解離性身份疾患(DID):全面深入的指南
解離性身份疾患(Dissociative Identity Disorder, DID),前稱多重人格障礙,是一種複雜的精神疾病,影響約全球人口的1.5%。雖然罕見,但DID常伴隨著嚴重的心理健康問題,包括自殘行為和自殺企圖,這使得該病症經常被誤診。DID屬於解離性障礙的一種,其特徵是個體內存在兩個或更多的不同身份,每個身份具有自己獨特的行為、記憶以及與世界互動的方式。本文將探討DID的病因、症狀、診斷挑戰、治療選擇,以及跨專業團隊在管理該病症中的重要角色。
什麼是解離性身份疾患?
解離性身份疾患是一種解離性障礙,患者的身份感被分裂成多個不同的身份或「分身」(Alters)。每個分身都有其獨特的行為、記憶,甚至生理反應。這些身份可能會突然轉換,導致患者感到困惑、記憶缺失,以及日常生活中的不連貫性。
DID患者通常會經歷解離現象,即他們的思想、感受、記憶或身份感之間產生了脫離。這種解離是一種防禦機制,通常是在童年早期經歷嚴重創傷時發展出來的,作為應對難以承受的情感負荷的一種方式。
病因:創傷的角色
DID的主要病因被認為是嚴重且反覆發生的童年創傷。創傷破壞了正常的身份形成過程,導致患者通過解離來應對難以忍受的經歷。研究人員認為,大腦通過創建分離的身份來分隔創傷,這樣個體即使面臨巨大的情感負擔,也能繼續運作。
有兩個主要的理論來解釋DID的發展:
創傷理論:該理論認為,解離是極端創傷的直接結果,特別是在童年早期。
幻想模型:這一模型則認為,DID患者可能是因為高度的易感性,加上心理症狀的先天傾向和社會孤立,通過幻想和暗示產生了分裂身份。
無論是哪種理論,童年創傷,尤其是情感、身體或性虐待,是DID的主要促發因素。
流行病學:DID的罕見性與誤診率
根據研究,解離性障礙的全球患病率約為1%至5%。其中,嚴重的解離性身份疾患大約占1%至1.5%。由於DID的複雜性,患者往往需要長達5到12.5年的治療時間才能確診。在這期間,他們常被誤診為其他人格障礙或精神病性障礙,這進一步延誤了正確的治療。
在臨床上,DID患者常見的症狀包括非自殺性自殘行為和自殺企圖。他們也經常因為解離症狀被誤認為患有邊緣性人格障礙(BPD),這些誤診導致患者無法及時獲得正確的治療。
病理生理學:分身的運作方式
根據國際創傷與解離學會(International Society for the Study of Trauma and Dissociation)的說法,DID患者的每個分身都是獨立運作的身份,這些身份具有自己獨立的記憶、行為和對外界的感知,並且彼此之間可能完全不相互交流。分身之間的切換往往會伴隨著某些行為徵兆,例如眼神呆滯、頻繁眨眼、眼睛翻白或姿態的改變。
主要的假設是,分身是由於創傷兒童無法在各種行為狀態下發展出統一的自我意識,特別是在創傷發生於5歲之前時更為明顯。這樣的早期創傷干擾了孩子建立完整和持續的自我感,導致身份分裂。
診斷挑戰:複雜的評估過程
DID的診斷通常需要由精神科醫生和經驗豐富的心理學家進行詳細的歷史評估。由於DID的症狀常與其他人格障礙(如邊緣性人格障礙)相似,且解離性症狀如失憶也常見於多種精神疾病,因此診斷過程可能需要多次長期評估,並需從多個來源獲取病史。
一些常用的診斷工具包括:
解離經歷量表(Dissociative Experiences Scale):這是一份28項的自我報告問卷,主要評估解離性症狀如記憶吸收、人格脫離和現實感喪失等。
解離問卷(Dissociation Questionnaire):這份63題的問卷主要用於測量身份混亂、記憶丟失及人格碎片化等症狀。
情緒調節困難量表(Difficulties in Emotion Regulation Scale, DERS):這是一份36題的自我報告量表,測量情緒控制困難、衝動行為和情緒反應等。
治療與管理:多元化的治療方法
DID的治療通常基於人格障礙的三步驟結構進行:
建立安全性、穩定性和症狀減輕:首要目標是確保患者的安全,尤其是在他們表現出自殺或自殘行為的情況下。
處理與整合創傷記憶:治療的第二階段集中於面對和處理創傷記憶,幫助患者容忍和整合過去的痛苦經歷,並且可能需要與不同分身一起工作來分享記憶。
身份整合與康復:最終的階段集中於幫助患者整合其分離的身份,並改善他們與自我和外界的關係。
**心理動力治療(Psychodynamic Therapy)**是最常見的治療方法,治療師通過逐步與患者建立信任,幫助他們處理創傷。然而,**創傷焦點認知行為治療(Trauma-Focused Cognitive Behavioral Therapy, CBT)和辯證行為治療(Dialectical Behavioral Therapy, DBT)**也被認為對一些患者有效,尤其是針對情緒調節困難和壓力管理的症狀。
其他治療方式
催眠治療:研究顯示,DID患者的催眠感受性較高,因此催眠療法被用來幫助患者接觸未顯現的分身,並促進治療過程。
眼動脫敏與再處理(EMDR):這是一種針對創傷記憶的療法,但必須在患者具備足夠的穩定性和應對技巧時才適合使用。
藥物治療並非DID的主要治療手段,但可以用於控制伴隨的情緒障礙或創傷後壓力症候群(PTSD)等症狀。由於不同分身的症狀和需求可能不同,藥物治療的效果通常有限。
預後與患者教育
不幸的是,DID通常在患者的成年期才被診斷出來,而錯誤的診斷和治療常會延遲患者獲得正確治療的機會。一旦診斷並開始治療,這往往需要長期或終身的支持,並強調現實基礎的干預措施。
患者及其家庭需要深入了解這一疾病,包括分身的存在及其帶來的挑戰,並學習如何應對和使用安全技術。
結論:跨專業團隊的重要性
DID的治療需要一個由精神科醫生、心理學家、護士、創傷治療師等多專業組成的團隊共同合作。治療的重點是與患者建立強大的治療聯盟,並密切關注患者的安全計劃和現實檢測干預。透過定期的隨訪和團隊協作,可以提高患者的治療效果,幫助他們更好地應對疾病帶來的挑戰。
Dissociative Identity Disorder
Paroma Mitra; Ankit Jain.
Author Information and Affiliations
Last Update: May 16, 2023.
Continuing Education Activity
Dissociative identity disorder (DID) is a rare psychiatric disorder diagnosed in about 1.5% of the global population. This disorder is often misdiagnosed and often requires multiple assessments for an accurate diagnosis. Patients often present with self-injurious behavior and suicide attempts. This activity reviews the evaluation and treatment of dissociative identity disorder and explains the role of an interprofessional team in caring for patients diagnosed with dissociative identity disorder (DID). This activity also reviews the association between DID and suicidal behavior.
Objectives:
Describe the constellation of behavioral symptoms that lead to a diagnosis of dissociative identity disorder.
Review risk factors for the development of a diagnosis of dissociative identity disorder.
Explain the different modalities of evidence-based treatment for dissociative identity disorder.
Outline some interprofessional strategies that can improve patient outcomes in patients with dissociative identity disorder.
Access free multiple choice questions on this topic.
Introduction
Dissociative identity disorder (DID) is a rare disorder associated with severe behavioral health symptoms. DID was previously known as Multiple Personality Disorder until 1994. Approximately 1.5% of the population internationally has been diagnosed with dissociative identity disorder.[1] Patients with this diagnosis often have several emergency presentations, often with self-injurious behavior and even substance use.[2]
Of note, DID has been observed and described in several countries and associated with terms such as "outer world possession" and "possession by demons."[3] Several case reports have been described with those terms; however, trauma and its association came with DID much later.
Etiology
Dissociative identity disorder is typically associated with severe childhood trauma and abuse.[4] Dalenberg and his team have detailed the role of trauma in the development of dissociative disorder and dismissed the previous model, which was based on fantasy and often associated with suggestibility, cognitive distortions, and fantasy. However, newer research tends to describe a combination of both severe traumas (which may be in any form physical/emotional/sexual)as well as some effects of cognitive suggestion. Stress experienced by an individual secondary to trauma has been seen to contribute to the formation of an accurate understanding of the trauma being unreal, even posttraumatic dissociation such as leaving one's body, etc., and poor sleep. However, in the fantasy theory-it has been seen that people with high levels of vulnerability, predisposition of psychological symptoms, media influences, and likely social isolation and vulnerability.[5]
Several prominent psychologists, such as Kluft, have broken down the theory behind DID-in-sum. The theory describes predisposing factors for dissociation, which include an ability to dissociate, overwhelming traumatic experiences that distort reality, creation of alters with specific names and identities, and lack of external stability, which leads to the child's self-soothing to tolerate these stressors. These four factors must be present for DID to develop.[6]
Epidemiology
Dissociative disorders show a prevalence of 1% to 5% in the international population. Severe dissociative identity disorder is present in 1% to 1.5% of this population. Patients may spend up to 5 to 12.5 years in treatment before being diagnosed with dissociative identity disorder.[7] Patients with DID come with increased rates of non-suicidal self-injurious behavior and suicide attempts.[8]
Pathophysiology
The DID person, per the International Society for the Study of Trauma and Dissociation, is described as a person who experiences separate identities that function independently and are autonomous of each other. The International Society describes alternate identities or "alters" as independent identities with distinct behaviors and memories distinct from others and may even differ in language and expressions used. Signs of a switch to an altered state include trance-like behavior, eye blinking, eye-rolling, and changes in posture.
The major hypothesis by Putnam et al. is that "alternate identities result from the inability of many traumatized children to develop a unified sense of self that is maintained across various behavioral states, particularly if the traumatic exposure first occurs before the age of 5." [9] The theories have been studied by groups in the inpatient unit services in the 1990s.
History and Physical
The way to diagnose dissociative identity disorder is via detailed history taken by both psychiatric practitioners and experienced psychologists. Often, persons with DID are misdiagnosed with other personality disorders, most commonly borderline personality disorder, as elements of dissociation are prominently seen and even amnesia. Longitudinal assessments over long periods and careful history-taking are often required to complete diagnostic evaluations. History is often gathered from multiple sources as well. Neurological examinations are often required to rule out autoimmune encephalitis, often requiring electroencephalograms, lumbar punctures, and brain imaging.
Dissociative Disorders are classically characterized as disrupting normal consciousness/memory/identity and behavior. The disorders are classically broken down into "positive " and "negative " symptoms -positive symptoms are often associated with "new personalities, derealization," and negative symptoms are symptoms such as autism and paralysis.[10] Dissociative identity disorder is part of the larger dissociative disorders spectrum; however, it has more specific criteria outlined by the Diagnostic And Statistical Manual Edition-5.
The Diagnostic and Statistical Manual (DSM-5)criteria for DID include at least two or more distinct personalities. Each personality varies in behavior, sense of consciousness, memory, and perception of the outside world. Persons with DID experience amnesia, distinct gaps in memory, and recollections of daily and traumatic events. They cannot be directly related to substance use or part of cultural norms or practices. Importantly, these symptoms must cause a notable lack of daily functioning.[11][10]
Evaluation
As explained above, a detailed history from multiple sources and multiple longitudinal assessments over time is of the essence. However, some evaluation tools have been developed to diagnose DID. Some of these are below:
Dissociative Experiences Scale - a 28-item self-report instrument whose items primarily tap the absorption of outside information, use of imagination depersonalization, derealization, and amnesia.[12]
Dissociation Questionnaire - 63 questions that measure identity confusion and fragmentation, loss of control, amnesia, and absorption.
Difficulties in Emotion Regulation Scale (DERS) - 36-question subjective questions around challenges in goal-directed work, impulsivity, emotional responses to situations, ability to self-regulate emotions, etc.[13]
Treatment / Management
Some treatment approaches for dissociative identity disorder include basic structures from work with personality disorders in a three-pronged approach:
Establishing safety, stabilization, and symptom reduction;
Confronting, working through, and integrating traumatic memories
Identity integration and rehabilitation.[14]
The first step focuses on the safety of patients with DID, as many present with suicidal ideation and self-injurious behavior.[8] It is important to mitigate that risk. The second phase focuses on working with traumatic memories and includes tolerating, processing, and integrating past trauma. This may focus on continuing to re-access traumatic memories with different alternate identities and may help share memories. The third and final treatment phase focuses on the patient’s relationship to self as a whole and to the rest of the world. Through all the phases of treatment, a strong therapeutic alliance and trust are encouraged
The most common approach is via psychodynamic psychotherapy steps, broken down above. Recent approaches include trauma-focused cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT).[15] There are no controlled clinical trials for CBT. The reason DBT skills are used is essentially secondary to some of the overlapping symptoms between borderline personality disorder and DID. Even with varying therapy approaches, some core treatment features include more education, emotional regulation, managing stressors, and daily functioning.
Another mode of treatment is the use of hypnosis as therapy. According to the literature, DID patients are more hypnotizable than other clinical populations.[16] There have been some studies as recent as 2009 that have shown efficacy in the use of hypnosis to treat DID.[17] Many DID patients are considered autohypnotic. Some techniques include accessing alternate identities not present in the session, an intervention that can facilitate the emergence of identities critical to the therapeutic process.[6]
Another mode of treatment has been the use of Eye Movement Desensitization and Reprocessing (EMDR). The guidelines, however, advocate for EMDR to be used as part of integrative treatment. EMDR processing is recommended only when the patient is generally stable and has adequate coping skills.EMDR interventions for symptom reduction and containment, ego strengthening, work with alternate identities, and, when appropriate, the negotiation of consent and preparation of alternate identities.[18]
Psychopharmacology is not the primary treatment for DID. Medications may be used to target certain symptoms reported. The most commonly used medications include medications for mood disorders and PTSD (post-traumatic stress disorder).[19] The challenges of using psychopharmacological medications remain as different alters may report different symptoms. Some alters may report compliance, and some may not. The literature review has shown that many medications have been used for DID, including antipsychotic medications, mood stabilizers, and even stimulants; however, no medication has been effective in the treatment of DID.[20]
Differential Diagnosis
As mentioned above, the most common differential diagnosis includes borderline personality disorder, histrionic personality disorder, and even primary psychotic disorders such as schizophrenia and schizoaffective disorders. As mentioned, patients with DID often present with symptoms of dissociation and amnesia, which are also seen in patients with borderline personality disorder. Often, patients' symptoms are considered symptoms of psychosis as alters as mistaken as hallucinations, which often precipitate the use of antipsychotic medications. Given that trauma is a focus, post traumatic stress disorder is also a differential diagnosis.
The most common differential diagnosis is borderline personality disorder.[21] Borderline personality disorder is also associated with extensive trauma, which often presents with micropsychotic and dissociative symptoms.
Pertinent Studies and Ongoing Trials
There have been case studies and case reports formerly reported in the '90s and early 2000s. Some more treatment interventions have been described in naturalistic and longitudinal studies that continue to inform outcomes.[7]
Prognosis
Unfortunately, Dissociative identity disorder is a medical condition often diagnosed later in life. Often, patients are misdiagnosed with other diagnoses as described above and treated with medications and even therapies that may not directly address DID. Once in treatment, this tends to be lifelong as DID patients continue to require reality-based and grounding interventions. Safety planning with DID patients is lifelong. The prognosis without treatment and correct diagnosis is poor.
Complications
The patients remain at increased risk of self-injurious behavior given the presence of alters as well as latent trauma.[22] There have been newer research studies that have described suicidal ideation, especially during dissociation, which describes decreased pain tolerance and more emotional dysregulation. Most treatment interventions advocate for safety planning and reality testing before the use of more advanced psychotherapy techniques
Inpatient hospitalizations and day treatment programs may also be recommended for patients who struggle with thoughts of self-injurious behavior, poor impulse control, or acute mood dysregulation. Medications may be added for mood stabilization.
Deterrence and Patient Education
Patient education must focus on informing patients on the correct diagnosis when it is determined. Family members are encouraged to be educated about the nature of this illness, including the presence of alters, as well as safety and grounding techniques. Another vital aspect continues to maintain a strong therapeutic alliance with the treatment team and engage in maintaining safety techniques.
Education may be done with multiple alters that do not communicate with each other, and this must be recognized. On the other hand, DID patients often do not want their diagnosis shared publicly, and their privacy must be respected.
Enhancing Healthcare Team Outcomes
Dissociative identity disorder requires treatment by an interprofessional healthcare team - this will often consist of medical specialists such as a psychiatrist, mid-level practitioners, nursing staff, specialized therapists, trauma counselors, peer counselors, and therapists who all communicate and collaborate. A psychiatrist and primary care physician complete the team. Maintaining a strong therapeutic alliance with the patient and involved family members continues to be of utmost importance. DID patients require frequent check-ins and follow-up appointments and an almost daily focus on safety planning and reality-based interventions.