AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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. Many studies have revealed early severe abuse to be associated with an increased risk for various psychiatric conditions, including dissociative identity disorder. This condition manifests with an emergence of 2 or more personality states including auditory hallucinations, severe depression and suicidality, phobic anxiety, somatization, substance abuse, and borderline features that partially or fully predominate the psychologic function of the individual for a period.

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. 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.^{1, 2}

Regarding MPD, Kluft's reports from 1984 and 1987 view the condition as a chronic dissociative PTSD originating in childhood.^{3, 4} He has proposed a 4-factor theory to explain the genesis of MPD, as follows:

• Individuals have an innate potential to dissociate that is reflected in hypnotizability ratings.
• Traumatic experiences in early childhood may disturb personality development, leading to greater potential for psychodynamic dividedness.
• Individuals may be denied the chance to spontaneously recover because of continued emotional and/or social deprivation.
• Final presentation is shaped by psychodynamic and extrinsic factors, including psychosocial influences.

Frequency

United States

True prevalence is unknown; however, dissociative identity disorder has been shown to be more common than previously thought. 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.^{5, 6}

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. Reports of all types of abuse increased from 669,000 children in 1976 to 3 million in 1995 (1 out of every 25 children).

International

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.

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.⁷

Age

Because most abuse cases occur during the preschool years, children may be particularly vulnerable to dissociation during those years. In 1991, the National Child Abuse and Neglect Data System indicated that 24% of 838,232 reports were for physical abuse and that 7% of children who were abused were younger than 1 year, 27% were younger than 4 years, and 28% were aged 4-8 years. The rate of reports decreases for older children. Early age at onset was also correlated with a higher degree of dissociation.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Because children normatively exhibit age-related differences in levels of dissociative behavior, exhibiting fantasy play and displaying various parts of their personalities in various settings, the clinician must determine if a particular behavior deviates from that of other children of the same age and if a child is exhibiting dissociative symptoms.

Children have a much poorer sense of continuity of their behavior and the flow of time than adults do. Symptoms such as the sense of loss of time are not easy for children to discern. Even well into adolescence, children may not recognize loss of time or discontinuity of experience as unusual or abnormal experiences. In fact, discontinuity of experience is probably the norm for young children; it is consistent with the cycle through sleep and drowsy states and is developmentally appropriate for children to find themselves in new or changed surroundings without awareness of passage of time. This is qualitatively distinct from the loss of time of dissociation, during which the individual is awake.

Dissociation reflects disruptions in the integration of memories, perception, and identity into a coherent sense of self. Disruptions in identity may assume the blurring of boundaries between a child's self and fantasy characters. Important to note, however, is that in young children, dissociation is often viewed as a normative process related to imagination and fantasy capacity.

Dissociative phenomena is divided into 2 categories: detachment and compartmentalization. These 2 factors have diverse natures and manifest as conversion disorder, hypnosis, dissociative amnesia, and dissociative identity disorder.

• Dissociative identity disorder is characterized by the existence of 2 or more personalities within the individual. Clinically, only one of the personalities is present at any given moment, and one of them is dominant most of the time.
• The various personalities are almost always quite discrepant and often seem to be opposite. The original personality usually has no knowledge of the other personality. When a given personality is dominant and interacting with the environment, the other personalities may not perceive all that is happening.
• Each personality is well integrated and is a complex aggregate of unique memories, behavior patterns, and social relationships that control each individual's function during its dominant intervals.
• Transition from one personality to another is sudden, often dramatic, and usually precipitated by stress.
• Patients with dissociative disorder have associated borderline personality disorder, somatization disorder, major depression, PTSD, and history of suicide attempt more often than other psychiatric patients. Childhood sexual abuse, physical neglect, and emotional abuse are strongly associated with dissociative disorders. 
• Other, more subtle, signs of dissociation may be present, such as episodes of amnesia or blackout in the absence of substance abuse, the patient referring to himself or herself as we, the patient being told by others of behavior he or she does not recall, or the patient being greeted by people he or she does not know. A patient may miss objects that cannot be accounted for or find objects or samples of strange handwriting.
• Fugue states, sleepwalking, and automatic writing may represent dissociation.
• A child who is experiencing dissociative symptoms may appear withdrawn, frightened, or uninvolved.
• Frequently, the child is identified as being "different" from other children, although referring clinicians, caseworkers, foster parents, and teachers are often at a loss to characterize the differences.
• Children with dissociative disorders exhibit a plethora of fluctuating abilities, moods, fears, and anxieties; shifting preferences; inconsistent knowledge; and other evidence of erratic access to information and skills.
• Auditory hallucinations are present in most children and adolescents with dissociative disorder; however, "phobic" hallucinations in severely stressed children and young adolescents do not necessarily indicate an enduring psychotic disorder and may be transient phenomena.
• Initial or short-term effects of abuse include early reactions occurring within the first 2 years of termination of abuse.
• • Emotional reactions and self-perceptions
  • • In 1981, Anderson et al reviewed clinical charts of 155 female adolescent sexual assault victims and reported psychosocial complications in 63% of them.⁸
    • Tuft's researchers found differences in the amount of pathology reported for different age groups.⁹ The highest incidence of psychopathology was found in children aged 7-13 years. Of the group aged 4-6 years, 17% met the criteria for clinically significant pathology. The following reactions are found to be common among patients who have been abused: breaking down emotional impact into specific reactions, anger and hostility, and guilt and shame.
• • Effects of sexual abuse on sexuality: Reactions of inappropriate sexual behavior in patients who have been sexually abused are well documented. Patients with dissociative disorder are more likely to have experienced childhood physical abuse and childhood sexual abuse than patients with other psychiatric conditions.
  • Effects on social functioning: People who have experienced sexual abuse are also found to have problems in social functioning, including the following:
  • • School difficulties
    • Truancy
    • Running away from home
    • Delinquency
• Long-term effects are noted in the same areas.
• • Emotional reactions and self-perceptions: Depression, anxiety, and tension are the most commonly reported long-term problems among adults who were molested as children.
  • Impact on interpersonal relations
  • • Difficulty in parenting and responding to their own children
    • Difficulty trusting others
    • Fear, often undifferentiated
    • Hostility
    • Sense of betrayal
  • Effects on sexuality
  • • Problems with sexual adjustment
    • Promiscuity (increased level of sexual behavior)
  • Effects on social functioning
  • • Prostitution
    • Substance abuse

Physical

• Suspect physical abuse when a child who presents with possible dissociate disorder has an injury is unexplained, unexplainable, or implausible.
• Bruises are the most common manifestation of child abuse and may be found on any body surface.
• Approximately 10% of cases of physical abuse involve burns. A burn's shape or pattern may be diagnostic when it reflects the pattern of an object or method of injury.

Causes

• No evidence suggests any biological cause for dissociative identity disorders.
• Traumatic experiences in childhood may enhance the individual's ability to dissociate. In 1986, Putnam et al reported the highest correlative figures; 97% of patients with MPD were reported by their clinicians to have a history of abuse in childhood.¹⁰ Sexual abuse, usually incest, was reported in 75% of those cases.
• Middleton provided early photographs and school reports that provided further suggestive evidence of childhood disturbance.¹¹
• In 2001, Macifie documented that maltreated children, especially children who were physically and/or sexually abused, demonstrated more dissociation than did normally treated children.¹²
• Gast reported high prevalence of traumatic experiences during childhood.¹³ Of the participants in this study, 85% reported some sort of childhood trauma.
• In Sar et al's 2004 study, the rates of reported childhood physical and sexual abuse were 44.7% and 26.3%, respectively.¹⁴
• MPD tends to have its origin in early childhood, from age 2.5-8 years, and issues arise during adolescence. Traumatic childhood experiences, especially of physical abuse and neglect, are reported to be common in people who develop MPD. How these traumatic experiences lead to a presentation of MPD in later life is unclear.
• The effects of exposure to situations of extreme ambivalence and abuse in early childhood may be coped with in a psychodynamic formulation by an elaborate form of denial so that the child believes the event to be happening to someone else. This process may be facilitated in childhood, a time with a rich fantasy life that often includes imaginary companions.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Comorbidities are noted among patients with dissociative identity disorder. In a study by Tezcan et al, all patients with dissociative disorder also had other psychiatric disorders.¹⁵ A high prevalence of dissociative disorder is noted among patients admitted from emergency psychiatric departments. Comorbid major depression, somatization disorder, and borderline personality disorder is seen in most of these patients. Auditory hallucinations, psychogenic amnesia, flashback experiences, and childhood abuse and/or neglect are other features seen in patients with a dissociative disorder. Many patients receive different diagnoses because of lack of awareness of this condition.

Temporal lobe epilepsy

Dissociation is more common in patients with temporal lobe epilepsy than in any other neurologic disorder. The clinician should refer patients with dissociative symptoms for a thorough neurologic workup to rule out the presence of temporal lobe epilepsy or other organic processes. The standard EEG is of little help in distinguishing MPD from temporal lobe epilepsy because a high rate of nonspecific abnormalities has been detected in patients with MPD, most commonly bilateral temporal lobe slowing.

Schizophrenic disorders

The differentiation between MPD and schizophrenia can be made along several lines.

• Patients with schizophrenia hear voices emanating from the external world, whereas patients with MPD hear voices originating from within the individual's own head.
• Patients with schizophrenia may experience visual hallucinations, although they are less well formed than those observed with certain other brain disorders. Patients with MPD occasionally experience hypnagogic phenomena.
• Poor reality testing is observed with schizophrenia, whereas patients with MPD have essentially intact reality testing.
• Tangential or loose associations accompanied by inappropriate affect are commonly observed with schizophrenia. Patients with MPD may have circumstantial association with appropriate affect.

Borderline personality disorder

Borderline personality disorder has been diagnosed in 70% of a sample of 33 patients with dissociative disorder and in 23% of 70 patients with dissociative disorder. Putnam acknowledged that a large number of his cases resembled Briquet syndrome or somatization disorder, but, like other investigators, he proposed that once the diagnostic criteria for MPD are satisfied, MPD should be considered the superordinate diagnosis because working with the alternates can provide a therapeutic device that cannot be used in the unified individual.

Malingering

Malingering is said to be an important differential diagnosis in times when an obvious gain may result from mental health intervention. Malingering is the deliberate and fraudulent production of false and exaggerated symptoms to deceive observers for secondary gain that is recognizable with an understanding of the individual's circumstances.

Dissociative amnesic disorder

MPD may prove difficult to distinguish from other dissociative amnesic disorders. With other dissociative amnesic disorders, behavior may be complex, but recovery is often complete, recurrences are less common, and the onset of amnesic spells may be intimately related to stressful events or to ingestion or intoxication.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

Although no laboratory studies are specifically indicated for the diagnosis of dissociative disorder, studies can be performed to check for abuse.

• Obtain screening tests in all cases of bruising to rule out a bleeding diathesis, but remember that children with bleeding problems may also be abused.
• Screen urine and stool for blood if abdominal trauma is suspected.

Imaging Studies

As with laboratory studies, no imaging studies are indicated for the diagnosis of dissociative disorder; however, results of imaging studies can indicate abuse.

• A bone survey consisting of multiple views of the skull, thorax, long bones, hands, feet, pelvis, and spine is necessary with children younger than 2 years if abuse is suspected. If suspicion is strong, repeat the survey in 7-10 days to examine for healing or fractures not observed on the initial radiographs.
• Bone scanning may be of value in detecting new fractures of hands, feet, or ribs. They are not valuable in detecting skull fractures.
• Perform head CT scanning if the child has been severely injured.
• Abdominal CT scanning may reveal damage to internal organs.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Patients who are survivors of extensive childhood abuse frequently present complicated clinical dilemmas. Dissociative episodes, flashbacks, and self-destructive and suicidal impulses are common difficulties encountered by such patients.

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.

• Encouraging healthy coping behaviors
• • 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.
  • Embarking on a treatment plan can be dangerous if the patient has not developed ways to tolerate the emotional turmoil that arises when uncovering traumatic memories. Until the patient can learn healthy alternatives to tolerate feelings and control behaviors, he or she cannot adequately or safely undertake the exploratory work involved in uncovering and processing memories of abuse.
  • Control is a major issue for survivors of abuse, and by learning new ways to control and contain their symptoms, patients no longer view themselves as victims of the past.
  • The emphasis is to have patients reconnect with their sense of power. Encouraging patients to design and choose which technique to use and when to use it contributes to their sense of being in charge of themselves; patients can begin to deal correctly with feelings of helplessness.
• Logging and monitoring emotions
• • Many patients who experience loss of time through dissociation or flashbacks describe the events as being abruptly triggered. These symptoms sometimes become so severe that patients can no longer function in their usual way.
  • One way to help patients begin to work with their sense of unpredictability is to have them keep a log of their emotions. The patients must first identify emotions. Once they have developed the ability to identify feelings, they can monitor the intensity of each feeling.
  • Patients usually report a cluster of recurrent emotions such as anxiety, sadness, or rage. Quite frequently, these symptoms precede dissociation, flashbacks, self-destructive impulses, and suicidal impulses. Patients should be coached on how to intervene long before anxiety rises to a critical level.
• Developing a crisis plan
• • Identifying the cause of the anxiety is also important. Teaching patients to develop a list that ranges from simple to complex activities is helpful. Once patients become engaged in the activities, the intensity of emotions usually decreases. In addition, patients feel more in control. This reconnects them to personal strengths and the choices that can be exercised.
  • Most patients require time to learn new and effective coping skills. Emphasize that patients must practice new skills and techniques until they develop a sense of mastery.
  • If the difficulties experienced by patients with histories of abuse are directly related to the abuse experiences, definitive treatment cannot seemingly be successful without acknowledgment of these experiences. Clinicians treating such patients may collude with them in their beliefs about themselves if unaware of the existence of the traumatic etiologies of the current disturbance.

Consultations

If the reason for the dissociative disorder is likely abuse, promptly initiate appropriate medical, surgical, and mental health consultation. The law requires that a child suspected of being abused or neglected be reported immediately to CPS.

• Psychiatrist or behavioral/developmental pediatrician
• Social services representative
• Child abuse and sexual abuse (CASA) specialist

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Pharmacologic management is essentially the same as for Posttraumatic Stress Disorder in Children. If the patient is currently being abused, treatment should be appropriate for acute stress disorder.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Hospital admission is indicated for children in the following cases:
• • When medical or surgical condition requires inpatient management
  • When the diagnosis is unclear
  • When no alternative safe place for custody is immediately available

Further Outpatient Care

• If a child or adolescent is being treated, the parent or guardian must be seen. The guardian or parent must learn how to deal with the child during expression of multiple personalities or amnestic episodes.
• A mental health professional with special experience in this area should provide follow-up care for these patients.

In/Out Patient Meds

• Pharmacologic management is the same as for PTSD.

Deterrence/Prevention

• Stopping child abuse as early as possible maximizes chances for prevention.
• With suspicion of abuse, siblings should undergo full examinations within 24 hours.

Complications

• In 1981, Allison found criminal activity in patients with MPD.¹⁶
• Other literature also notes complications of other social problems, such as prostitution and antisocial outbursts and actions.
• Childhood sexual and physical abuse are highlighted as predictors of both paranoid and antisocial personality disorders. Patients with dissociative disorder also reported suicide attempts and self-mutilative behavior.

Prognosis

• A patient with MPD who seeks and finds adequate treatment has an excellent prognosis. Physicians and therapists who have worked with patients with MPD are optimistic about recovery. Recovery requires specially trained skilled psychiatrists who thoroughly understand the condition.

Patient Education

• Patient education is of utmost importance. When patients with MPD understand what is really happening in their lives, they become excellent, cooperative patients.
• For excellent patient education resources, visit eMedicine's Children's Health Center and Public Health Center. Also, see eMedicine's patient education articles Child Abuse and Sexual Assault.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Legal requirements for reporting abuse to the proper social services and CPS should be thoroughly understood. Reporting abuse is required by law; it is not optional. Physicians must neither overlook nor mismanage the opportunity to identify abuse.
• Physicians are sometimes hesitant to report suspected cases of abuse because they are not absolutely certain of the diagnosis. Remember that physicians are required by law to report all suspicious cases. Additionally, physicians are protected by law from legal retaliation by the parents.

Special Concerns

• Physicians must first maintain an open mind to the possibility that abuse commonly occurs.
• If an injury is incompatible with the history provided or with the child's development, abuse should be suspected.
• A delay in seeking medical help should increase suspicion.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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23. Ellason JW, Ross CA. Two-year follow-up of inpatients with dissociative identity disorder. Am J Psychiatry. Jun 1997;154(6):832-9. [Medline].
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26. Putnam FW. Diagnosis and Treatment of Multiple Personality Disorder. New York, NY: Guilford Press; 1989.
27. Putnam FW. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry. Mar 2003;42(3):269-78. [Medline].
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Article Last Updated: Nov 28, 2007