Dissociative identity disorder: a disorder of diagnostic and therapeutic paradoxes

Abstract

Dissociative identity disorder (DID) is life-long, childhood-onset, posttraumatic developmental disorder where chronic early-life maltreatment and attachment disturbances prevents the child’s development of a continuous sense of self across emotional states, relationships, and social contexts. As development proceeds, these self-states acquire a sense of themselves, a capacity for information processing, memory, emotion, and behavior. Conceptualizing DID involves paradoxes and apparent contradictions. DID has been categorized as a severe mental illness with major psychiatric comorbidities. Studies show that DID individuals have a unique personality organization with repeated, often covert posttraumatic reactivity, especially in relationships (e.g., therapy). Paradoxically, research shows that, during development, DID individuals preserve psychological resiliencies consistent with responsivity to long-term, psychodynamically informed treatment. These include, when not stressed, capacities for therapeutic alliance, reality testing, and observing ego.

Keywords:

• Dissociative identity disorder
• trauma
• posttraumatic stress disorder
• transference
• countertransference
• psychoanalysis
• developmental trauma
• psychological organization

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. For simplicity, we will use the terms “psychoanalytic’ interchangeably with ‘psychodynamic’ in this paper, albeit not all psychodynamically oriented clinicians are psychoanalysts; and there are theoretical schisms among psychoanalytic/psychodynamic schools. Also, unless specifically noted, for simplicity and space considerations, we will use the term ‘clinician’, ‘therapist’, or ‘practioner’ to include clinicians, researchers, academicians, theorists, et al of any background or theoretical perspective.

2. Therapists trained in hypnosis require additional training to work with trauma and dissociation in psychotherapy. Training in hypnosis for complex trauma and DDs is offered by the American Society for Clinical Hypnosis (https://www.asch.net/aws/ASCH/pt/sp/home_page).

3. Disgust is summarized by drinking spoiled milk (yuk!); dissmell is smelling the spoiled mild before drinking it (pew).

4. Self and identity are linked but distinct concepts. Self is our subjective ‘I’ and ‘me’, our moment-to-moment sense of our ‘selves’. It is tied to our memory of our history, and that we can see ourselves in the future (autonoetic consciousness). Identity is more about our longer-term descriptors, some more internalized than others: sex, gender, age, ethnicity, religion, social class, profession, and many others. Identity can be negatively used against people in racist, sexist, and similar denigration of the ‘other’. In DID, the secondary elaborations of the self-states are understood as identity enactments.

5. Hypnotic inductions may begin by having the patient ‘hyperfocus’ on something (e.g., the place where 2 walls connect at the corner of the room). Often, this is followed by eye-closure as the patient enters hypnotic trance.

6. The clinician must ascertain if the patient is currently in an abusive contemporary relationship (e.g., violent relationships; ongoing involvement with perpetrators, etc.), as the patient will see self-destructive behavior as a life-long necessity for survival. Helping trauma survivors exit abusive relationships is usually a long, grueling process that can be painful for the therapist to endure, as the patient repeatedly returns to be hurt, and new ways of coping are overwhelmed by more humiliating, controlling perpetration.

7. It is recommended that terms like ‘child pornography’, ‘child prostitution’ be replaced by more descriptive terms as the former may imply some active involvement by exploited, trafficked child.

8. The notion of ‘continuous memory’ is itself problematic since we do not continually remember our autobiography. This is among the many terminological issues in this area that are outside the scope of this paper (e.g., ‘recovered memory’; one can say all memories are 'recovered'). The intrapsychic process of dissociation is different from that of ‘repression’; large blocks of experience are unavailable in dissociation, not relatively singular memories. The subjective experience of delayed recall is different, and is often accompanied by intense emotions at minimum, and more often frank PTSD intrusive symptoms.

9. A real-world example of this mixture of good and evil is that of Daniel Gadjusek who won the Nobel Prize for medicine for his work on what are now called prion diseases. However, he used his research site in New Guinea to bring back and adopt over 50 young boys, many of whom he sexually abused and trafficked among his friends. Goudsmit (2009). Daniel Carleton Gajdusek (1923–2008). Nature, 457(7228), 394–394. https://doi.org/10.1038/457394a