Since, I’ve been gone so long here is a paper I did this semester. If anyone is interested in Dissociative Identity Disorder, you may find it interesting. Anyone? Just me? Oh well!
Dissociative Identity Disorder (DID) is an Axis I disorder recognized by the Diagnostic and Statistical Manual of Mental Disorders, as the occurrence of two distinct personalities exist along with the clear identification of dissociative symptoms (2000). DID’s validity as a diagnosable disorder is widely disputed and controversial, due to the complexity of the symptom picture, differential diagnosis, and media exposure. Primarily, DID develops as a result of a childhood trauma, in most cases extreme sexual and physical abuse, although it could be a result of repeated medical procedures, natural disasters (e.g., hurricanes, earthquakes, or tornados), war, or death of a caregiver (Traub, 2009). It has been reported that individual psychotherapy, with hypnosis, has been most effective when treating someone with DID (Spring, 2011).
Dissociative Identity Disorder
United States of Tara is an American television program created by Diablo Cody staring Toni Collette, as Tara. The crux of the series is centered on Tara living with Dissociative Identity Disorder (DID), formerly Multiple Personality Disorder. Tara is a middle-aged Caucasian female, who is happily married to her husband, and has two high-school aged children. While in search of discovering her childhood trauma, Tara commits to no longer consuming prescribed medication and is undergoing psychotherapy (International Society for the Study of Trauma and Dissociation, 2010). Throughout this popular television program, Cody portrays the controversy related to the complexities of a DID diagnosis, while producing an entertaining and accurate depiction of the difficult life of Tara.
The following pages will explore the adversities of the fictional character, Tara, by using her created life as examples, it will also address the congruence of Tara’s symptom picture with the DSM as a diagnosis, explore differential diagnosis, discuss different viewpoints regarding evidence of DID, review different supports and interventions, and address other pertinent information as it relates to the relevance of DID.
According to the Diagnostic and Statistical Manual of Mental Disorders, (4th ed., text rev.; DSM–IV–TR), “Dissociative Identity Disorder (formerly Multiple Personality Disorder) is characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individual’s behavior accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. It is a disorder characterized by identity fragmentation rather than a proliferation of separate personalities” (American Psychiatric Association, 2000, p. 519).
A person suffering from DID may experience “absences” from their reality, while experiencing dissociative amnesia and dissociative fugue, along with other types of unusual behavior which disrupts the person’s life (Austrian, 2005).
DID typically develops as a result of a childhood trauma, in most cases extreme sexual and physical abuse, although it could be a result of repeated medical procedures, natural disasters (such as hurricanes, earthquakes or tornados), war, or death of a caregiver (Traub, 2009). Such is the case for Tara. Throughout the series’ lifespan it was implied that Tara’s stepbrother sexually molested her, but this was never directly confirmed.
In the beginning stages of DID, the child compartmentalizes certain memories associated with their trauma, and begins to dissociate. While dissociative behavior is adaptive by allowing the child to escape from reality, and oftentimes physical pain, it may become maladaptive if the child fails to adequately cope with their experiences and continues to detach from oneself as an adult, resulting in an “alter” personality (Austrian, 2005).
Typically, the major symptom associated with DID is the presence of two or more distinct identities or personalities, and Tara is no exception. At the onset of the series Tara presents three identities, which are often referred to as “alters’”; additional “alters’” are introduced as the series progresses. First, Tara transforms into an “alter” named “T”, which is an impulsive teenaged girl, who oftentimes smokes cigarettes, recklessly operates vehicles, exhibits sexual promiscuity, and has abnormal excessive spending sprees. The next “alter” is a middle-aged male, named Buck, that is prone to aggressive behavior, consumed large amounts of alcohol, and is sexually attracted to females. Thirdly, Alice is presented as a 1950’s housewife, that enjoys baking, creating the “perfect family”, expresses passive aggressive behaviors, and generally believes in “sweeping things under the rug” (Dombeck).
Tara’s “alters’” may create many different symptom pictures. However, the most common symptom picture of a person with DID is similar to individuals suffering from Posttraumatic Stress Disorder (PTSD) in that the trauma may spark panic attacks, flashbacks, nightmares, re-experiencing of the traumatic event, alterations in consciousness, hyper-vigilance, and dissociation. A major differentiation between PTSD and DID, and the most common symptom, is a fugue state, which occurs when individuals find themselves in another place with no information or memory of how they got there (Stickley & Nickeas, 2006).
In most instances, Tara would experience a fugue state when she returned to her host personality, with no memory of her actions or the length of time that had lapsed as an “alter”. Normally, when Tara was faced with a stressful situation or challenging event, she would transition to one of her “alters” to help combat that certain situation. For instance, during one episode Tara’s daughter was arguing with a sexually aggressive boyfriend, which triggered Tara. As a result, she transitioned into Buck, went to her daughter’s school and physically assaulted her boyfriend. It was not uncommon for Tara to transition back to her host personality and have bodily damage, only to learn her actions from the previous days. DID is a very rare and understudied area, and the symptom picture is complex as the life of an individual is completely disrupted without any control or knowledge of a precipitating event.
DID is a controversial disorder, with conflicting data regarding the rarity of occurrence. Historically, there have been very few documented cases, which have increased in recent decades. Regardless of the incident rate, one thing that clients with DID have in common is that treatment options need to be extensively researched and much trust needs to be given to the process (Chilebowski & Gregory, 2012). Different treatment interventions have been available to clients with DID, including: psychodynamic psychotherapy, cognitive behavioral therapy (CBT), hypnosis, group and family therapy, cognitive analytic therapy (CAT), dialectical behavior therapy (DBT), and Dynamic deconstructive psychotherapy (DDP). (Chilebowski & Gregory, 2012).
Typically, it has been reported, “individual therapy with hypnosis was the most common form of treatment” (Chilebowski & Gregory, 2012, p. 166), which is congruent with the majority of the research that has found that long-term individual psychotherapy to be most effective (Spring, 2011). Tara’s intervention consisted of individual therapy with hypnosis, eventually participating in an inpatient setting to help uncover her childhood trauma. Interestingly, towards the end of the series Shoshana Schoenbaum was introduced as an “alter” personality. Shoshana was a successful shrink from New York that was helping Tara overcome her DID symptoms; in actuality, Tara was counseling herself. As Shoshana’s character was developed, Tara began having ego-dystonic episodes where she knew she was talking to someone that was foreign to her, instead of her usual transition into a “alter” personality, without knowledge of the transition.
Tara’s development of a shrink “alter” is puzzling and very rare, however it brings attention to an interesting point of treating the “alter” personality. Austrian, reports “the host personality is usually the one who is in control most of a given period and is almost always the personality that is identified at the onset of intervention” (2005, p. 135). Throughout Tara’s treatment the host personality was normally present, although as her intervention progressed she would often rapidly transition between “alter” personalities, which I believe was sensationalized for viewing purposes. Austrian reports that usually one personality is present during intervention, sometimes more “alter” personalities emerge over the course of intervention (Austrian, 2005).
When treating a client with DID, there are many factors such as the client’s resources, level of function, and motivation, that can determine the successfulness of treatment (Spring, 2011). Tara was a well educated, financially stable, mother with many familial supports, which allowed her to make several attempts at different treatment options. It has been the consensus of many experts that the phase-oriented treatment interventions are most effective. According to Spring, the most common stages are: (1) “establishing safety, stabilization and symptom reduction, (2) working through and integrating traumatic memories, and (3) integration and rehabilitation” (2011, para. 13). While it’s important to be familiar with this model, it is unlikely for it to be a linear progression (Spring, 2011).
As evidenced above, treating a client that has DID is a lengthy, complex, undertaking and the provider should be aware of the complexities for both parties. Transference and counter-transference responses are highly likely to occur during therapy, and special attention must be paid to boundary setting and developing a plan if “alter” personalities appear during sessions (Spring, 2011). In efforts to avoid confronting the client on validity, the clinician should try to understand and treat the client as if the different identities are not separate personalities, but different identities that have yet to be integrated. This may help the client-therapist relationship, while cultivating a better understanding of how the client may potentially function as one (Spring, 2011).
The misdiagnosis of individuals suffering from DID happen for various reasons, but mainly due to the reluctance of discussing the symptoms of the disorder to the clinician, and thus presenting feelings of depression, which may lead to the diagnosis of an affective disorder (Austrian, 2005). In United States of Tara, a diary video blog was kept by Tara, which oftentimes presented moments of depression and hopelessness. Although, the viewer is already aware of her diagnosis, this symptom picture could be easily polarized on the presented symptoms of depression.
When reviewing Tara’s symptom picture, there may be a variety of possible Axis I disorders that may be diagnosed, primarily Mood and Anxiety Disorders; being a fictional character it is difficult to successfully determine the meeting of each individual criterion. However, it is likely that Tara would be assessed for: Dysthymic Disorder (due to her persistent, mild, depressed affect); Bipolar I and II Disorder (as evidenced by the characteristics of her “alter” personalities); and Substance-Induced Mood Disorder (more information is needed on specific medications) (DSM–IV–TR, 4th ed., text rev., 2000).
In addition to Mood Disorders, PTSD is often strongly linked to individuals suffering from DID. When experiencing symptoms of DID, an individual typically has marked anxiety and panic attacks, unusual alterations of consciousness, flashbacks, and nightmares (Stickley & Nickeas, 2006). In addition to the PTSD symptoms, oftentimes Dissociative Amnesia and Dissociative Fugue co-occur with individuals with DID (DSM–IV–TR, 4th ed., text rev., 2000). For example, during one episode Tara’s teenaged “alter” “T”, drove to a local bowling ally and participated in unusual sexual contact with a minor. Upon returning to the host personality, Tara did not remember traveling or any information regarding the previous day’s activities.
Due to the nature and extent of symptoms presented with someone who has DID there may be a multitude of different mental disorders, such as: Schizophrenia, Bi-polar Disorder, with Rapid Cycling, and Anxiety Disorders (DSM–IV–TR (2000) 4th ed., text rev., p. 529). For instance, Tara displayed many Schizophrenic symptoms, such as delusion, auditory and visual hallucinations when she was communicating with Shoshana. Also when “T” became present, much of her symptoms could be interpreted as Bi-polar disorder, which is evidenced by her elevated mood as a teenager, which could be interpreted as a Manic Episode.
In addition to the presented symptoms associated with DID, it is possible that the patient is being treated for a medical condition, and prescribed medications may present symptoms such as: hallucinations, sleep disturbances, and Fugue States, which are also symptoms of DID. The symptom presentation of DID can easily prompt many separate diagnoses, however, it is the presence of a distinguished dissociation along with sudden shifts in identity states that differentiate DID from other diagnosis. Although, Tara may exhibit other symptoms and mood disorders, her obvious dissociation into different parts of herself is what legitimizes the presence of DID (DSM–IV–TR, 4th ed., text rev., 2000).
As mentioned earlier, it is the overwhelming belief that DID is a result of extreme traumatic experiences in childhood, which disrupts the attachment system resulting in the child developing abnormal integration of self (Spring, 2011). When reviewing the etiology of DID, there are many perspectives that seem to question the authenticity of DID being a valid disorder. Some viewpoints range from the perspective that media influences are adjusting the perceptions of popular movies and books which are inadvertently encouraging the over diagnosis of DID, to some studies suggesting that the differences in cerebral blood flow can alter personalities (Traub, 2009). Regardless of where one sits on the spectrum of etiology, everyone can agree that more information is needed on this disorder to fully understand all the factors that join to develop DID.
Due to the intense nature surrounding the diagnosis of DID, it is natural that assessment and evaluation may be challenging. In a study by done by Chlebowski & Gregory, three adult females, who have been clinically diagnosed with DID with co-occurring Borderline Personality Disorder (BPD), found that after being treated for 12 months with dynamic deconstructive psychotherapy (DDP) had significantly decreased their scores on the Dissociative Experiences Scale (DES), 12 months into treatment (2012). All of the participants used maladaptive coping mechanisms such as heavily drinking and using drugs as a way to cope with traumatic flashbacks (Chlebowski & Gregory, 2012).
One participant in the study clinically met the criteria for Bipolar I, Alcohol and drug dependence, PTSD, anorexia nervosa, bingeing/purging type, and obsessive-compulsive disorder. Based on such a wide scope of symptoms presented by the participant, it may reveal the complications associated with successfully determining the accurate diagnosis (Chlebowski & Gregory, 2012). However, as mentioned above, it is the distinction of dissociative symptoms into separate personalities that verify the diagnosis of DID.
When reviewing the study by Chlebowski & Gregory, one may begin to consider the vulnerabilities of participants, simply due to the scope of their symptom picture. Tara was at a great advantage due to her familial supports and financial resources, which is likely not the case for many people with DID. It is important for the clinician to be cognizant of certain social factors (e.g., insurance, housing, employment, etc.) that may exacerbate the symptoms presented by the client. It may be necessary for basic needs of the client to be met before one can fully assess a DID diagnosis due to the complexity of the disorder. Much research suggests that DID is not dissipating, but will steadily become more prevalent (Traub, 2009). Regardless of the diagnosis, when working with someone with such large symptom picture, it is of the upmost importance to consider all possible diagnosis while maintaining the awareness of the client’s vulnerabilities and basic needs.
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Austrian, S. G. (2005). Mental disorders, medications, and clinical social work . (3rd ed.). New York: Columbia University Press.
Chlebowski, S.M., & Gregory, R.J (2012). Three cases of Dissociative Identity Disorder and co-occuring Borederline Personality Disorder treated with Dynamic Deconstructive Psychotherapy. American Journal of Psychotherapy, 66(2), 165-180.
Dombeck , M. (n.d.). “united states of tara”: Dissociative identity disorder (multiple personality) on television. Retrieved from http://www.mhcinc.org/poc/view_doc.php?type=doc&id=24421
International Society for the Study of Trauma and Dissociation. (2010). isst-d.org. Retrieved from http://www.isst-d.org/education/united_states_of_tara-ISSTD-information.htm
(International Society for the Study of Trauma and Dissociation, 2010)
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Stickley, T.T., & Nickeas, R.R. (2006). Becoming one person: living with dissociative identity disorder. Journal of Psychiatric & Mental Health Nursing, 13(2), 180-187. doi: 10.1111/j.1365-2850.2006.00939.x
Traub, C.M. (2009). Defending a diagnostic pariah: validating the categorization of Dissociative Identity Disorder. South African Journal of Psychology, 39(3), 347-356.