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Dissociative Identity Disorder Theories and Treatments

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Dissociative Identity Disorder Theories and Treatments

  1. 1. Running head: Neurobiological Driven Treatment of DID Neurobiological Research Driven Treatment for Dissociative Identity Disorder Jennifer Espenschied Lindenwood University
  2. 2. Neurobiological Driven Treatment of DID 2 Abstract Dissociative Identity Disorder (DID) is an often misunderstood phenomenon by clinicians and lay people alike. Current research leads experts to believe that this disorder may often go unnoticed or be misdiagnosed due to the overlapping symptomology and abundance of comorbidities that exist within DID. Its prevalence may in fact, be greater than currently reported. Although many theories exist, most theories converge on the idea that DID is a result of severe and often repeated trauma occurring in early childhood. These trauma based theories conceptualize that what manifests as a debilitating disorder in adulthood was meant as a protective coping mechanism and shield for the traumatized child. Much of the brain research concerning DID reveals findings consistent with the disorder of post- traumatic stress syndrome. (PTSD.) Though DID begins in early childhood, it is most often diagnosed in adolescence or adulthood. Though there have been success stories, treatment of DID has been largely unsuccessful on a global scale. Recent neurobiological research on the causes, functions, and mechanisms of DID provides a new hope and foundation upon which clinicians can base their treatment plans. More research is needed for full apprehension and productive treatment of this disorder.
  3. 3. Neurobiological Driven Treatment of DID 3 Neurobiological Research Driven Treatment for Dissociative Identity Disorder Dissociative Identity Disorder (DID) is under-researched and often misunderstood. (Chlebowski & Gregory, 2012). The disorder can be intimidating to both doctors and counselors. Many researchers agree with Gleaves and Williams (2005) when they lament that, …many professionals have no formal education and training in the psychopathology, assessment and treatment of posttraumatic stress disorder (PTSD) and dissociative disorders. In particular, many of the ideas that clinicians have about DID may come from hearsay or the popular media, not theoretical and empirical research regarding trauma and dissociation. (p. 648) There is a great need for clinicians to be made aware, educated and trained in the theories and treatment of dissociative disorders and specifically, DID. A review of the literature helps to crystalize the origins, purposes and processes of this disorder. Treatment of DID has been largely unsuccessful in the past, but current research providing insight into the processes of dissociation is providing clinicians with the direction needed to create successful treatment plans. The bulk of this review will resolve around treatment of DID as it presents in adolesence or adulthood because as Boysen (2011) concludes from his review of research on childhood DID, “…childhood DID itself appears to be an extremely rare phenomenon…” (p. 329).
  4. 4. Neurobiological Driven Treatment of DID 4 Understanding DID “Dissociation means to bring apart, split off or disconnect elements that have something in common, as the opposite of association.” (Diseth, 2005, p. 79) The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) (DSM - 5) acknowledges that dissociation can affect memory, consciousness, identity and perception of environment. Sensation, movement and other bodily functions can also be disturbed. Many or all of these occurances are common in the patient with DID. What sets DID apart from the other dissociative disorders is the prescence of a disruption of identity. In order to meet the DSM -5 criteria for DID, two or more separate personality states must exist and exhibit amnesia in relation to each other. Often several of these parts will take control of the behavior of the individual. Although reports vary and further research is needed, Johnson and collegues, as sited in Chlebowski & Gregory, (2012), found DID to be prevalent among about 1.5% of the general population. Foote and colleagues found the prevelance to be between 5-6% among both inpatient and outpatient psychiatric patients (as cited in Chlebowski & Gregory, 2012). Females are much more likely to meet criteria for DID with Maldonado, Butler & Spiegel (as cited in Durand & Barlow, 2013) reporting as high as a 9:1 ratio. Ross (1997) as well as Sackeim & Devanand (1991), found that clinicians report the average number of separate identities to be around 15 (as cited in Durand & Barlow, 2013). Most treatment models for DID agree that intergration of dissociated parts is the culminating and confirming factor of healing. Unfortunately, research by Ross (1997) suggests that roughly 22% of those suffering from DID will achieve full integration after two full years of continuous therapy (as cited in Durand & Barlow, 2013). This poor prognosis makes it clear that further research is needed to bring about effective treatment in the future. With intergration as
  5. 5. Neurobiological Driven Treatment of DID 5 the main goal for healing, much of the current research resolves around discovering the causes, functions and mechanisms of the process of trauma related dissintegration. If we can learn how and why the brain was able to dissociate, maybe we will gain a better understanding of the processes needed to undo the effects of severe and complex dissociation. It was in the late 1990s that dissociative traits were measured in general population studies and correlations were found between dissociative symptoms and those with childhood abuse in their past. Currently, the focus is on understanding the developmental causes and outworkings of the trauma-related dissociative process and its connection to possible treatment models. (Diesth & Christie, 2005) The revelation of neurobiological implications of dissociation through recent research has proved helpful to this cause. Neurobiological Research “The difficulty that individuals may have with synthesizing and personifying terrifying experiences seems related to biological reactions to severe threat.” (Nijenhuis, van der Hart, & Steele, 2010) The mind and body connection is powerful in relation to trauma and dissociation and may be a key to unlocking the mystery that once seemed to surround DID. Both structural and chemical reactions have been linked to trauma related dissociation. “In both animal and human studies, early stress has been shown to be associated with changes in the structure of the hippocampus, which plays a crucial role in learning, memory, and stress regulation.” (Vermetten, Schmahl, Linder, Loewenstein, & Bremner, 2006, p. 630) A study by Vermetten et al.(2006) found a 19.2% decrease in the mean volume of the left and right hippocampus of DID patients. But Nijenhuis et al. (2010) report that “women who fully recovered from DID had more hippocampal volume compared to women with DID.” (p.4) In this case, the damage to the
  6. 6. Neurobiological Driven Treatment of DID 6 hippocampus created by trauma-related dissociation was somehow reversed, and volume regained in the healing process! The connections being made in these findings should provide hope and direction to researchers, clinicians, and sufferers of DID that solid, researched based treatments are on the horizon. Research Driven Treatments The phase oriented treatment of DID for instance, in a preliminary finding is linked with substantial growth of both the left and right hippocampal volume. (Nijenhuis, van der Hart, & Steele, 2010) This treatment consists largely of three phases. The goal of the treatment, as stated by Nijenhuis et al. (2010) “concerns resolution of the structural dissociation of the personality by exposing the dissociative parts of the personality, and their mental contents to each other in carefully planned steps that promote integration and preclude re-dissociation” (p. 18). The first phase, according to Nijenhuis et al. (2010) involves increasing the coping capabilities of the patient. During this phase, phobia of dissociated parts of the personality are addressed and overcome. In order for DID to be maintained, dissociated parts will remain phobic of each other while the part of the personality most often apparent to the world will persist in phobia of traumatic memories. In order to return to unity, the therapist must help the patient go from fear to acceptance of her parts and memories. Attachment phobias are dealt with and hopefully lead to a secure alliance with the therapist and cooperative relationships between dissociated parts. Nijehuis et al. (2010) are careful to point out that, in order to prevent redissociation from occuring, the patient must be secure in her acceptance of parts and strengthened in coping skills before moving to phase two. This phase involves overcoming the phobia of traumatic memories through gradual access and exposure. Substantiated methods for the treatment of PTSD, such as Eye Movement Desensitization and Reprocessing, Cognitive Behavioral Therapy, guided
  7. 7. Neurobiological Driven Treatment of DID 7 imagery, and hypnosis, are commonly used in this phase. The main goals of the third phase, according to Nijenhuis et al. (2010) are overcoming fears of intimacy, synthesizing dissociated parts of the personality and learning to replace dissociative and avoidant measures with healthier coping mechanisms to face the tragic griefs caused by early endured trauma. Diesth & Christie (2005), agree with this model when they conclude that, “the currently agreed aim of treatment…is to reveal the trauma, then work through it by introducing new frames and strategies for coping and control…” (p. 284). They also recommend that, “The most successful treatment approach is often the most eclectic…” (p. 285) and encourage therapists to be well researched and flexible. (p. 285) They warn that therapuetic interventions be based on what is currently known about the neurobilogical processes of dissociation and trauma. Some of the treatments recommended by Diesth & Christie (2005) include the use of dissociation as a tool to help patients gradually approach their trauma memories, increase affect tolerance, and gain control over intrusive images. Schema-focused cognitive therapy points out early maladaptive schemas and works to restructure them into healthier, more truthful perspectives. Diesth & Christie provide neurobiological support for the use of hypnotherapy when they remind us that, “since traumatic experiences are coded in a special emotional state and not accessible only by cognitive approaches, therapists…integrate hypnotherapeutic approaches” (p. 287). Conclusion DID has long been a source of controversy and some mystery among professionals and the community at large. Fortuneately, new research into the brain chemistry and structures affected by DID is providing insight into the causes, functions and mechanisms of
  8. 8. Neurobiological Driven Treatment of DID 8 this disorder. These insights have provided researchers and clinicians with a foundation to base formation of individualized treatment plans to assist patients to achieve integration of personality and to put adaptive coping mechanisms in place of maladaptive dissociative coping strategies. Vermetten et al. (2006) encourage us that, “These findings may have clinical implications for the treatment of DID patients….understanding DID as…involving neural circuitry alterations in brain areas associated with…PTSD may help clinicians better understand…treament sessions.” (p.635) More research is needed in the area of neurobiological affects of DID. As researchers uncover more information it is hopeful that the percentage of DID patients achieving full intergration of personality will increase significantly.
  9. 9. Neurobiological Driven Treatment of DID 9 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Boysen, G. A. (2011). The Scientific Status of Childhood Dissociative Identity Disorder: A Review of Published Research. Psycotherapy and Psycosomatics, 80, 329-334. Chlebowski, S. M., & Gregory, R. M. (2012). Three Cases of Dissociative Identity Disorder and Co-Occuring Boderline Personality Disorder Treated with Dynamic Deconstructive Psycotherapy. American Journal of Psychotherapy, 66 (2), 165-180. Diesth, T. H., & Christie, H. J. (2005). Trauma related dissociative (conversion) disorders in children and adolescents - an overview of assessment tools and treatment principles. Nordic Journal of Psychiatry, 59, 278-292. Diseth, T. H. (2005). Dissociation in children and adolescents as reaction to trauma-an overview of conceptual issues and neurobiological factors. Nordic Journal of Psychiatry, 59, 79- 91. Durand, M. V., & Barlow, D. H. (2013). Essentials of Abnormal Psychology. Belmont : Wadsworth, Cengage Learning. Gleaves, D. H., & Williams, T. (2005). Critica Questions: Trauma, Memory, and Dissociation. Psychiatric Annals, 35 (8), 648-654. Nijenhuis, E., van der Hart, O., & Steele, K. (2010). Trauma-Related Structural Dissociation of the Personality. Activitas Nervosa Superior, 52 (1), 1-23. Vermetten, E., Schmahl, C., Linder, S., Loewenstein, R. J., & Bremner, D. J. (2006). Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder. American Journal of Psychiatry, 163 (4), 630-636.