Psychiatry Advisor: What might suggest that your client has DID?

DID develops as a coping skill to protect an individual and help them survive the traumatic events he/she is experiencing. By their very nature, someone with DID is not aware of their various self-states. The goal of having amnestic barriers between their self-states is to protect the individual psychically. Therefore, it is very rare that an individual would enter treatment with the pronouncement that they have DID or show more overt signs as the famous movie Sybil depicts. The goal of the clinician is to pick up on the fluctuations in identity and relatedness.

Clues might include changes in demeanor, affect, style of relating, eye contact, and fluctuations in perceived comfort/discomfort while with the clinician from 1 session to the next, or even within 1 session. Additional clues include noticing when an individual loses their train of thought or forgets what was just discussed in session, or when an individual cannot recall their whereabouts during the previous week. 

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Individuals with DID experience auditory and visual hallucinations that are dissociative in nature. For example, a patient with DID may report hearing voices and seeing different self-states as if they were separate people. This fractured sense of self is a key symptom of DID. It is important to note, however, that DID is not a form of schizophrenia, despite the presence of “hearing voices.”13,14 Rather, it is a complex trauma-related disorder.

Psychiatry Advisor: How do you investigate the possibility that the client has a DD?

I ask questions found on the Dissociative Experiences Scale II.15 I might ask questions about amnesia such as: “Has it ever happened to you that you found yourself in a location and you do not recall how you arrived there? Has that happened recently? Has it happened today? Have you ever noticed that items in your house seem to move around without any recollection that you had moved them yourself?”

I also ask about depersonalization and derealization: “Have you ever noticed looking at yourself in the mirror and not recognizing yourself? Does it ever happen to you that people who you usually know suddenly look like strangers to you? Do you ever feel that your surroundings seem like they are not real?” To assess the presence of fluctuation in sense of identity, I ask, “Do you ever feel like you are someone else?”

The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised16 is another helpful tool.

Psychiatry Advisor: Are there pharmacologic treatments for DDs?

Medication can be helpful and even necessary.17,18 It is often useful to take a treatment team approach in working with someone who has severe dissociative symptoms and a complex trauma history.

Pharmacotherapies for symptoms of dissociation are listed in Table 2.

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Psychiatry Advisor: What nonpharmacologic interventions do you recommend?

Psychotherapy is helpful and often necessary to heal from complex trauma and dissociative symptoms. Before initiating therapy, it is important to evaluate symptoms and gather an accurate understanding of the individual’s presenting problems, including risk factors.

Trauma-informed treatment is a 3-phase process.19

Phase 1 is focused on safety and stabilization.19,20 This includes teaching patients adaptive coping skills to manage overwhelming symptoms. It is also a time when there is much work to be done around developing a therapeutic alliance.21 Because people with complex trauma histories and dissociative disorders have often been harmed by the very people who were supposed to care for them, developing a trusting relationship with a therapist takes quite a bit of time and effort. The approaches to this phase are found in Table 3. It is important to note that this phase of treatment is often the longest, and sometimes the entire treatment is focused on safety and stabilization when indicated.