Practice Essentials
Dissociative identity disorder is increasingly understood as a complex and chronic posttraumatic psychopathology closely related to severe, particularly early, child abuse. Children who have been maltreated or abused are at risk for experiencing a host of mental health problems, including dissociative identity disorder. [1]
Signs and symptoms
This condition is characterized by a) the presence of 2 or more distinct personality states or what some cultures may describe as an experience of possession, and b) recurrent episodes of amnesia. [2]
Diagnosis
Although no laboratory studies are specifically indicated for the diagnosis of dissociative disorder, studies can be performed to check for abuse.
As with laboratory studies, no imaging studies are indicated for the diagnosis of dissociative disorder; however, results of imaging studies can indicate abuse.
Management
Once the diagnosis of abuse has been made, the initial task of therapy is to detoxify the patient's environment by stopping all forms of abuse. Treatment must be geared toward trust issues, toleration of affect with the patient's understanding of himself or herself, and enabling the patient to function as effectively as possible.
The primary focus is to help patients learn to control and contain their symptoms. Patients must learn to deal with dissociation, flashbacks, and intense affects such as rage, terror, and despair.
Background
Dissociation is the disruption of the normal integrative processes of consciousness, perception, memory, and identity that define selfhood.
Dissociative identity disorder is increasingly understood as a complex and chronic posttraumatic psychopathology closely related to severe, particularly early, child abuse. [3] Children who have been maltreated or abused are at risk for experiencing a host of mental health problems, including dissociative identity disorder. [1] This condition is characterized by a) the presence of 2 or more distinct personality states or what some cultures may describe as an experience of possession, and b) recurrent episodes of amnesia. [2]
The deleterious effects of childhood abusive experiences on growth and development have been well documented and are associated with various later mental health problems. Diagnosis of dissociative identity disorder is not usually made until adulthood, long after the extreme maltreatment thought to engender the condition has occurred. Therefore, although the most common cause of the disorder is agreed to be early, ongoing, extreme physical and/or sexual abuse, accounts of such abuse are usually provided retrospectively by the patient and lack objective verification. Researchers have shown that, in many instances, borderline personality disorder and posttraumatic stress disorder (PTSD) in adulthood may be traced to childhood abuse.
The existence of significant dissociative psychopathology related to physical and sexual abuse experienced in childhood was known to clinicians in the last century. However, only recently have modern mental health practitioners begun to appreciate implications of this forgotten linkage.
Clinical and research reports indicate that a history of physical and sexual abuse in childhood is more common among adults who develop major mental illness than previously suspected. Dissociation has also been linked specifically to childhood physical neglect in patients diagnosed with schizophrenia. Various degrees of dissociative disorders are recognized, ranging from passive disengagement and withdrawal from the active environment to multiple personality disorder (MPD), a severe dissociative disorder characterized by disturbances in both identity and memory and best understood as a posttraumatic, adaptive dissociative response to the fear and pain of overwhelming trauma, most commonly abuse. Fully expressed MPD is not often diagnosed as such in the pediatric population; however, other forms of dissociative disorders are not uncommon, as described in this article.
Pathophysiology
Dissociation is a psychophysiologic process that alters a person's thoughts, feelings, or actions so that, for a time, certain information is not associated or integrated with other information as it normally is. This process, which manifests along a continuum of severity, produces a range of clinical and behavioral phenomena involving alterations in memory and identity. In extreme cases, the process gives rise to a set of psychiatric syndromes known as dissociative disorders. Not all abused children develop a dissociation disorder; however, studies have shown that abused children demonstrate more dissociation than nonabused children do. [4, 5]
Regarding MPD, Kluft's reports from 1984 and 1987 view the condition as a chronic dissociative PTSD originating in childhood. [6, 7] He has proposed a 4-factor theory to explain the genesis of MPD, as follows:
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Individuals have an innate potential to dissociate that is reflected in hypnotizability ratings.
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Traumatic experiences in early childhood may disturb personality development, leading to greater potential for psychodynamic dividedness.
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Individuals may be denied the chance to spontaneously recover because of continued emotional and/or social deprivation.
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Final presentation is shaped by psychodynamic and extrinsic factors, including psychosocial influences.
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Some patients may report triggers for their dissociative identity episodes. [8]
Epidemiology
Frequency
True prevalence is unknown; however, dissociative identity disorder has been shown to be more common than previously thought. In one small US community study, the 12-month prevalence of the disorder among adults was 1.5%. The prevalence across genders in that study was 1.6% for males and 1.4% for females. [2]
Abuse may be the hidden feature in patients who are the most difficult to diagnose and treat. In 1984, by studying psychiatric inpatient charts, Carmen et al and Mills et al proposed a relationship between history of abuse and certain indicators of the severity of psychiatric symptoms. [9, 10]
Incidence of child sexual abuse is difficult to estimate, partly because of differences in its definition and the varied factors that can contribute to its impact, including the age of the victims (ie, very young children who are not able to verbally report it), the relationship to perpetrators, and the characteristics of the family. People who have been sexually abused are often unaware of the possible relationship between their presenting symptoms of dissociative disorder and the sexual abuse. Even when seeking psychotherapy, patients rarely disclose abuse; they may feel ashamed to talk about it.
Since mandated reporting began in the 1960s, the number of reports to children's protective services (CPS) and law enforcement agencies has steadily increased. In 2014, the CDC reported approximately 702,000 victims of child abuse. Of these children, 58,000 were victims of sexual abuse. [11]
Pathological dissociation is less well known in certain parts of the world, especially in China. It can be easily detected among psychiatric patients but is much less common in general population. It is more frequent among subsamples of population with previous evidence of emotional or psychiatric trauma.
Mortality/Morbidity
An estimated 2000 children die each year of abuse. Head trauma is the most common cause of death from physical abuse. Intra-abdominal injuries from impacts are the second most common cause of death.
Race
No racial group is exempt. Abuse has been reported from most racial, religious, and socioeconomic groups of people from most geographic, educational, and occupational backgrounds. However, higher rank-ordered scores for dissociation are reported in American children. [12]
Sex
Girls experience childhood sexual abuse more commonly than boys, with a female-to-male ratio of 10:1. Girls, more than boys, are most at risk for sexual abuse. Edwards reported a significantly higher prevalence of childhood sexual abuse in women and a significantly higher prevalence of childhood physical abuse in men. [13] However, a factor described as pathological dissociation has emerged that was predicted by participants being male. [14]
Age
Because most abuse cases occur during the preschool years, children may be particularly vulnerable to dissociation during those years. In 2014, the National Child Abuse and Neglect Data System (NCANDS) indicated that 17% of 702,000 reports were for physical abuse and that 27.4% of children who were abused were younger than 3 years. The victimization rate was highest for children younger than 1 year (24.4 per 1,000 children in the population of the same age). [11] The rate of reports decreases for older children. Early age at onset was also correlated with a higher degree of dissociation.
Adolescents with dissociative identity disorder are more likely to experience higher rates of psychiatric comorbidities. [15]
Prognosis
The prognosis in children and adolescents can vary widely among patients and between the specific types of dissociation disorder; however early treatment offers the greatest possibility of full recovery. [16] Recovery requires specially trained skilled psychiatrists who thoroughly understand the condition.
Patient Education
Patient education is of utmost importance. When patients with multiple personality disorder (MPD) understand what is really happening in their lives, they become excellent, cooperative patients.
