multiple personality disorder


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Related to multiple personality disorder: schizophrenia

Multiple Personality Disorder

 

Definition

Multiple personality disorder, or MPD, is a mental disturbance classified as one of the dissociative disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It has been renamed dissociative identity disorder (DID). MPD or DID is defined as a condition in which "two or more distinct identities or personality states" alternate in controlling the patient's consciousness and behavior. Note: "Split personality" is not an accurate term for DID and should not be used as a synonym for schizophrenia.

Description

The precise nature of DID (MPD) as well as its relationship to other mental disorders is still a subject of debate. Some researchers think that DID may be a relatively recent development in western society. It may be a culture-specific syndrome found in western society, caused primarily by both childhood abuse and unspecified long-term societal changes. Unlike depression or anxiety disorders, which have been recognized, in some form, for centuries, the earliest cases of persons reporting DID symptoms were not recorded until the 1790s. Most were considered medical oddities or curiosities until the late 1970s, when increasing numbers of cases were reported in the United States. Psychiatrists are still debating whether DID was previously misdiagnosed and underreported, or whether it is currently over-diagnosed. Because childhood trauma is a factor in the development of DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). DID and PTSD are conditions where dissociation is a prominent mechanism. The female to male ratio for DID is about 9:1, but the reasons for the gender imbalance are unclear. Some have attributed the imbalance in reported cases to higher rates of abuse of female children; and some to the possibility that males with DID are underreported because they might be in prison for violent crimes.
The most distinctive feature of DID is the formation and emergence of alternate personality states, or "alters." Patients with DID experience their alters as distinctive individuals possessing different names, histories, and personality traits. It is not unusual for DID patients to have alters of different genders, sexual orientations, ages, or nationalities. Some patients have been reported with alters that are not even human; alters have been animals, or even aliens from outer space. The average DID patient has between two and 10 alters, but some have been reported with over one hundred.

Causes and symptoms

The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:
  • An innate ability to dissociate easily
  • Repeated episodes of severe physical or sexual abuse in childhood
  • The lack of a supportive or comforting person to counteract abusive relative(s)
  • The influence of other relatives with dissociative symptoms or disorders
The relationship of dissociative disorders to childhood abuse has led to intense controversy and lawsuits concerning the accuracy of childhood memories. The brain's storage, retrieval, and interpretation of childhood memories are still not fully understood.
The major dissociative symptoms experienced by DID patients are amnesia, depersonalization, derealization, and identity disturbances.

Amnesia

Amnesia in DID is marked by gaps in the patient's memory for long periods of their past, in some cases, their entire childhood. Most DID patients have amnesia, or "lose time," for periods when another personality is "out." They may report finding items in their house that they can't remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

Depersonalization

Depersonalization is a dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of their body, or as watching a movie of themselves.

Derealization

Derealization is a dissociative symptom in which the patient perceives the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail to recognize relatives or close friends.

Identity disturbances

Identity disturbances in DID result from the patient's having split off entire personality traits or characteristics as well as memories. When a stressful or traumatic experience triggers the reemergence of these dissociated parts, the patient switches—usually within seconds—into an alternate personality. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Patients vary with regard to their alters' awareness of one another.

Diagnosis

The diagnosis of DID is complex and some physicians believe it is often missed, while others feel it is over-diagnosed. Patients have been known to have been treated under a variety of other psychiatric diagnoses for a long time before being re-diagnosed with DID. The average DID patient is in the mental health care system for six to seven years before being diagnosed as a person with DID. Many DID patients are misdiagnosed as depressed because the primary or "core" personality is subdued and withdrawn, particularly in female patients. However, some core personalities, or alters, may genuinely be depressed, and may benefit from antidepressant medications. One reason misdiagnoses are common is because DID patients may truly meet the criteria for panic disorder or somatization disorder.
Misdiagnoses include schizophrenia, borderline personality disorder, and, as noted, somatization disorder and panic disorder. DID patients are often frightened by their dissociative experiences, which can include losing awareness of hours or even days of time, meeting people who claim to know them by another name, or feeling "out of body." Persons with the disorder may go to emergency rooms or clinics because they fear they are going insane.
When a doctor is evaluating a patient for DID, he or she will first rule out physical conditions that sometimes produce amnesia, depersonalization, or derealization. These conditions include head injuries; brain disease, especially seizure disorders; side effects from medications; substance abuse or intoxication; AIDS dementia complex; or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph (EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient is malingering and/or offering fictitious complaints.
If the patient appears to be physically normal, the doctor will next rule out psychotic disturbances, including schizophrenia. Many patients with DID are misdiagnosed as schizophrenic because they may "hear" their alters "talking" inside their heads. If the doctor suspects DID, he or she can use a screening test called the Dissociative Experiences Scale (DES). If the patient has a high score on this test, he or she can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). The doctor may also use the Hypnotic Induction Profile (HIP) or a similar test of the patient's hypnotizability.

Treatment

Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.

Psychotherapy

Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized training is important because the patient's personality switches can be confusing or startling. In addition, many patients with DID have hostile or suicidal alter personalities. Most therapists who treat DID patients have rules or contracts for treatment that include such issues as the patient's responsibility for his or her safety. Psychotherapy for DID patients typically has several stages: an initial phase for uncovering and "mapping" the patient's alters; a phase of treating the traumatic memories and "fusing" the alters; and a phase of consolidating the patient's newly integrated personality.
Most therapists who treat multiples, or DID patients, recommend further treatment after personality integration, on the grounds that the patient has not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help the patient's family understand DID and the changes that occur during personality reintegration.
Many DID patients are helped by group as well as individual treatment, provided that the group is limited to people with dissociative disorders. DID patients sometimes have setbacks in mixed therapy groups because other patients are bothered or frightened by their personality switches.

Medications

Some doctors will prescribe tranquilizers or antidepressants for DID patients because their alter personalities may have anxiety or mood disorders. However, other therapists who treat DID patients prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many DID patients have at least one alter who abuses drugs or alcohol, substances which are dangerous in combination with most tranquilizers.

Hypnosis

While not always necessary, hypnosis is a standard method of treatment for DID patients. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many DID patients exhibit, such as self-mutilation, or eating disorders like bulimia nervosa. In the later stages of treatment, the therapist may use hypnosis to "fuse" the alters as part of the patient's personality integration process.

Alternative treatment

Alternative treatments that help to relax the body are often recommended for DID patients as an adjunct to psychotherapy and/or medication. These treatments include hydrotherapy, botanical medicine (primarily herbs that help the nervous system), therapeutic massage, and yoga. Homeopathic treatment can also be effective for some people. Art therapy and the keeping of journals are often recommended as ways that patients can integrate their past into their present life. Meditation is usually discouraged until the patient's personality has been reintegrated.

Prognosis

Some therapists believe that the prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the prognosis.

Prevention

Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

Resources

Books

Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

Key terms

Alter — An alternate or secondary personality in a patient with DID.
Amnesia — A general medical term for loss of memory that is not due to ordinary forgetfulness. Amnesia can be caused by head injuries, brain disease, or epilepsy as well as by dissociation.
Depersonalization — A dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving.
Derealization — A dissociative symptom in which the external environment is perceived as unreal.
Dissociation — A psychological mechanism that allows the mind to split off traumatic memories or disturbing ideas from conscious awareness.
Dissociative identity disorder (DID) — Term that replaced Multiple Personality Disorder (MPD). A condition in which two or more distinctive identities or personality states alternate in controlling a person's consciousness and behavior.
Hypnosis — An induced trance state used to treat the amnesia and identity disturbances that occur in dissociative identity disorder (DID).
Multiple personality disorder (MPD) — The former, though often still used, term for dissociative identity disorder (DID).
Primary personality — The core personality of an DID patient. In women, the primary personality is often timid and passive, and may be diagnosed as depressed.
Trauma — A disastrous or life-threatening event that can cause severe emotional distress. DID is associated with trauma in a person's early life or adult experience.

multiple

 [mul´tĭ-p'l]
manifold; occurring in various parts of the body at once.
multiple myeloma a malignant neoplasm of plasma cells in which the plasma cells proliferate and invade the bone marrow, causing destruction of the bone and resulting in pathologic fracture and bone pain. It is the most common type of monoclonal gammopathy, characterized by presence of a monoclonal immunoglobulin (immunoglobulin recognized as a single protein), Bence Jones proteins in the urine, anemia, and lowered resistance to infection. Called also plasma cell myeloma.

Diagnostic procedures to confirm suspected multiple myeloma include blood analyses, quantitative immunologic assays of serum and urine, urinalysis, bone marrow aspiration and biopsy, and skeletal x-rays. Findings indicative of the disease are an increased number of plasma cells in the bone marrow (usually over 10 per cent of the total), anemia, hypercalcemia due to release of calcium from deteriorating bone tissue, and elevated blood urea nitrogen, Bence Jones protein in the urine, and osteolytic lesions that give the bone a honeycomb appearance on x-ray and lead to vertebral collapse.
Treatment. Treatment of multiple myeloma involves chemotherapy and radiation to relieve pain and manage the acute lesions of the spinal column. High-dose chemotherapy followed by blood cell rescue has shown some efficacy in certain situations. Individuals diagnosed with multiple myeloma who show no symptoms do not usually receive treatment.
Patient Care. Major problems presented by the patient with multiple myeloma are related to anemia, hypercalcemia, bone pain and pathologic fractures, and emotional distress created by trying to cope with the day-to-day physiologic and emotional aspects associated with the diagnosis of a malignant disease. The more common complications to be avoided are infection, renal failure, and the sequelae of spinal cord compression.

Transfusions with packed red blood cells can help alleviate and minimize some of the more severe symptoms of anemia. It is important that the patient be adequately hydrated to improve viscosity of the blood and circulation, to help avoid hypercalcemia, and to maintain kidney function for excretion of the products of protein metabolism. Continued ambulation and moderate exercise help slow down the loss of minerals, especially calcium, from the bones. Other problems are related to the administration of highly toxic antineoplastic drugs.
Multiple myeloma. Radiographs of the skull, ribs, and vertebrae show multiple punched out lesions. There is anemia secondary to bone marrow lesions that replace red blood cell precursors. Kidney failure is the most common cause of death. The urine contains Bence Jones protein. From Damjanov, 2000.
multiple organ dysfunction syndrome (multiple organ failure) failure of two or more organ systems in a critically ill patient because of a complex and interrelated series of events.
The pathogenesis of multiple organ failure. From Datex Medical Instrumentation, Inc., Tewksbury, MA.
multiple personality disorder dissociative identity disorder.
multiple-puncture test an intracutaneous test in which the material used (such as tuberculin) is introduced into the skin by pressure of several needles or pointed tines or prongs. This procedure is used in mass screenings, but it is not as accurate as other tests because of lack of precise measurement of the amount of medication actually entering the skin.
multiple sclerosis (MS) a chronic neurologic disease in which there are patches of demyelination scattered throughout the white matter of the central nervous system, sometimes extending into the gray matter. The disease primarily affects the myelin and not the nerve cells themselves; any damage to the neurons is secondary to destruction of the myelin covering the axon. The symptoms caused by these lesions are typically weakness, incoordination, paresthesias, speech disturbances, and visual disturbances, particularly diplopia. More specific signs and symptoms depend on the location of the lesions and the severity and destructiveness of the inflammatory and sclerotic processes.

The course of the disease is usually prolonged, with remissions and relapses over many years. Brief exacerbations, even with acute and severe symptoms, are thought to be the result of a transient inflammatory depression of neural transmission. Recovery occurs when there has been no permanent damage to the myelin sheath during the attack. Repeated attacks can, however, eventually permanently denude the axons and leave the yellow sclerotic plaques that are characteristic of the disease. Once the disease process reaches the stage of sclerosis the affected axons cannot recover and there is permanent damage.

The prevalence of MS is not certain because the disease is not one that is reported, and mild cases can be either misdiagnosed or never brought to the attention of a health care provider. It is far more common in the temperate zones of the world than in tropical and subtropical climates. The onset of symptoms most often occurs between the ages of 20 and 40 years, and the disease affects both sexes about equally.

The cause of multiple sclerosis is unknown. It is likely that an inherited immune response is somehow responsible for the production of autoantibodies that attack the myelin sheath. Some authorities believe that infection by one of the slow viruses occurs during childhood and after some years of latency the virus triggers an autoimmune response. Others believe there is an antigen or environmental trigger for the disease.

The diagnosis of multiple sclerosis is difficult because of the wide variety of possible clinical manifestations and the resemblance they bear to other neurological disorders. There is no definitive diagnostic test for the condition, but persons with objectively measured abnormalities of the central nervous system, a history of exacerbation and remission of symptoms, and demonstrable delayed blink reflex and evoked visual response are diagnosed as having either possible or probable multiple sclerosis. With time and progressive worsening of symptoms the diagnosis can become definite.
Treatment. A multidisciplinary approach is required to diagnose the condition and help patients and their families cope with the attendant problems. Multiple sclerosis has an impact on physical activity and life style, role, and interpersonal relationships; therefore, vocational guidance, counseling, and group therapy are helpful. It is important that the patient with severe disability maintain a positive attitude, focusing on functional abilities rather than disabilities. Regeneration of the damaged neural tissue is not possible but retraining and adaptation are. Stress due to trauma, infection, overexertion, surgery, or emotional upset can aggravate the condition and precipitate a flare-up of symptoms.

Supportive measures include a regimen of rest and exercise, a well-balanced diet, avoidance of extremes of heat and cold, avoidance of known sources of infection, and adaptation of a life style that is relatively unstressful while still being as productive as possible.

Therapeutic measures include medications to diminish muscle spasticity; measures to overcome urinary retention (such as credé's method or intermittent catheterization); speech therapy; and physical therapy to maintain muscle tone and avoid orthopedic deformities. Management of MS has been greatly enhanced by the availability of interferons beta-1a and beta-1b. Research support is strong that these medications reduce the frequency and severity of relapses.

Many multiple sclerosis patients and their families receive valuable support and encouragement from communication with others coping with the condition. A local chapter of the National Multiple Sclerosis Society is within reach of most persons in the United States. Information and assistance in all phases of the disease are available by writing to The National Multiple Sclerosis Society, 733 Third Ave., 6th floor, New York, NY 10017, or consulting their web site at http://www.nmss.org.

mul·ti·ple per·son·al·i·ty dis·or·der

older term for dissociative identity disorder.

multiple personality disorder

n.
A psychiatric disorder in which two or more distinct personalities exist in the same person, each of which prevails at a particular time. Also called dissociative identity disorder.

multiple personality disorder

multiple personality disorder

Split personality Psychiatry The 'presence of two or more distinct identities or personality states…that recurrently take control of behavior.' See Dissociate, Fugue, Personality, Schizophrenia.

mul·ti·ple per·son·al·i·ty dis·or·der

(MPD)
See: dissociative identity disorder (q.v.).
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