID patients may be misdiagnosed or undiagnosed. A study has shown it takes an average of seven years to properly diagnose DID patients. The best indicator of a possible misdiagnosis is a patient’s unresponsiveness to treatment. Some believe that undiagnosed and misdiagnosed DID patients may end up in prisons or mental institutions. (Oksana, 2001)
Estimates in the mid 1980′s suggest that about twenty percent of patients with MPD may also be cult abuse victims. (Mangen, 1992) Noblitt discusses a proposed diagnosis in DSM format of Cult and Ritual Trauma Disorder, whose diagnostic features include disturbing or intrusive recollections of abuse and involuntary dissociated states, due to ritual abuse. Dissociation of identity is a feature of this disorder and DID or DDNOS are frequently concurrently diagnosed. (Noblitt and Perskin, 2000) A clinician may want to evaluate a client for a diagnosis of DID or DDNOS when the patient has a history of repeated, severe abuse.
Oksana divides the symptoms of the aftereffects of sadistic/ritual abuse into two categories. The first, enabling dissociation, describes how a survivor avoids, distracts from and medicates their pain. The remaining categories describe how one’s body and mind might be trying to reconnect or associate (as opposed to dissociate) with repressed experiences. The possible signs of enabling dissociation include the use of addictions to distract or medicate oneself, following diversions such as keeping very busy, focusing on others’ pain instead of your own, spacing out, using alters to escape or becoming a zealot to avoid getting in touch with oneself. Dissociated behaviors may include, having been an extremely obedient child, unusual changes in vision, handwriting, performance or concentration, fear of losing control or leaving things to chance, taking controlled thrills, fear of self expression of one’s creativity, always smiling or feeling it is dangerous to show sadness or disappointment and problems with sexuality. Dissociated emotions and cognitions might include, detachment during crises, fear of spontaneous emotion, thinking instead of feeling, inability to stay with a feeling, an inappropriate level of responses, living in constant fear, feeling abnormal levels of guilt and shame, feeling uncontrollable levels of anger and feeling one doesn’t belong. Possible signs of dissociation include being confused or disorientated in certain situations, changing subjects abruptly, feeling one’s body size changes, feeling unreal or in someone else’s story, hearing voices arguing in your head and dissociating in a crisis. (Oksana, 2001)
While making a diagnosis, it is also important to distinguish a disorder from other disorders that may have similar symptoms. DID should be distinguished from symptoms that are caused by the physiological effects of a medical condition (Axis III disorders). DID should be distinguished from dissociative symptoms caused by complex partial seizures, but both disorders may co-occur. Seizure episodes may last 30 seconds to five minutes and don’t have the enduring structures of identity usually found in DID. Symptoms caused by the physiological effects of a substance must also be distinguished from DID. The diagnosis of DID takes precedence over other dissociative disorders. The differential diagnosis between DID and other mental disorders (like psychotic disorders) is made difficult by overlapping symptoms. A dissociated identity state may be mistaken for a delusion, inter alter communication may be mistaken for auditory hallucinations, or shifts between identity states may be confused with bipolar cyclical mood fluctuations. The factors that may support a diagnosis of DID in these cases may include sudden shifts in identity states, reversible amnesia and high scores on tests of dissociation and hypnotizability. DID must also be distinguished from Malingering, where there may be forensic or financial gain and Factitious disorder, where there may be a pattern of help-seeking behavior. (Diagnostic and statistical manual of mental disorders, 2000)
Dissociative disorder not otherwise specified (DDNOS) is included in the DSM-IV-TR as a category for disorders where a predominant feature is a dissociative symptom, but the symptoms do not meet the criteria for the previously mentioned dissociative disorders. DDNOS presentations may be similar to DID but do not meet the total criteria for DID. These include presentations where there are not two or more personality states or where the amnesia of important personal information doesn’t occur. Other DDNOS features may include, in adults, derealization not accompanied by depersonalization, dissociation due to intense coercive persuasion (like brainwashing), dissociative trance disorder, loss of consciousness not due to a medical condition and Ganser syndrome (giving approximate answers to questions). (Diagnostic and statistical manual of mental disorders, 2000)
In conclusion, Dissociative Identity Disorder has clear guidelines for diagnosis, but yet it takes an average of seven years before a primary diagnosis of DID is given. It takes several diagnoses before a DD is given to children. Some of the factors involved in the delay of diagnosis or misdiagnosis include client compensatory techniques to cover for the symptoms of DID, and the mistaken diagnosis of secondary symptoms, instead of the primary diagnosis of DID. It may be helpful for clinicians to take a thorough history of each client, carefully building a time line of life events to look for major gaps, as well as watching for any dissociative symptoms that may present during the client interview. A history of repeated, severe abuse may suggest the existence of a dissociative disorder. Therefore in these cases, it may be best for clinicians to watch closely for dissociative symptoms and give clients the necessary aforementioned tests to ensure a proper diagnosis. Once given, a proper diagnosis can help a client’s prognosis and treatment.
American Psychological Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, D. C: Author.
Barlow, D.H. (2001). Clinical handbook of psychological disorders (3rd ed.). New York, NY: Guilford Press.
Brown, D., Frischholz, E., Scheflin, A. (1999). Iatrogenic dissociative identity – an evaluation of the scientific evidence. The journal of psychiatry and law. 27, 549-637.
Brown, D., Scheflin, A. W., Hammond, D. C. (1998). Memory, Trauma treatment and the law. New York: W. W. Norton & Company.
Carson, R.C., Butcher, J.N., & Mineka, D. (2000). Abnormal psychology and modern life. Boston, MA: Allyn & Bacon.
Drummond, R. J. (1996). Appraisal procedures for counselors and helping professionals (4th ed.). Englewood Cliffs, NJ: Merrill.
Groth-Marnot, G. (1996). Handbook of psychological assessment (3rd ed.). New York, NY: Wiley & Sons.
Mangen, R. (1992). Psychological testing and ritual abuse. In Sakheim, D. K., Devine, S. E. (1992). Out of darkness – Exploring satanism and ritual abuse. New York: Lexington Books. (pp. 147 – 173)
Maxmen, J. S., & Ward, N.G. (1995). Essential psychopathology and its treatment (2nd ed.). New York, NY: W. W. Norton & Company.
Noblitt, J. R., Perskin, P. S. (2000). Cult and Ritual Abuse (Rev. Ed.). Westport, CT: Praeger Publishers.
Oksana, C. (2001). Safe passage to healing : A guide for survivors of ritual abuse. Lincoln, NE: iUniverse.com, Inc.
Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Publications.
Putnam. F. W. (1997). Dissociation in children and adolescents : a developmental perspective. New York : Guilford Press
Whitfield, C. L. (1995). Memory and abuse – Remembering and healing the effects of trauma. Deerfield Beach, FL: Health Communications, Inc.
Whitfield, C. L. (2001). The “false memory” defense: Using disinformation and junk science in and out of court. In Whitfield, C. L., Silberg, J. Fink, P. J. Eds. (2001). Misinformation Concerning Child Sexual Abuse and Adult Survivors New York: Hawthorn Press, Inc. (pp. 53 – 78)