Multiple personality disorder

Dissociative pathology, when the patient feels the division of the previously integral Self, manifests itself in many clinical variants. One of them, its extreme manifestation, is multiple personality, that is, the division of the Self into several subpersonalities (alter-personalities, ego-states), each of which thinks, feels and interacts with the outside world in its own way. These personalities regularly take turns controlling the individual's behavior. Unconscious dissociation is more common, patients do not notice the division of their Self and do not control the activity of their unconscious subpersonalities, since their change is accompanied by complete amnesia. Each personality has its own memory. Even if some memories are preserved in the real personality, the alternative ego-state is perceived as alien, uncontrollable and related to some other person.

American psychiatry diagnoses this phenomenon as dissociative identity disorder. The current ICD-10 classification calls a similar condition "multiple personality disorder" and classifies it with other dissociative (conversion) disorders, without isolating it as a separate nosology. The diagnostic criteria are generally the same. They are described most fully and clearly in the new version of the International Classification of Diseases, 11th revision (ICD-11), where this mental disorder already has its own code.

However, not all psychiatrists recognize the existence of the mental phenomenon of multiple personality. The disorder is quite rare, poorly studied and difficult to diagnose. Patients usually do not notice the fact of dissociation of their personality, and therefore do not seek medical help. Basically, such cases are detected when one of the subpersonalities commits illegal actions (usually this is not the real personality). The diagnosis is made after a thorough forensic psychiatric examination, designed to identify simulation. [ 1 ]

Epidemiology

Statistics for dissociative identity disorder (the most modern and correct name for the pathology) are based on a small sample, since it used to be very rare (up to 1985, about 100 cases were registered and described). Such mental disorders are usually first diagnosed at the age of about 30 (the average age of patients was 28.5 years). They occur much more often in women than in men: according to various studies, there are from five to nine female patients per one representative of the stronger sex. The prevalence of the pathology, according to various researchers, is estimated from a complete absence of such cases to 2.3-10% of the total number of residents of the country. [ 2 ], [ 3 ] The incidence is higher in English-speaking countries, but this may be due to the fact that multiple personality disorder is not recognized everywhere.

Three percent of psychiatrists reported that they had treated or assessed one or more patients who met DSM-III criteria for multiple personality disorder, and 10% reported that they had seen multiple personality disorder at least once during their professional careers. Patients were not equally distributed among psychiatrists; three colleagues reported that they had seen a significantly larger number of patients with multiple personality disorder. The point prevalence of multiple personality disorder among patients seen by psychiatrists is 0.05–0.1%. [ 4 ]

In recent years, there has been an inexplicable surge in "morbidity" in industrially developed countries; approximately 40,000 multiple personalities are already known. However, most of them raise doubts about the correctness of the diagnosis. There are not many psychiatrists in the world who have seriously studied multiple personality syndrome, and, as practice shows, it takes six to eight years to establish a diagnosis.

Causes multiple personalities

According to the American psychiatrist Frank W. Putnam and his other colleagues, who closely studied the phenomenon of multiple personality, the division of the integral Self into alter personalities is based on repeated violence experienced in childhood, most often sexual, the perpetrators of which are the closest people called to protect and defend the child. The cause may also be physical violence from parents or other family members - severe beatings and other cruel abuse of the child. In many cases, these forms of violence, physical and sexual, were applied to the victim simultaneously. [ 5 ]

Risk factors

Risk factors such as rejection, total indifference to the child on the part of parents or significant others, also, according to research, led to the development of multiple personality syndrome, and even more often than pure cruelty (without a sexual component).

The likelihood of developing personality dissociation is higher in cases where the relatives living nearby, although not participating in the abuse, do not acknowledge it, pretending that nothing is happening. This causes the victim to feel helpless in the face of the circumstances.

The regularity of the psychotraumatic impact, which depletes the internal reserves of the individual, is also important.

Experts suggest that war, destructive natural disasters, prolonged separation from the mother at the age of two, the death of parents and other critical situations may act as stressors. [ 6 ]

Pathogenesis

The pathogenesis of split personality, which is essentially a type of post-traumatic stress disorder, is triggered by regular severe mental trauma, which is superimposed on the characteristics of the victim's character, his ability to separate his identity from consciousness (to dissociate), the presence of personality disorders and more serious mental pathologies in the family, which generally fits into the scheme of hereditary predisposition. Multiple personality disorder is considered a defensive reaction that helps an individual who was subjected to cruel treatment in childhood to adapt and even simply survive. Research suggests that alter personalities usually appear in early childhood, since under conditions of unbearable stress, childhood development does not occur as it should, and instead of a relatively unified identity, a segregated one appears.

There is no single view on the pathogenesis of this disorder. Not even all psychiatric schools agree with its existence. There are several theories of the origin of multiple personality. One hypothesis considers it a type of psychogenic amnesia of purely psychological origin, by means of which the victim can repress from memory traumatic events of a certain period of life that go beyond the normal human experience.

Another theory is iatrogenic. The emergence of a large number of multiple personalities in recent years is associated with the widespread use of various types of psychotherapeutic help in the civilized world, including hypnosis, as well as books and films in which the hero suffers from this mental disorder. At least, most cases are considered iatrogenic when the patient remembers, in whole or in part, the events that occurred with his other identities and seeks psychiatric help himself. The origin of multiple personality in this case is associated with suggestion or self-hypnosis, and the factors that contribute to the development of such a disorder are called individual characteristics of a person. These are hypnotizable or hysterical individuals, focused on themselves and prone to fantasizing.

Symptoms multiple personalities

It is almost impossible to suspect multiple personality disorder in oneself, since the dissociation of the Self into several alternative personalities is usually not realized. Switching personalities is usually accompanied by amnesia, and naturally the patient himself does not have any complaints. The first signs that the patient may feel are, for example, the discreteness of time, when it seems to be torn and some time intervals "fall out" of memory, and those that are preserved are perceived as unrelated to each other. In established and described cases of the disorder, people noticed the loss of money (which, as it turned out later, their subpersonalities spent), the level of gasoline in the car (it turned out that someone was driving it while the patient, as he thought, was sleeping), etc. Large time episodes that cannot be attributed to forgetfulness are amnestic. People around you may notice that a person's behavior and mood change abruptly, just to the diametrically opposite, that he may not show up for a pre-arranged meeting, is genuinely surprised and denies that he even knew about the meeting and promised to come. But various inconsistencies in a person's behavior and oddities do not at all indicate that he has a split personality. To make a diagnosis, it is necessary to observe the patient for several years.

The specific manifestations of dissociative disorder are very diverse, there can be many alternative personalities - on average 14-15, there were cases when the doctor counted up to 50 identities. They had different ages, genders, nationalities, characters, preferences, dressed differently and spoke in different voices, and were not always even human beings.

Their existence is also qualitatively very different: one patient may have both stable and complexly organized identities, as well as fragmentary ones; some may never “appear,” but the rest or some of the subpersonalities “know” about their existence.

The clinical picture of multiple personality disorder may include any manifestations of "minor" dissociative disorders as symptoms. There are dissociative phenomena that, depending on the degree of expression, can be either a normal variant or a symptom of pathology. These include absorption (a state of all-encompassing absorption in something), absent-mindedness (daydreaming, a blank look - the individual is "not with us"), obsession, trance and hypnoid states, somnambulism (sleepwalking), dissociation of consciousness into the mental I and the physical I ("separation of the soul from the physical body") and near-death experiences.

And also certainly pathological forms of dissociation: mental amnesia - a condition when events that occurred in a certain period of time are amnesic, usually after a psychotraumatic event (local mental amnesia). Sometimes some events (traumatic) related to a certain period are selectively amnesic (suppressed from memory), but others (neutral or pleasant) remain in memory. Mental amnesia is recognized by the patient, he knows that he has forgotten some important information about himself. It is observed in 98% of patients with multiple personality disorder. [ 7 ]

Psychogenic fugue - when a person suddenly leaves home, work, and his personal identification changes completely or partially, and the original disappears or the patient is very vaguely aware of it. Fugue, unlike the previous condition, is not conscious. Fugue episodes occurred in more than half of patients.

Every second patient has a deep depersonalization/derealization syndrome or some of its manifestations. A fifth of patients walk in their sleep.

Individuals with multiple identities may experience: marked mood lability; unstable behavior; time fragmentation (loss of memory for entire time periods); amnesia for all or part of childhood; missed appointments, including with a doctor; conflicting information during medical history clarification (depending on which identity is currently attending the appointment).

The symptom complex known as Ross's "dissociative triad" includes the following manifestations:

• dissociation itself is manifested by a feeling of external control of feelings and thoughts, their openness, the presence of voices commenting on the patient’s actions, which is caused by the unconscious disintegration of mental functions;
• auditory pseudo-hallucinations are present constantly and do not lead to a break from reality (unlike schizophrenia);
• the patient's medical history includes a history of intentions or attempts to commit suicide or cause less significant harm to oneself.

In addition, each ego state may have its own mental disorders, which significantly complicates diagnosis. Depressive disorder is the most common (approximately 88%). 3/4 of patients with dissociative identity disorder attempted suicide, and slightly more than a third admitted to causing themselves bodily harm. Many suffer from insomnia, headaches, and regularly have nightmares. Anxiety disorders and phobias often preceded the "switching" of identities, but could also be independent disorders. Such people are prone to addictive behavior, transsexualism, and transvestism, since identities can be of different sexes. They often have hallucinations, catatonic manifestations, and thinking disorders associated with a crisis in the identity system, since none of them is able to fully control the individual's behavior, preserving his authenticity. On this basis, one of the identities, which imagines itself to be dominant, may develop delusions of independence. [ 8 ]

Multiple personality disorder is rare and poorly studied, requiring a long time to diagnose (approximately six to eight years from the moment it comes to the attention of a psychiatrist). Psychiatrists have had the opportunity to observe people with a full-blown disorder. Nevertheless, its belonging to adaptation syndromes does not cause objections, and the stages of development of adaptation syndrome are known.

The first stage of anxiety caused by a psychotraumatic event, when the victim first experiences shock and the equilibrium state of all body functions is disturbed. In our case, the individuals were regularly bullied in childhood, feeling absolutely defenseless and unable to change anything, the stress was chronic and caused a feeling of hopelessness. However, our body is designed in such a way that it strives to restore balance, albeit at some other level, in new conditions. The second stage begins - adaptation, at which the body turns on defense mechanisms, tries to resist stressors. Again, in our case, it is not possible to suspend their action, the body is exhausted in an unequal struggle, and the third stage begins - exhaustion, delimitation of vital functions, both mental and physical, since the defense mechanisms of the integrated personality have not justified themselves. A system of ego states with its own functions appears. At this stage, it is no longer possible to get out on your own, outside help is needed.

In the new international classifier ICD-11, dissociative identity disorder is singled out as a separate nosological unit among other dissociations, and is not included in other specified ones as in ICD-10. The name "multiple personality disorder" was abandoned, since the recognition of the fact of the existence of several subpersonalities calls into question the basic philosophical concept of the unity of personality and consciousness. Therefore, the concept of "alternate personalities" was replaced by the concept of "identity system", which embodies independent entities with fairly stable emotional and cognitive parameters. [ 9 ] The true (original) personality, outwardly normal, is called the owner. He may not suspect the existence of his other ego states, but there are cases when all identities knew each other and formed a close-knit team. The change of ego states is manifested by such symptoms as nystagmus, eye rolling, tremor, convulsions, absences. [ 10 ]

If one personality is dominant, that is, controls the patient's behavior most of the time, and other ego states take over periodically, but not for long, then such a pathology is referred to as complex dissociative intrusion disorder.

Multiple personality is one of the most mysterious and ambiguously interpreted mental disorders. It is a chronic disease that can remain with the patient for life, and its specific manifestations are largely determined by the individual characteristics of the patient and the duration of dissociative experiences. All types of dissociation phenomena can be present as symptoms of multiple personality, located at the most extreme point of this spectrum. [ 11 ]

Complications and consequences

Although dissociative identity disorder is recognized as a mental pathology, not everything is clear with it. Not only do not all psychiatrists agree with its existence, many consider it a variant of the norm - a kind of existential state. Therefore, if the multiplicity of ego states does not cause discomfort to the individual and does not lead to the commission of illegal actions, then there is nothing to treat.

At the same time, most of the known multiple personalities were discovered and came to the attention of psychiatrists due to the fact that they committed a serious crime. Psychiatrists involved in forensic examination, subsequent study of these phenomena and their treatment consider this disorder to be a pathology, and a very severe one at that, which is difficult to treat. Eventually, multiple personalities begin to have problems with integration into society, which, as practice shows, can lead to extreme manifestations of maladaptation - suicide or a crime against another person. [ 12 ]

Diagnostics multiple personalities

Currently, the diagnosis of multiple personality is made according to the ICD-10 and DSM-V criteria, which, with minor differences, require that the patient regularly and alternately feels himself as different personalities (identities) with different individual characteristics, memories, and value systems. This is not easy to establish, in addition, each alter-identity has its own mental disorders, and in order to understand this "bouquet" of pathologies, it is necessary to observe the patient over a number of years.

Different methods of psychological testing are used. The patient is interviewed according to a strictly structured interview scheme for diagnosing dissociative disorders, proposed by the American Psychiatric Association. Questionnaires are used: dissociative experiences, peritraumatic dissociation. The results are assessed according to the dissociation scale. [ 13 ]

Differential diagnosis

Differential diagnostics are carried out with mental illnesses, in particular, schizophrenia. In this case, they rely on specific symptoms that are not characteristic of dissociative disorders. Schizophrenics experience a split in mental functions, impaired perception, thinking and emotional reactions, in addition, they perceive the ongoing disintegration of the personality as a result of external influence. With multiple personality disorder, independent and rather complex identities are formed, each of which, differently, but integrally draws its own picture of the world. [ 14 ]

Organic pathologies of cerebral structures, substance abuse, and severe somatic diseases are also excluded, for which purpose an examination of the patient’s general health is carried out.

Multiple personality disorder is differentiated from religious practices and childhood fantasies that do not go beyond the norm.

Treatment multiple personalities

People suffering from this disorder are treated at their own request, with the exception of cases where one of the identities (usually not the host personality) has committed a crime. Various methods of psychotherapeutic influence are used - cognitive-behavioral, insight-oriented psychodynamic, family therapy. Methods of clinical hypnosis can also be used with extreme caution. [ 15 ]

There are only a few psychiatrists in the world with experience in treating such patients. Many of them have summarized their experience working with such patients and shared their treatment methods in books. For example, Richard Klaft and Frank W. Putnam describe very similar models and techniques for treating multiple personalities, which boil down to unifying (integrating) all ego states and merging them with the host personality. In general, however, it is possible to achieve a significant weakening of the influence of alternative personalities. This makes it possible to alleviate the patient's condition and ensure a safe existence for him and those around him. The aforementioned psychiatrists suggest establishing contact with all personalities, addressing the system of identities simultaneously as a single whole. Then, in fragments, since each identity often has separate episodes of memories, a holistic picture of the experienced psychological trauma is restored, events are spoken out, and connections with the actual personal disunity are analyzed. The conversation takes place with each alter-identity, with which (in the presence of others) their own strengths and weaknesses are discussed. This allows one to realize that alter-identities complement each other, the weaknesses of one are compensated by the strengths of the other. Such a technique allows one to effectively unite ego-states into one personality. Work with dreams and keeping diaries are also used.

Some identities are easier to contact with the psychotherapist (Putnam calls them internal helpers). The sooner such a helper is identified, the more effective the psychotherapy is. Others, on the contrary, are hostile to the host personality, to treatment, and to other ego states (internal persecutors). It is also desirable to identify them as quickly as possible and begin working with them.

The treatment is long-term, full integration is not guaranteed. After unification, long-term post-integration therapy is carried out. A possible satisfactory effect is considered to be the result when the psychiatrist achieves fruitful conflict-free coexistence and cooperation of all identities.

Drug therapy is used exclusively symptomatically (for example, antidepressants for severe depression) to alleviate the patient's condition and ensure more fruitful cooperation with him.

Prevention

The origin of this disorder is not entirely clear. It has been established that most known multiple personalities were distinguished by increased self-suggestibility. They were born that way, and there is nothing to be done about it. At the same time, most people with this quality do not suffer from multiple personality disorder.

The development of the most severe form of dissociation was caused by chronic psychological trauma in childhood - in most cases, it was sexual and/or physical abuse by one of the parents (less often - other family members). Such "skeletons in the closet" are usually carefully hidden, they are not easy to prevent. All officially registered persons with this disorder (there are currently about 350 of them) have a history of severe traumatic situations associated with violence.

Psychiatrists who recognize dissociative identity disorder believe that it is theoretically possible for it to develop in the absence of severe psychological trauma in childhood. This is also supported by the increase in the number of people seeking psychiatric help for various types of "multiple personalities" in recent years. In this case, the main role is played by personal predisposition (a tendency to theatricality, fantasizing, self-hypnosis, narcissism), and the provoking factor is information that discusses this topic - books and films about multiple personalities. Such a plot is usually a sure thing, many authors, both classics and our contemporaries (R.L. Stevenson, A. Hitchcock, K. Muni) have addressed it, the works always arouse increased interest and become bestsellers. It is impossible to eliminate their influence on predisposed individuals.

The cases of complaints, which have become more frequent recently, raise doubts about the validity of the diagnosis among serious clinicians - experts in the field of this pathology. In addition, in the West there is an opinion that multiple personality is not a disease. It is an existential condition that does not need to be prevented or treated, at least until it causes discomfort to the host personality and is not dangerous in a social sense.

Based on the above, the prevention of the development of multiple personality disorder is a socio-psychological problem of eradicating child abuse that has not yet been solved in any country in the world.

Forecast

First, diagnosis and then treatment of dissociative identity disorder lasts for years, often the patient needs psychotherapist consultations for the rest of his life. The goal of psychotherapy - reintegration of different identities into a single normally functioning personality is not always achieved, a satisfactory result is considered to be the absence of conflict between ego states and cooperation between them, that is - a stable and normally functioning multiple personality that does not experience psychological discomfort.