Diagnosing DID

from Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Publications. Putnam writes about Multiple Personality Disorder (MPD), now called DID, and the way therapists can determine its diagnosis. He defines it as a chronic dissociative condition, not transient like psychogenic amnesia and fugues. A thorough history can help determine if a patient has had dissociative experiences. But other diagnostic interventions may be necessary. It may be difficult to get a clear chronology of life events. The host personality, which usually presents for treatment, may have the least access to early biographical information. MPD patients may describe their lack of memory as the result of having a poor memory. MPD patients may have developed compensatory behaviors to help them answer or avoid questions when they have memory gaps. Useful inquiries may include asking question about time loss or fugue-like experiences, depersonalization and derealization experiences (though these symptoms may be present in other disorders),questions about common life experiences, like being called a liar, large gaps in the continuousness of childhood memories, the occurrence of intrusive mental images, having dreamlike memories and having life skills that have unknown source, and questions about Schneiderian Primary Symptoms for schizophrenia, like hearing voices or feeling as if their body is controlled by an external force.

Manifestations of MPD may be displayed during interview interactions with patients. Two ways of detecting personality switching with patients are to notice the physical signs, which include facial and vocal changes. The second is to be alert for intrainterview amnesia, due to an alter personality's emergence, admitting to and then denying symptoms. Other signs include a patient's making references to themselves in the third person or the first person plural and an exaggerated startle reflex.

A diagnosis of MPD is more likely to be made after an extended period of observation. Diagnostic procedures include a mental status examination for appearance, speech, motor and thought processes, hallucinations, intellectual functioning, judgment and insight. Extended interviews for three hours may help, as it is difficult for MPD patients to keep from switching that long during the stress of an interview. The MMPI questions relating to blank spells and lack of knowledge of past actions show fairly high retest validity. The Rorschach test has a lot of diversified movement responses and labile and conflicting color responses. Physical examinations can help rule out other neurological disorders causing amnesia and may help detect self-mutilation scars. A diagnosis of MPD can only be made once a clinician has met a distinct alter state and not a transient ego-state phenomena.

Physiological studies showing differences between DID patients and non-DID patients

J Am Optom Assoc. 1996 Jun;67(6):327-34. Visual function in multiple personality disorder. Birnbaum MH, Thomann K. State College of Optometry, State University of New York, NY 10010, USA. BACKGROUND: Multiple personality disorder (MPD) is characterized by the existence of two or more personality states that recurrently exchange control over the behavior of the individual. Numerous reports indicate physiological differences, including significant differences in ocular and visual function, across alter personality states in MPD....The possibility of MPDs should be considered in patients who demonstrate unusual variability in ocular and visual findings, particularly with a positive psychiatric history. The existence of visual and other physiologic differences across alter personalities in MPD offers a unique potential for the study of mind-body relationships.

Clin Electroencephalogr. 1990 Oct;21(4):200-9. Brain mapping in a case of multiple personality. Hughes JR, Kuhlman DT, Fichtner CG, Gruenfeld MJ. Department of Neurology, University of Illinois, Chicago 60612. Brain maps were recorded on a patient with a multiple personality disorder (10 alternate personalities). Maps were recorded with eyes open and eyes closed during 2 different sessions, 2 months apart. Maps from each alternate personality were compared to those of the basic personality "S", some maps were similar and some were different, especially with eyes open. Findings that were replicated in the second session showed differences from 4 personalities, especially in theta and beta 2 frequencies on the left temporal and right posterior regions....Maps from S acting like some of her personalities or from a professional actress portraying the different personalities did not reveal significant differences. Some of these findings are consistent with those in the literature.

J Nerv Ment Dis. 1988 Sep;176(9):519-27. Multiple personality disorder. A clinical investigation of 50 cases. Coons PM, Bowman ES, Milstein V. Carter Memorial Hospital, Indianapolis, Indiana 46202. To study the clinical phenomenology of multiple personality, 50 consecutive patients with DSM-III multiple personality disorder were assessed using clinical history, psychiatric interview, neurological examination, electroencephalogram, MMPI, intelligence testing, and a variety of psychiatric rating scales. Results revealed that patients with multiple personality are usually women who present with depression, suicide attempts, repeated amnesic episodes, and a history of childhood trauma, particularly sexual abuse. Also common were headaches, hysterical conversion, and sexual dysfunction. Intellectual level varied from borderline to superior. The MMPI reflected underlying character pathology in addition to depression and dissociation. Significant neurological or electroencephalographical abnormalities were infrequent. These data suggest that the etiology of multiple personality is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction. PMID: 3418321

Arch Gen Psychiatry. 1982 Jul;39(7):823-5. EEG studies of two multiple personalities and a control. Coons PM, Milstein V, Marley C. There are few reports of EEG findings in patients with multiple personalities. In our study, EEGs were visually scanned and frequency analyzed in two patients with multiple personalities and one control....These data suggest that EEG differences among personalities in a person with multiple personalities involve intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of persons with multiple personalities and those of normal persons.

Responses to those that state that DID is iatrogenic or a social construct

Iatrogenic DID-An Evaluation of the Scientific Evidence: D. Brown, E. Frischholz & A. Scheflin" from The fall-winter 1999 issue of "The Journal of Psychiatry & Law - "Conclusions...At present the scientific evidence is insufficient and inadequate to support plaintiffs' complaints that suggestive influences allegedly operative in psychotherapy can create a major psychiatric disorder like MPD per se...there is virtually no support for the unique contribution of hypnosis to the alleged iatrogenic creation of MPD in appropriately controlled research.....alter shaping is not to be confused with alter creation." p. 624

D. Gleaves July, 1996 "The sociocognitive model of dissociative identity disorder: a reexamination of the evidence" Psychological Bulletin Volume 120, issue=1, pages=42-59 "No reason exists to doubt the connection between DID and childhood trauma."

C. Ross, G. Norton, G. Fraser (1989) "Evidence against the iatrogenesis of multiple personality disorder "Dissociation" volume=2, issue=2, pages 61-65, https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1424/1/Diss_2_2_2_OCR.pdf "Exposure to hypnosis does not appear to influence the phenomenology of MPD(DID)....There is no evidence derived from the study of clinical MPD that the disorder is artifactual. In fact there is not one case of MPD created artifactually by a specialist in dissociation reported in the literature. Given the absence of positive evidence for the artifactual nature of clinical MPD, the data in the present study provide compelling evidence that MPD is a genuine disorder with a consistent set of core features."

Kluft, R.P. (2003) Current Issues in Dissociative Identity Disorder in journal Bridging Eastern and Western Psychiatry 1(1) |p. 71-87 http://www.psyter.org/allegati/180/Kluft.pdf "In inpatient psychiatric populations, mixed inpatient uncommon, occurs in many different countries at and outpatient groups, and chemical dependency approximately the same rate in the psychiatric inpatient treatment settings, previously undiagnosed DID is found population, and usually goes undiagnosed. Even among in between 4% and 18.6% of the patients. Taken diagnosed DID patients, Putnam and his coworkers together, these studies suggest that DID is not found that the average patient had been in the mental health care delivery system for 6.8 years before being accurately diagnosed....It has long been clear that many of the symptoms of DID can be created by simple suggestion or experimental manipulation, and that with minimal suggestion, subjects can be induced to enact several DID behaviors. This data has been summarized by many authors. However, the enactment of behaviors associated with a mental disorder is not proof that one has the mental disorder -- anymore than a stage hypnotist's subject's clucking like a chicken is a justification for cooking him or her for dinner. Cultural influence and expectations may exert a significant impact upon the phenomenology of DID, but this does not make the condition invalid....There is considerable controversy over whether the condition can be created de novo from iatrogenic pressures. My review of the literature, and my experience with many situations in which this is alleged to have occurred, suggest that if this does occur, it is infrequent and happens only after prolonged and intense interventions. Therefore, if the manifestations of DID are noted after relatively brief clinical contact, or in the context of efforts that do not involve prolonged and intense indoctrination, iatrogenesis is not a likely etiology....A review of the DID literature demonstrates numerous instances of documented abuse. Two studies of younger dissociative patients found documentation of abuse for 95% of their young subjects. The documentation of recovered memories of childhood abuse in DID populations has been documented. However, I have also documented that DID patients may represent confabulated recollections of abuse as if they had occurred and that both accurate recovered memories patient, either spontaneously or in response to of abuse and confabulated memories of abuse may occur in the same DID patient. The literature, then suggests that DID patients usually have a background of overwhelming childhood circumstances, usually involving child abuse, but that pseudomemories can be encountered in this patient population....DID is emerging as a not uncommon consequence of overwhelming childhood events. It has been identified as occurring in many nations and is often very responsive to treatment.:

Braun, B. Iatrophilia And Iatrophobia in The Diagnosis And Treatment of MPD M.d. - Dissociation, Vol. II, No. 2: June 1989 "The most convincing evidence that alters are not being iatrogenically induced comes with time," Putnam writes, "Although new personalities may be created in therapy, the great majority will have a life history that predates therapy. This history, with sufficient documentation, will emerge as the therapist and patient reopen the past and make it clear. In the long run, the question of iatrogenesis becomes less urgent" (1989, p. 132). In this statement, an experienced MPD clinician and investigator erodes the myth that hypnosis can induce an alter personality that meets the criteria of DSM-III-R (1987) including an enduring pattern of perceiving, relating to and thinking about self and the environment....Hypnotizability, as a manifestation of the ability to dissociate, is not an indication that hypnosis can induce true alter personalities....other means is highly unlikely, given the DSM-III-R criteria for defining an alter. Fear of iatrogenesis may deter some therapists from making the diagnosis of MPD or undertaking therapy."

from Brown, D., Scheflin, A. W., Hammond, D. C. (1998). Memory, trauma treatment and the law. New York: W. W. Norton & Company. "Proponents of the iatrogenesis hypothesis argue that patients simulate DID to get attention, yet Gleaves cites several empirical studies that show no significant relationship between histrionic personality and other attention-seeking traits and DID. In a study done by Ross, Norton and Wozney (1989), only 27% of those with DID had hypnosis before getting the DID diagnosis. The iatrogenesis argument also doesn't account for the fact that many patients with DID had a long history of dissociative symptoms before the DID diagnosis was made. Putnam in 1986 showed no significant differences in the clinical features of those with DID, whether hypnosis was used or not in treatment. Gleaves also states that researchers have found a strong association between forms of childhood trauma and DID." "The treatment strategy recommended by proponents of the iatrogenesis of DID that therapists discourage alter behavior and recollections of abuse may be harmful. Not dealing with the condition of DID may cause interminable treatment. Simply because some of the features of DID can be role played, this does not meaningfully explain the etiology of any mental disorder. Gleaves believes the iatrogenesis model is flawed and lacks support. The role-playing theory cannot account for the primary features of DID."