Guilty by Dissociation

Quoted from Serendip
"Dissociative Identity Disorder" by Rachel Kaplan

Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder (MPD) is considered by the American Psychiatric Association to be one of 4 main kinds of dissociative disorders (DSM-IV): "The essential feature of dissociative disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness" (8). If identity is the main function affected, the person is said to have DID.
Most non-DID people have one identity comprised of many parts that work harmoniously together. They have only one I-function which consists of a conglomeration of thoughts and feelings formed from connections between many different brain areas. People with MPD, however, have a decentralized, internal network of 2 or more I- functions or "alters," each with its own physiology, behavior, and cognitions.
Dissociation often enables victims to maintain a relatively healthy level of functioning because traumatic memories are disconnected from other information in their minds. A multiple presents her view of DID: "We do not SUFFER FROM MPD. We SURVIVE because of MPD" (6). Living with this disorder is often an extremely lonely, confusing experience. Luckily, there has been much success in treating this disorder thanks to the extensive research conducted into DID etiology.
The etiology may be explained by the diathesis-stress model. There appears to be a biological component given the fact that most people with DID have a family history of the disorder. It has also been found that people who are easily hypnotized are more susceptible to DID (5). The stress is known to come from severe physical, emotional, and/or sexual abuse at a developmentally sensitive stage in childhood (3).
When a person experiences extreme stress "endogenous, stress-responsive neurohormones, such as cortisol, epinephrine and norepinephrine (NE), vasopressin, oxytocin and endogenous opioids" are released (10). These substances induce glucose release and activate the immune system, enabling the organism to effectively deal with the stress. Chronic stress, however, such as repeated sexual abuse, decreases the effectiveness of this system. It has been hypothesized that when the system is bombarded with chronic stress, there is a malfunction in the negative feedback loop which goes from the neurohormones back to the hypothalamus and pituitary gland. As a result, the system begins operating in positive feedback mode; increased cortisol release, for example, leads to increased cortisol production. The desensitization of the system causes the person to have an intense stress reaction in the presence of even the smallest trigger. Abnormalities in the limbic system have also been implicated in this condition.
This desensitized state exacerbates the dissociative process. In order to survive extreme stress, many children psychologically separate "thoughts, feelings, memories, and perceptions of traumatic experiences" (2). This coping method becomes increasingly ingrained the more frequent the abuse. The resulting highly conditioned, hypersensitive survival technique leads to impaired functioning. A person with a young child as one of his alters might bring out that child whenever there is even the slightest threat of an anxiety-provoking situation. In this way, if a traumatic event occurs, the pain gets isolated to one faction, a storage space, of the overall personality.
Memories from traumatic experiences are encoded in a unique way. Pierre Janet has suggested that the emotional impact of the trauma prevents the victim from translating the experience into the words and symbols which would be stored in the semantic memory. Instead, the experience gets stored in a "somatosensory or iconic level" form which makes for vivid and accurate recall (10). For example, 4-5 months after witnessing a murder, subjects showed excellent recall for details about the event (Cutshall 1989) (11). Neuroimaging studies have shown that during the stimulation of traumatic memories, there is decreased activity in Broca's area, the part of the brain most concerned with the translation of experience into words, and increased activity in the right hemisphere areas, parts which are involved in the processing of emotional and visual information. (Rauch et al., 1995) (11). A person with DID has stored these emotional and visual representations of traumatic incidents in a whole identity that is as stunted as the memories themselves.
Storage in semantic memory is easier on the ego because experiences are tempered through their translation. Also, because semantic memory integrates input into existing mental schemata, the information is subject to learning effects (10). When recalled, these memories are subject to distortion because of their emergence in a new context. There is debate, however, about whether traumatic memories can ever be changed. It has been found that with time sensorimotor and iconic memories tend to become restored as words and symbols which can be processed in connection with existing mental schemes (10). LeDoux, on the other hand, has postulated that "once formed, the subcortical traces of the conditioned fear response are indelible, and that 'emotional memory may be forever'" (10). LeDoux's theory does not bode well for the ability of trauma victims to unload their burdensome memories. There is definitive evidence, at least, that memories may be recovered.
Research has shown that memory retrieval is "state dependent (10): "physiological arousal in general can trigger trauma-related memories, while, conversely, trauma-related memories precipitate generalized physiological arousal (10). This phenomenon might explain why the presence of a trigger for a traumatic memory may induce a "switching" of alters. The memory may induce a stress reaction which would ultimately produce a different physiological state. It seems possible, given that alters have been shown to have different physiologies, that a specific physiological state might correspond with a specific alter. The concept of corollary discharge may be used to explain why the actions of one alter may affect the mind-set of others despite the psychological separation of these entities.
People with DID are reluctant to integrate their separate identities because they use them to cope; however, patients' quality of life has been shown to increase following treatment. Therapy should involve a nursing, medical, and primary therapist component. Therapists may direct patients to increase the strength of the entire system through increased internal communication and cooperation, the build up of ego strength, and the increased taking of responsibility for internal actions (7). It is very important that the patient gain a sense of control over his current cognitions and past memories. The multiple may gain control by recognizing the abused child's thoughts and feelings and by altering negative self-images (8). It is also vital that both the therapist and the patient show equal respect to all the alters.
Hypnotherapy and nonverbal therapy are commonly used in the treatment of DID. Hypnotherapy is commonly used in treating DID because of its facilitation of memory retrieval, "calming, soothing, containment, and ego strengthening" qualities (4). It can be used to increase communication between the alters and between the alters and the therapist. This method may also help in "fusion rituals (when previous psychotherapeutic work has cause a particular separateness to no longer serve a meaningful function for the patient's intrapsychic and environmental adaptation and when the patient is no longer narcissistically invested in maintaining the particular separateness)" (4). This is interesting because it indicates that a patient's pride might serve as an obstacle to his convalescence. The danger to hypnotherapy is that it may cause a patient to believe in a fantasy which he creates while under hypnosis.
Nonverbal treatment methods such as art and play therapy have also been proven useful in treating DID. Art therapy seems to be a freer expression of thoughts and feelings than verbal methods. The right side of the brain is more involved with creativity and the imagination; whereas, the left side is more concerned with language. Stimulating the right hemisphere might bring up "sensorimotor and iconic" memories more readily than if the person needed to filter input through the left hemisphere (10).
In general, most people respond fairly well to treatment depending on their baseline comorbidity (9). It has been shown that 60% of patients who undergo treatment maintain stable integration, which is defined by Kluft as "3 stable months of continuity of contemporary memory, with the absence of behaviorally evident separate identities (9).
DID research raises a lot of questions about the nature of the I-function. What are the implications of its being able to be fragmented? Perhaps the other I-functions, or separate identities, are merely different centers of connections with some of the same and some of their own links to other brain areas. Maybe the mechanism of the "fusion rituals" during hypnosis involves the solidification of links between the most dominant I-function and the alters such that when one is activated, the whole system becomes activated. Another possibility is that everyone possesses different centers of connections and somehow after repeated dissociation episodes, some people's links become severed.
Findings from DID research may be helpful for DID and non-DID sufferers alike. Research into this area has shed a lot of light into what kinds of cognitions lead to healthy functioning, among the most important of which are the need for a sense of control and self-love and respect. The research also highlights the interconnectedness of the mind and body: the fact that the psychological has a very real affect on the physiological and vice versa.
 

Works Cited