DID

Question 1

Classification of DID

Answer 1

• 2+ distinct personality states
• Amnesia - gaps in recall of everyday events or traumatic experiences inconsistent with normal forgetting

Question 2

Classification of Depersonalization/Derealization

Answer 2

• Depersonalization - detached from oneself
• Derealization - experience of unreality, distance or distortion
• Presence of one or both ^

Question 3

Classification of Dissociative Amnesia

Answer 3

• Inability to recall important autobiographical info, usually of trauma, that is inconsistent with ordinary forgetting
• WITH OR WITHOUT figure:
• Fugue is purposeful travel where they leave and develop a different identity then memories come back and they can go back to their past life. Fugue can last months and people try to figure out who this is

Question 4

Differential for DID

Answer 4

PTSD, bipolar, BPD

• Overlap with BPD but to have PD need single, enduring, inflexible, pervasive, stable pattern of inner experience so if you have multiple alters than can’t have BPD but 60% of people with DID will have all symptoms with BPD, they can have personalities that have BDP and personalities that done.

Question 5

Assessment

Answer 5

• Watch out for: using “we”, changes in behaviour demeanour, motivations, knowledge, language, having child abuse
• Risk factors
• Differentials

Question 6

Risk factors

Answer 6

• Child abuse that needs to start in a developmental window if they experience this after 7-8 then very unlikely as personality is integrated enough to not fully come apart
• Environmental factors, especially families who are secretive and keeping everything within family even partner abuse etc
• Attachment: disorganised – goes to attachment figure then they become chaotic (because the same attachment figure is the one who hurts them, in DID they become masters of reading how other people are because they need to know when it is safe or not to go to attachment figure)
  o Disorganised comes from a parents who is either frightened: If parent is frightened, not engaged, depressed, dazed, anxious, afraid, or frightening: attack, intrusive, loud, startling, sudden movement – doesn’t mean abusive parent but doesn’t know how to read their child.
• Lack of support & nurturance following trauma (don’t tell anyone etc)

Question 7

Models of DID

Answer 7

Symptom level
1. Continuum Model - Pathological dissociation is merely a quantitative extension from non-pathological dissociation
2. Taxon Model - Dissociation is continuous to a point, but then a qualitative and quantitative distinction occurs (Amnesia/fugue/DID categorically separate)

Process Level
1. BASK Model- breakdown in integrative functioning in 4 domains, do not integrate with everything else
B- Behaviour (eg contracture)
A- Affect (eg numbing)
S- Sensation (eg analgesia)
K - Knowledge (eg amnesia)
2. Information Processing Model (kennedy)
- Integrative breakdowns are possible at 3 stages in info processing
Stage 1) Early, Autonomic Stage
- Breakdown at sensory level (missing visual info)
Stage 2) Within Modes
- Cognitive schema (remember what happened), Behavioural schema (remember behavioural response eg what did), Physiological schema (how felt in body), but Affect schema is dissociated from rest of memory (person may display numb affect when telling trauma story)
Stage 3) Between Modes
- Dissociation between different sets of memories eg home memories not integrated with school memories

Structural Level
- Mind is organised around 2 action systems: Action systems of Daily Life (ASDL) (eg work, study, relationships, care of others) and Action systems of Defense (ASD) (fight, flight etc). When trauma occurs, ASDL separate from ASD (mind left with 2 separate parts after trauma).
- Apparently Normal Personalities (ANP) becomes organised with ASDL
- Emotional Personalities (EP) becomes organised with ASD
- If trauma continues - dissociation occurs at EP level and fight,flight etc become separated - not connected with any normal frontal lobe functioning so if they feel like fight they will engage in that
- If trauma continues - further dissociation in ANP (eg person’s different roles won’t be together but separate so mother, worker, lover separate to one but 3 different)

Dissociation: The impact of trauma leads to breakdown of integration. Different structures of personality developed (ANP and EP). Further trauma leads to dissociation of EP. Further trauma leads to dissociation of ANP. This gives rise to symptoms eg intrusive voices.

The problem with DID is not having more than one personality it is having less than one. The components of such a personality structure are often quite limited.

“DID is more like a never-assembled psychological jigsaw puzzle, not a shattered mirror. All the DID self- states constitute the mind of the person; they are not “separate people”.

Question 8

Treatment of DID

Answer 8

Phasic multimodal trauma focused psychotherapy

1. Stabilisation of safety issues - rapport, psychoed, stabilising heightened affect/impulses
2. Processing of traumatic memories - allowing them to develop a coherent narrative of traumatic and non-traumatic memories and developing sense of self identity by exploring meaning and impact of trauma including cognitive distortions and expressing emotions that might have been previously avoided
3. Re-integration into life - focus on current life issues and goals