Dissociative Identity Disorder Case Study w Mil w Jeong

Dissociative Identity Disorder 1

RUNNING HEAD: CASE STUDY ON DISSOCIATIVE IDENTIY DISORDER

James Cook University Singapore

Case Study on Dissociative Identity Disorder

Pear Chi Guan (12332056)

Fok Kean Jeong (12379048)

Mildred Tan Xin Yu (12392289)


Introduction

Dissociation is defined as “A disruption in the usually integrated functions of consciousness,

memory, identity, or perception (APA, 1994).”Dissociative identity disorder is a disorder

characterized by identity fragmentation characterized by the presence of two or more distinct

identities or personality states that recurrently take control of the individual’s behaviour. This

is also accompanied by an inability to recall important personal information that cannot be

explained by ordinary forgetfulness, it is also commonly accompanied by other symptoms

such as headaches, hallucinations, suicide attempts and self-abusive behaviour (Kring,Ann

M., Gerald C. Davison, John M. Neale, Sheri L. Johnson, 2005). Research has also shown

that it is extremely rare to see a case of dissociative identity disorder without any additional

psychiatric disorders like depression, substance use disorders and borderline personality

disorder (Putnam F.W, Guroff J.J, Silberman E.K, 1986; Anderson G, Yasenik L, Ross C.A,

1993). However, for this paper we would only be focusing on Dissociative identity disorder.

First of all, one of the most important students of the theory of dissociation was Pierre

Janet (1920), who suggested that in response to trauma, dissociative disordered patients

develop a set of characteristic psychological processes that serve to keep some experiences

out of conscious integration with the bulk of mental life (Janet P, 1920). Following that, two

major theories of DID the posttraumatic model and the sociocognitive model. The

posttraumatic model emphasises that DID begins in childhood as a result of severe physical

or sexual abuse (Kring et al., 2005). While the sociocognitive model emphasises that DID to

be the result of learning to enact social roles, which can be suggested through therapy, media

or other cultural influences (Kring et al., 2005). Other suggestions regarding DID are for

instance, Armstrong’s theory that dissociation is a factor that promotes resiliency in the midst

of trauma by helping to preserve essential human intellectual and emotional capacities such

as hour, hope and joy (Armstrong JG, 1994). A more clinical perspective on how dissociation


can be explained can be found through the neurological model, which suggests that some

underlying neurological process, such as hemispheric disconnection or epilepsy plays a role

in promoting dissociative symptoms (Maldonado JR, 2007).

Diagnosis of DID

As discussed earlier on, individuals with DID usually experience various comorbid

conditions. Therefore the diagnosis of DID should not be simply based on the background

information or symptoms provided by the patients, it should involve a complex process which

includes a battery of tests and also requires the assessors to have knowledge of the

assessment and also the disorder itself. Like many psychological disorders, it requires the

patient to reveal what is often a private, hidden world to a stranger. Thus a collaborative

relationship will definitely help in the results.

To begin the diagnosis, two test of dissociation namely the Dissociative Experiences

Scale (DES) and the Structured Clinical Interview for DSM-IV Dissociative Disorders-

Revised (SCID-D-R) which has extensive reviews could be used (Bernstein EM, Putnam FW,

1986; Steinberg M., 1994). The DES is a 28-item self-report scale that requires the

respondent to indicate the frequency of various dissociative experiences, such as

derealization, depersonalization, and psychogenic amnesia on 100-mm visual analogue scales

(VAS). A sample item is “Some people have the experience of looking in a mirror and not

recognizing themselves. Mark the line to show what percentage of the time this happens to

you”. The anchors of the 100-mm VAS are 0 (never) and 100 (always). The DES also

exhibits high internal consistency and test-retest correlations ranging from .74 to .84

(Bernstein EM, Putnam FW, 1986; Timo Giesbrecht, Harald Merckelbach, 2006).


The SCID-D-R is a semi structured interview developed by Steinberg, Rounsaville,

and Cicchetti (1990) with 200 questions to assess the presence and severity of amnesia,

depersonalization, derealisation, identity confusion, and identity alteration symptoms. Each

symptom is then rated on a 4-point scale and ratings of severe are generally awarded if a

symptom is present for a prolonged period, occurs frequently, produces dysphoria or

produces impairment in social or occupational functioning. General, open-ended screening

questions are followed by more detailed questions. SCID-D-R also exhibits a high inter-rater

reliability of .90 for the diagnosis of DID (Steinberg, M., Rounsaville, B., & Cicchetti, D.,

1990).

Projective tests can also be particularly useful in assessing DID because the ambiguity

of the tests requires an individual to project their own ways of organizing reality onto the

tests (Bethany L. Brand, Judith G. Armstrong, Richard J. Loewenstein, 2006). One such test

is the Thematic Apperception Test (TAT) which consists of 20 black-and-white drawings that

depict people and scenes (Armstrong JG, 1996). Subjects would be told to tell stories to

describe the characters’ thoughts and feelings. This provides a description of how the subject

expects people to interact both internally in their altered world and externally in the social

world. One example is that adolescents who are traumatized have been found to tell TAT

stories that are characterized by negative affect, and have characters that are malevolent and

self-centered, with themes of violence (Armstrong JG, Kaser-Boyd N., 2004).

Another projective test is the Rorschach test which is useful because it requires the

subjects to delve into their internal store of associations, which is the very thing dissociation,

has been helping them to avoid. It also provides a broad view of a person’s cognition and

problem solving skills. Patients with dissociative disorders have been found to be flooded

with emotions and bothersome percept while completing the Rorschach (Bethany L. Brand,

Judith G. Armstrong, Richard J. Loewenstein, 2006).


In spite of battery of tests, diagnosing DID should also be based on the DSM-IV

diagnostic criteria (APA, 1994), which are A. 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). B. At least two of these identities or personality states

recurrently take control of the person’s behaviour. C. Inability to recall important personal

information that is too extensive to be explained by ordinary forgetfulness. D. The

disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or

chaotic behaviour during alcohol intoxication) or a general medical condition (e.g., complex

partial seizures).

Therapy

There are numerous examples of treatment for DID, most psychodynamic treatments

basically involve the same processes. The process of psychodynamic treatment we are

emphasising on for this case would involve six-stages: (a) establishing the diagnosis, (b)

developing awareness of multiplicity, (c) developing awareness of past history and the

purpose of alters, (d) working through the dissociative defences, (e)integration and fusion

and (f)termination. Each of these stages involves a complex process which integrates with h

and would take around an average of two-years, with 2-3 sessions per week on a basis of 2hrs

per session.

The first stage of the treatment would require establishing a therapeutic relationship

and a high degree of trust as it is essential in the context of ongoing psychotherapy

(Horevitz,R., 1983). In addition, it is also important to establish trust with both the host and

his/her different personalities/identities as well as not to ignore or favour one identity over

another since cooperation is needed from all personalities (Putam, F. W., 1989).


Once a working relationship has been establish in stage one, the second stage of the

therapy can be undertaken: developing awareness of multiplicity. At this stage, the patient

must come to terms and acknowledge his/her diagnosis (MacGregor, 1996). For this reason a

healthy working relationship with the patient have to be established at stage one. For instance

according to the posttraumatic model, disassociation is used as a defence mechanism to avoid

the trauma experienced (Kring,Ann M., Gerald C. Davison, John M. Neale, Sheri L. Johnson,

2005). Therefore being able to aware and acknowledge the existence of the multiplicity of

alters and the dissociative coping style would facilitate the following stages of therapy.

The purpose of the third stage of therapy is to help the patient become aware of

his/her early traumatic experiences and how each of the alters developed as a coping device

towards the trauma experienced (MacGregor, 1996). The goal of this phase is to lessen and

then eliminate the need for dissociative barriers. Mapping can be incorporated in this stage,

which is a technique that allows patients to develop a physical map of their personality

system. From this map, therapist can gather valuable information regarding the nature of the

different personalities to help generate a deeper understanding of these personalities and

ensure that all alters are being addressed (Ross, C. A., & Gahan, P., 1988). Additionally, this

would also help facilitate the realization for the DID patient. An age regression technique

from hypnosis can also be integrated at this stage to help facilitate the mapping, this involves

using hypnosis to bring the patient back to a time when these different personalities were

manifested (MacGregor, 1996).With reference to the social-cognition model, these

personalities evolved from social-cultural factors that varied between social contexts. Hence

being able to understand these personalities would also create a deeper understanding of the

patient and his/her social barriers and dissociative defences (Scott O.Lilienfeld, Irving Kirsch,

Theodore R. Sarbin, 1999). Consequently this information would help the patient overcome

them at the later stages of the therapy.


The fourth stage of the therapy involves working through dissociative defences by

piecing together events, memories, and feelings so that full memories can be constructed.

One of the goals of this stage of therapy includes increase in internal communication, which

is facilitated by having the alters talk to each other (MacGregor, 1996). Methods of hypnosis

can be in- cooperated at this stage, specifically memory retrieval which allows the patient to

relieve traumatic memories at a controlled level and in addition, focus on working through

the painful affect, inappropriate self-blame and other reactions to these memories. Screen

techniques can also be introduced, where the patient visualizes these memories and divides

them onto two sides of an imaginary screen (MacGregor, 1996). For example, a woman

manages to remember a particularly painful episode in hypnosis. “When she was 12 years

old, her stepdad forced her to have oral sex with him, she recalled what he was forcing her to

do and remembered that she gagged and vomited all over him, which spoiled his fun.” One

side of the imaginary screen would picture what an abuse did to the patient, and the others

side would picture how the patient tried to protect himself or herself from the abuse.

Subsequently, the patient is able to reduce fragmentation and increase integration of these

memories in consciousness with a broader perspective of these traumas and therefore

reducing the need for dissociation as a means of keeping such memories out of consciousness

(Lindemann E, 1994).

Stage 5, comprises of fusion and integration. Fusion is the process of removing the

dissociative barriers that segregate specific alters. Integration is the complete and pervasive

restructuring of the personality which involves the combination of the separate alters and

elements of alters into a unified personality (Putam, F. W., 1989). The therapist must

continuously work with the patient to consolidate the new integrated self and the patient must

also actively develop and use non-dissociative defence mechanisms within the new integrated

self


At the final stage of therapy, the patient should have managed to integrate all of the

personalities and develop new nondissociative defence mechanisms. Nevertheless,

termination should only occur when the therapist feels that the patient is ready to deal with

the anxiety and stress of the social environment in a nondissociative manner.

The “rule of thirds” (Kluft RP, 1988) is a helpful guideline for psychotherapy as it

emphasises that therapist should spend the first one third of the therapy session assessing the

patient’s current mental state, life problems and also defining a problem area that might

benefit from retrieval into conscious memory and working through. The second third of the

therapy, the therapist can then access and work thought the patient’s memory, and finally

ending with helping the patient assimilate the information, regulate and modulate emotional

responses as well as discuss any responses to the therapist and plans for the immediate future.

Disassociation is usually used as a defence for DID patients, therefore it is important

for the patient to acknowledge that they experience themselves as fragmented, yet the reality

is that this fragmentation is a failure of integrating disparate memories and aspects of the self.

Consequently, therapies for DID should have a goal to facilitate integration of these elements.

A series of “rules of engagement” (JR, Maldonado, 2000) should also be used during the

treatment as these rules would help facilitate free access to old records and permission to

discuss all past and current information. Secrets are also a frequent problem for therapies

with DID patients as patients often like to confine plans or stories from the therapist, so as to

keep it from the other parts or the manifested parts of the self. Examples of these can be

traumatic memories or plans for self-destructive activities. Hence with this set of rules there

should be not secrets kept between therapist and client, and also confidentiality should not

apply between identities as this would hinder the process of integration.


Hypnosis can be helpful in both diagnosis and treatment of DID. Firstly, hypnotic

induction may elicit dissociative phenomena or activate alters/identities. The capacity to elicit

such symptoms on command provides the first hint of the ability to control these symptoms.

Using hypnosis, the therapist can also apply age regression to help the patient reorient to a

time when these different personality states was manifested. Alternatively, it would be

possible to simply “call up” these different identities and speak to these identities.

Also, memory loss in DID is complex and chronic, therefore its retrieval should also

be integrated into the psychotherapy. The strategy of memory retrieval focuses on working

through traumatic memories in addition to controlling the dissociation. This ability to control

the access the memories would greatly facilitate the therapy as the therapist can use hypnosis

to help the patient interact with different identities. In addition to that, the patient can work

through the painful affect, inappropriate self-blame and other reactions to these memories. A

model of grief work can be helpful as it enables the patient to acknowledge and bear the

import of such memories (Lindemann E, 1994)

Being able to visualize these memories would also be important as patients can also

divide the memories onto two sides of an imaginary screen which places them in a broader

perspective of these traumatic memories. Thus allow these traumatic memories to be more

bearable. One example of this technique is a woman manages to remember a particularly

painful episode in hypnosis. “When she was 12 years old, her stepdad forced her to have oral

sex with him, she recalled what he was forcing her to do and remembered that she gagged

and vomited all over him, which spoiled his fun.” One side of the imaginary screen would

picture what an abuse did to the patient, and the others side would picture how the patient

tried to protect himself or herself from the abuse. Besides that, this technique also reduces

fragmentation and integration by enabling patients to bear the memories in consciousness and


therefore reducing the need for dissociation as a means of keeping such memories out of

consciousness.

Before a hypnotherapy can be carried out successfully, it requires the client’s

willingness to cooperate (Braun, 2008). However, many people have misconceptions of

hypnosis, such as being made to do things that are morally opposing. Thu, the therapist will

have to clear the client’s misconceptions and reassure him that he will not lose control of

himself during hypnosis.

During therapy with DID patients, transference would sometimes be present, as

patients expect therapist to exploit them, just like how they presume that their caregivers who

acted in an exploitative and sadistic fashion. Therefore it is important to make these issues

frequent topics of discussion.

Transference frequently involves unconscious repetition of the past in present. The

relational model of psychoanalysis regards transference as an interactive process between the

client and the therapist (Corey, 2009). Through the interaction, the client may gradually be

conscious of their feelings as they start to exhibit a range of reactions and feelings to the

therapist. The client can then recognize and resolve events that have traumatized them from

past relationships. With the progression of each therapy, the feelings and conflicts which the

client experienced during childhood may begin to surface from the depths of

unconsciousness, resulting in him/her to regress emotionally. From there, the issues which

the client faced will slowly surface and this can be worked on individually.

Another method to deal with transference is applying the Empty Chair Technique

from Gestalt therapy as it allows the client to fully express his repressed feelings and

emotions by bringing the unresolved past into the present. However, the Empty Chair

Technique should only be applied towards the end of the therapy as the therapist should gain


the client’s trust through congruency and the rapport between the therapist and client must be

built before this therapy can be carried out successfully(Corey, 2009).

At the start of this phase of therapy, the client will be seated next to the therapist, with

an empty chair being placed in the opposite direction of them. In this instance, the client’s

unresolved past will be his mother. The client will be asked to imagine greeting his mother

and inviting her into the therapy room and seated down on the empty chair. The client will

then be encouraged to speak to his ‘mother’ regarding how he felt about his mother, the past

events and even things that he wished he could tell his mother but never had a chance to do

so. After several sessions using the Empty Chair Technique, the therapist should also

encourage the client to perform positive actions such as hugging his mother. Subsequently,

the client should also give ‘his mother’ a voice. For instance, the client may be asked how he

thinks his mum might respond to him, after expressing how he felt.

Ultimately, this therapy’s goal should be the integration of the disparate states. As

early in the therapy, dissociation is the primary defence for the patient. Hence, being able to

experience and work though fears with the help of a degree of integration and control of his

or her dissociative processes would set aside this dissociative defence.

**Other therapies.

Pharmacology drugs are widely used to help manage DID symptoms such as

depression, anxiety, impulsivity, and substance abuse. However, these drugs do not relieve

dissociation. Proper treatment is still needed to achieve integration which centers on

psychotherapy. (Schatzberg, 2000). Although there are no medications that specifically treat

DID, antidepressants, anti-anxiety medications or tranquilizers may be prescribed by doctors

to help control the mental health symptoms associated with DID. For patients who are unable


or unwilling to strive for integration, psychotherapy aims to facilitate cooperation and

collaboration among the identities and to reduce these symptoms.

Etiology

Subject suffered from sexual abuse during his childhood. These mistreatments lead to

overwhelming stress. As the child was mistreated by a trusted caregiver, splitting off the

awareness and memory of the traumatic event helped him survive in the relationship between

his foster parents. These memories and feelings go into subconscious state of the mind and

were later experienced in the form of a separate identity.

Dissociation becomes a coping mechanism when the individual is faced with a similar

stressful event, insufficient nurturing and compassion in response to overwhelmingly hurtful

experiences during childhood (Gleaves, D. 1996). Most people found suffering from DID are

usually victims of emotional, sexual or physical abuse. Some others suffering from this

disorder may not have experience early loss such as death of someone close to them or

experienced some stressful events (Kluft, R.P.1988).

These individuals may go through different cognitive phases such as emotional,

perception and memories of their life experience kept separated to help them escape from the

experience by zoning out or retreat into their own world. This will lead to a different state of

mind with the presence of two or more personalities. They will experience inability of at least

one of the altered state to recall important personal information (Gleaves, D. 1996).

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Dissociative Identity Disorder Case Study w Mil w Jeong