A brief description of the controversies surrounding the diagnosis of dissociative identity disorder is presented, followed by a discussion of the proposed similarities and differences between dissociative identity disorder and borderline personality disorder. The phenomenon of autohypnosis in the context of early childhood sexual trauma and disordered attachment is discussed, as is the meaning of alters or alternate personalities. The author describes recent neurosciences research that may relate the symptoms of dissociative identity disorder to demonstrable disordered attention and memory processes. A clinical description of a typical patient presentation is included, plus some recommendations for approaches to treatment. keywords: dissociative identity disorder, multiple personality disorder, borderline personality disorder, alters or alternates, childhood sexual trauma, attachment disorganized or disoriented type mary now edith: what are you talking about? psychiatrist: may i speak to mary? mary now edith: she doesn x02019 t have the guts to come here.

In 1988, dell1 surveyed clinicians to assess the reactions they had encountered from others as a result of their interest in dissociative identity disorder did , previously called multiple personality disorder. Of 62 respondents who had treated patients with did, more than 80 percent said they had experienced x0201c moderate to extreme x0201d reactions from colleagues, including attempts to refuse their patients x02019 admissions to hospitals or to force discharge of their patients, even patients that the respondents felt represented a serious suicidal risk. Reported cases of did by frankel,8 ganaway,9 and mchugh, 10 ,11 among others, have been attributed instead to social contagion, hypnotic suggestion, and misdiagnosis. These authors have argued that the patients described as having did are highly hypnotizable, and therefore are very suggestible. They argue that these patients likely would be prone to follow direct or implicit hypnotic suggestions, and that the majority of diagnoses of did are made by a few specialist psychiatrists. In 1993, lauer, black, and keen12 concluded that did was an epiphenomenon of borderline personality disorder, finding few differences in symptoms between the two diagnoses.

They described, rather, a x0201c syndrome x0201d of symptoms that occurs in persons with disturbed personalities, particularly borderline personality disorder. They concluded that did had x0201c no unique clinical picture, no reliable laboratory tests, could not be successfully delimited from other disorders, had no unique natural history and no familial pattern. X0201d that same year, after yeomans x02019 efforts to answer this question by empirically reviewing the literature, north et al13 concluded that the diagnosis has not been x0201c truly x0201d validated,14 but yet they x0201c came to believe in its existence.

X0201d they stated, x0201c current knowledge does not at this time sufficiently justify the validity of did as a separate diagnosis, x0201d but this also does not disprove the concept. Subsequently, spira15 edited a book by proponents of the existence of did, describing treatment options. Loewenstein16 and bliss17 concluded that did existed and spontaneous autohypnotic symptoms were basic to the phenomenology of did.

Gelinas18 described autohypnotic and posttraumatic stress disorder ptsd symptoms in did patients that likely were a response to childhood sexual abuse. Spiegel and rosenfeld19 attributed the x0201c spontaneous age regression x0201d to a younger alter seen in did patients to early trauma and also believed that ptsd symptoms related to trauma were central to did. Horevitz and braun20 found that 70 percent of patients who had been diagnosed with x0201c multiple personality disorder did x0201d would just as likely, by chart review, meet the criteria for borderline personality disorder. However, they also found other patients that could not be so characterized, and they concluded that did was in fact a distinct entity, but overdiagnosed. Coons et al21 performed assessments with the structured clinical interview for dsm disorders scid and structured interview for dsm i r personality disorders sidp r , dissociative disorder interview schedule ddis , the beck depression, beck hopelessness, and dissociative experiences scale des and shipley institute of living scales on patients who had been diagnosed with did. They found that 64 percent of patients diagnosed with did met criteria for borderline personality disorder, but of those who did not, they met many of the criteria for borderline personality.

However, as found by horevitz and braun,20 one third of persons previously diagnosed with did on axis i on the basis of the above mentioned assessment scales did not meet criteria for any axis ii disorder. Of special note was that the des was higher in did diagnosed subjects than in other subjects. Coons et al21 concluded that did was a x0201c syndrome x0201d that occurred in persons with disturbed personalities, particularly borderline personality disorder, and that both borderline personality disorder and did were on the same character disorder spectrum, with did representing its more severe end. The authors argued that the multiplicity of symptoms associated with did, including insomnia, sexual dysfunction, anger, suicidality, self mutilation, drug and alcohol abuse, anxiety, paranoia, somatization, dissociation, mood changes, and pathologic changes in relationships, supported their view. Herman22 has characterized did as a disorder of extreme stress, possibly a form of complex ptsd, due to prolonged repeated trauma. Although the alters described in did are sometimes referred to as ego states. They define ego state as an x0201c organized system of behavior and experience whose elements are bound together by some common principle but that is separated from other such states by boundaries that are more or less permeable.

In contrast, ptsd symptoms would more likely occur when trauma is experienced later in childhood or during adult life.24 severe child abuse, a disorganized and disoriented attachment style, 25 ,26 and the absence of social and familial support seem to precede the development of did. The tendency to dissociate seems to be related as much to a pathogenic family structure and attachment disorder acquired early in the life of the child as to original temperament or genetics. Parenting style toward these patients was usually authoritarian and rigid, but paradoxically with an inversion of the parent child relationship.27 blizard28 speculated that children who display a disorganized/disoriented pattern of attachment29 might be in the process of dissociating their representations of contradictory parent behavior and that, in did, distinct patterns of attachment may have been incorporated into the various personalities. The disorganization that is observed in the did patient x02019 s attachment pattern is particularly interesting in view of some of the recent neursciences findings about this disorder. Did patients showed increased vigilance, resulting in reduced habituation of startle reflexes and increased ppi.

This response is a voluntary process that directs attention away from unpleasant or threatening stimuli. X0201d they concluded that x0201c implicit x0201d memories could be best stored and retrieved mainly during discrete behavioral states of consciousness. By contrast, one identity could recognize neutral words learned by the other identity.34 also, memories of presumably neutral words,35 which were presented via auditory input but retrieved visually, showed interidentity memory transfer. Huntjens et al36 recommend that clinical models of amnesia in did should exclude impairments for emotionally neutral material. This would be predicted by the adaptive hypothesis described by stankiewicz and golczynska.39 the typical patient who is diagnosed with did is a woman, about age 30.

A retrospective review of that patient x02019 s history typically will reveal onset of dissociative symptoms at ages 5 to 10, with emergence of alters at about the age of 6. Typically by the time they are adults, did patients report up to 16 alters adolescents report about 24 , but most of these will fade quickly once treatment is begun. There generally is a reported history of childhood abuse, with the frequency of sexual abuse being higher than the frequency of physical abuse.

Patients who have been diagnosed with did frequently report chronic suicidal feelings with some attempts. Sexual promiscuity is frequent but patients usually report decreased libido and an inability to have an orgasm. Some patients report that they dress in clothing of the opposite gender or that they, themselves, are of the opposite gender. Patients often report x0201c extrasensory experiences x0201d related to dissociative symptoms, sometimes called hallucinations. They report hearing voices, periods of amnesia, periods of depersonalization, and may use the plural x0201c we x0201d instead of x0201c i x0201d when referring to the self.