5) Dissociative Identity Disorder (DID)
In some cases the identities are complete, each with their own behaviour, tone of voice,
and physical gestures.
Alters is the shorthand term for the different identities or personalities in DID.
Symptoms include amnesia as well as the identity has been fragmented – the defining
feature is not how many different personalities exist rather that certain aspects of the
person’s identity are dissociated.
The person who becomes the patient and asks for treatment is usually a “host” identity –
host personalities usually attempt to hold various fragments of identity together but end
up being overwhelmed – the original personality of the person is rarely the first to seek
treatment because they are not aware of what is going on.
The transition from one personality to another is called a “switch” which is usually
Can DID be faked? – it is possible that alters are created in response to leading questions
from therapists, either during psychotherapy or while the person is in a hypnotic state.
Etiology of DID – life circumstances that encourage the development of DID seem quite
clear in one respect, almost every patient presenting with this disorder reports that he or
she was horribly, often unspeakably, abused as a child.
In a situation like Sybil’s the child is too young to run away or call the authorities but the
one thing they can do is escape into a fantasy world and be somebody else – if the escape
blunts the physical and emotional pain than chances are you’ll escape again and the mind
learns there is no limit to the identities that can be created.
Childhood trauma that contributes to DID development is not always abuse; it can be
from other traumatic events as well like living in a war zone.
DID is rooted in a natural tendency to escape or “dissociate” from the unremitting
negative affect associated with severe childhood trauma – a lack of social support during
or after the trauma also seems implicated.
Dissociative amnesia and fugue states are clearly reactions to severe life stress (legal
difficulties, or severe stress at home or the job), however, the stress or trauma is in the
present rather than the past like DID
Some people do not develop severe pathological dissociate experiences (DID) no matter
how extreme the stress, which is consistent with the diathesis-stress model, in that only with the appropriate vulnerabilities will a person react to stress with pathological
DID seems very similar in its etiology to post-traumatic stress disorder (PTSD) – both
conditions feature strong emotional reactions to experiencing a severe trauma but not
everyone goes on to experience PTSD after severe trauma, only people who are
biologically and psychologically vulnerable to anxiety are at risk for developing PTSD in
response to moderate levels of trauma but still not everyone develops it therefore,
psychological and biological factors interact with the trauma to produce PTSD.
Suggestibility is a personality trait distributed normally across the population, some
people are much more suggestible than others, some are immune to suggestibility and the
majority fall in the mid-range – having a imaginary childhood playmate is much more
common among those with DID and it also seems to correlate with being suggestible or
easily hypnotized – a hypnotic trance is also very similar to dissociation and the person
can be vulnerable to suggestions by the hypnotist – according to the autohypnotic model,
people who are suggestible may be able to use dissociation as a defence against extreme
Biological Contributions – individuals with certain neurological disorders, particularly
seizure disorders, experience many dissociative symptoms, however, this is very different
from those having DID without a seizure disorder because the trauma is in the past and in
a seizure disorder, the dissociative symptoms develop in adulthood and are not associated
with trauma unlike DID – head injury and resulting brain damage may induce amnesia or
other types of dissociative experiences but these conditions are usually easily diagnosed
because they are generalized, irreversible and associated with the head trauma – there is
strong evidence that sleep deprivation produces dissociative symptoms and the symptoms
of people with DID worsen when they are tired.
Real and False Memories – memories of childhood abuse could be the result of strong
suggestions by careless therapists.
Individuals who experience dissociative amnesia or a fugue state usually get better on
their own and remember what they have forgotten – the episodes are so clearly related to
current life stress that prevention of future episodes usually involves therapeutic
resolution of the distressing situations and increasing the strength of personal coping
mechanisms – therapy focuses on recalling what happened during the amnesic or fugue
states, often with the help of friends or family who know what happened, so patients can
confront the information and integrate it into their conscious experience – for more
difficult cases, hypnosis or the use of benzodiazepines (minor tranquilizers) have been
For DID, the process is not so easy because with the person’s very identity shattered into
many different elements, reintegrating the personality might seem hopeless – many
documented successes exist of attempts to reintegrate identities through long-term
psychotherapy – the prognosis for most people remains guarded. The strategies that therapists use today in treating DID are based on accumulated clinical
wisdom, as well as on procedures that have been successful in PTSD – the fundamental
goal is to identify cues or triggers that provoke memories of trauma or dissociation and to
neutralize them, more importantly, the patients must confront and relive the early trauma
and gain control over the horrible events as they recur in the patient’s mind – to instill
this sense of control, the therapist must skillfully and very slowly, help the patient
visualize and relive aspects of the trauma until it is simply a terrible memory instead of a
current event – some aspects of the experience are often unknown to the patient or the
therapist until those memories emerge during treatment – hypnosis is used to access these
unconscious memories and bring various alters into awareness.
Occasionally, medication is combined with therapy, but there is little indication that it
helps much – antidepressants drugs might be appropriate in some cases. Chapter 7: Mood Disorder
An Overview of Depression and Mania
Mood disorders are a group of disorders involving severe and enduring disturbances in
emotionality ranging from elation to severe depression – the fundamental experiences of
depression and mania contribute, with singly or together, to all mood disorders.
The most commonly diagnosed and most severe depression is called a major depressive
episode – the DSM-IV-TR criteria indicate an extremely depressed mood state that lasts at
least two weeks and includes cognitive symptoms (such as feelings of worthlessness and
indecisiveness) and disturbed physical functions (such as altered sleeping patterns,
significant changes in appetite and weight, or notable loss of energy) to the point that even
the slightest activity or movement requires an overwhelming effort – the episode is typically
accompanied by a marked general loss of interest and of the ability to experience any
pleasure from life, including interactions with family or friends and accomplishments at
work or at school, which is termed anhedonia – recent evidence suggests that the physical
symptoms (somatic or vegetative symptoms) are central to this disorder – 9 month duration
The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or
euphoria – in mania, individuals find extreme pleasure in every activity; they become
extraordinarily active (hyperactive), requiring very little sleep and may develop grandiose
plans, believing they can accomplish anything they desire – speech is very rapid and may
become incoherent because the individual is attempting to express many exciting ideas at
once, this is called flight of ideas – the DSM-IV-TR criteria for a manic episode require a
duration of only one week, less if hospitalization occurs.
A hypnotic episode is a less severe version of a manic episode that does not cause marked
impairment in social or occupational functioning.
The Structure of Mood Disorders
Individuals who experience either depression or mania are said to have a unipolar mood
disorder, because their mood remains at one “pole” of the usual depression-mania
continuum – mania by itself is very rare, almost everyone with a unipolar mood disorder has
Someone who alternates between depression and mania is said to have a bipolar mood
disorder – however, this label can be misleading because depression and elation may not
exactly be at opposite ends of the same mood state because some individuals can experience
manic symptoms but feel somewhat depressed or anxious at the same time and this
combination is called dysphoric manic or a mixed episode. Depressive Disorders
The most easily recognized mood disorder is major depressive disorder, single episode,
defined by the absence of manic or hypomanic episodes; we now know that an occurrence
of just one isolated depressive episode in a lifetime is rare– if two or more major depressive
episodes occurred and were separated by at least two months during which the individual
was not depressed, major depressive disorder, recurrent, is diagnosed.
Recurrence is very important in predicting the future course of the disorder as well as in
choosing appropriate treatments – individuals with recurrent major depression usually have
a family history of depression, unlike people who experience single episodes – unipolar
depression is often a chronic condition that waxes and wanes over time but seldom
Dysthymic disorder is defined as a persistently depressed mood that continues for at least
two years, during which the patient cannot be symptom-free for more than two months at a
time – it differs from a major depressive episode only in the severity, chronicity, and
number of its symptoms, which are milder and fewer but last longer.
Double Depression is diagnosed when individuals experience both major depression
episodes and dysthymic disorder – typically dysthymic disorder develops first, perhaps at an
early age, and than one or more major depressive episodes occur later – do not recover from
the underlying dysthymic disorder.
From Grief to Depression
Pathological Grief Reaction is the extreme reaction to the death of a loved one that
involves psychotic features, suicidal ideation, or severe loss of weight or energy, or the less
alarming symptoms persist for more than two months.
The key identifying feature of bipolar disorders is the tendency of manic episodes to
alternate with major depressive episodes in an unending roller coaster ride from the peaks of
elation to the depths of despair – manic episodes might occur only once or repeatedly.
Bipolar II disorder, occurs when major depressive episodes alternate with hypomanic
episodes (less severe, still able to function) rather than full manic episodes – bipolar I
disorder is the same, except the individual experiences a full manic episode; for the manic
episodes to be considered separate they must have a symptom-free period of at least two
During manic or hypomanic episodes, patients often deny they have a problem - the high
during a manic episode is so pleasurable that people may stop taking their medication during
periods of distress or discouragement in an attempt to bring on a manic state. Like dysthymic disorder, cyclothymic disorder is a chronic alternation of mood elevation
and depression that does not reach the severity of manic or major depressive episodes –
individuals with this disorder tend to be in one mood state or the other for many years with
relatively few periods of neutral mood; this pattern must last for at least two years to meet
criteria for the disorder – these individuals alternate between the kinds of mild depressive
symptoms Jack experienced during his dysthymic states and the sorts of hypomanic
episodes Jane experienced; in neither case was the behaviour severe enough to require
hospitalization or immediate intervention, however, the chronically fluctuating mood states
are substantial enough to interfere with functioning and these individuals could potentially
develop the more severe bipolar I or bipolar II disorder.
Postpartum onset specifier is characterized by severe manic or depressive episodes that first
occur during the postpartum period (the four weeks immediately following childbirth),
typically two to three days after delivery – having an infant with a difficult temperament is
an important type of stressor that can contribute to postpartum depression; low
socioeconomic status and high levels of life stress are also related to the persistence of
postpartum depression following the birth.
Specifiers Describing Course of Mood Disorders
Three specifiers that may accompany recurrent mania or depression:
i. Longitudinal course specifiers – whether the individual has had major episodes of
depression or mania in the past is important as well as whether the individual fully
recovered between past episodes – whether the patient with a major depressive
episode had dysthymia before the episode (double depression) and whether the
patient with bipolar disorder experienced a previous cyclothymic disorder, this
predicts a decreasing chance of full interepisode recovery, the patient will require a
long and intense course of treatment to maintain a normal mood state.
ii. Rapid-cycling specifier – this temporary specifier applies only to bipolar I and
bipolar II disorders – an individual with bipolar disorder who experiences at least
four manic or depressive episode within a year is considered to have a rapid-cycling
pattern, which is a severe variety of bipolar disorder that does not respond well to
standard treatments and which is also associated with higher suicide attempts –
anticonvulsants and mood stabilizers may be more effective with this group.
iii. Seasonal pattern specifier – this temporary specifier applies both to bipolar
disorders and to recurrent major depressive disorder – it accompanies episodes that
occur during certain seasons – the most usual pattern is a depressive episode that
begins in late fall and ends with the beginning of spring whereas in bipolar
disorder, individuals may become depressed during the winter and manic during the
summer – this condition is called seasonal affective disorder (SAD).
People with winter depression tend toward excessive sleep (rather than decreased sleep),
increased appetite (rather than decreased appetite), and weight gain (rather than weight loss)
which is the opposite of major depressive episodes – SAD patients score higher on a
personality trait referred to as openness, which may be why they have a heightened
sensitivity to their environment and experience amplified reactions to reduced light levels
during winter months – biological explanations could be the over production of melatonin in the winter which might trigger depression in vulnerable people and that circadian rhythms
are delayed in the winter.
Anxiety and Depression
It has been concluded that the two moods (anxiety and depression) are more alike than
different – we now know that almost everyone who is depressed, particularly to the extent of
having a disorder, is also anxious, but not everyone who is anxious is depressed – this
means that certain core symptoms of depression are not found in anxiety, these core
symptoms are the inability to experience pleasure (anhedonia) and a depressive “slowing” of
both motor and cognitive functions until they are extremely labored and effortful; cognitive
content is more negative in depressed individuals.
In panic, the symptoms reflect primarily autonomic activation (excessive physiological
symptoms such as heart palpitations) and in anxiety, muscle tension and apprehension
(excessive worrying about the future) – many people with depression also have symptoms of
anxiety or panic – a large number of symptoms help define both anxiety and depressive
disorder because these symptoms are not specific to either kind of disorder, they are called
symptoms of negative affect.
Major depression usually follows anxiety and may be a consequence of it.
Causes of Mood Disorders
Familial and Genetic Influences
In family studies, we look at the prevalence of a given disorder in the first-degree relatives
of an individual known to have the disorder – these studies have shown that both unipolar
depression and bipolar disorder run in families and increasing severity and recurrence of
major depression in the individuals with the disorder was associated with higher rates of
depression in relatives.
In adoption studies, we look at the biological relatives of an individual with a given disorder
who was adopted at an early age – the data here is mixed showing a genetic contribution and
then not showing one.
The best evidence that genes have something to do with mood disorders comes from twin
studies, in which the frequency with which identical twins have the disorder compared to
fraternal twins is examined – studies suggest that the mood disorder are heritable – severe
mood disorders may have a stronger genetic contribution than less severe disorders.
Authors conclude that environmental events play a larger role in causing depression in men
than in women – genetic contribution to depression are higher for women than men. Wide agreement exists that it is the unique non-shared events, rather than what is shared,
that interact with biological vulnerability to cause depression (twin studies).
Joint Heritability of Anxiety and Depression
The same genetic factors contribute to both anxiety and depression but social and
psychological explanations seem to account for the factors that differentiate anxiety from
depression – the biological vulnerability for mood disorders may not be specific to that
disorder but may reflect a more general predisposition to anxiety or mood disorders; the
specific form of the disorder would be determined by unique psychological, social, or
additional biological factors.
Research implicates low levels of serotonin in the etiology of mood disorders but only in
relation to other neurotransmitters, including norepinephrine and dopamine – the primary
function of serotonin is to regulate our emotional reactions, for example, we are more
impulsive and out mood swings more widely, when our levels of serotonin are low, possibly
because one of the functions of serotonin is to regulate systems involving norepinephrine
and dopamine – current thinking is that the balance of the various neurotransmitters and
their subtypes is more important than the absolute level of any one neurotransmitter.
The Endocrine System
Cortisol (stress hormone) levels are elevated in depressed patients – investigators have
discovered that neurotransmitter activity in the hypothalamus regulates the release of
hormones that affect the HPA axis (spe