Treatments of DID

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Dissociative Identity Disorder

Treatments of Dissociative Identity Disorder
Patients with DID often possess multiple distinct personalities and each personality has its own memory and it is not interconnected within the patient. These memory lapses are the main target of DID treatment. However, patients with DID are often comorbid with other psychological disorders such as schizophrenia that make it difficult to diagnose and treat. It is now believed traumatic stress is the primary factor that causes DID[1]. Current treatments not only use psychotherapies but also involve medications in side-symptom reduction. Although treatments vary among each patient; but in general, they follow a common guide-lined approach, a three staged treatment by International Society for the Study of Dissociation[2]. This phasic treatment aims for the building of connection between memories and unification to the “host” personality. Numerous reports conducted on the recoveries of patients after receiving such treatment have shown that the combination of medication and long-term, periodic psychotherapies could be an effective way of treating DID[3].

1.1 Identification and targeted symptoms of DID

The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines dissociative identity disorder as DSM IV and the individual with DID must possess two or more distinct states of identity without memory linking between each state[4]
Therefore, the most common symptom of DID is dementia and a chaotic lifestyle resulted by interchanging identities. Dissociative amnesia as well as impaired level of functioning of the individual and associated stress are all characteristics of DID, severe cases are often co-morbid with depression; these symptoms are often diagnosed together[4]. It is commonly reported that patients with DID often reflect past experiences of being abused in different ways such as physical or sexual. The targeted symptoms of DID can be categorized as physiological or psychological. With physiological symptoms are often substance abuse and dementia, and constitutes as co-morbid symptoms of DID. On the other hand, psychological symptoms are often hard to treat through traditional psychological consulting. It is often required for the patients to seek psychotherapies on a regular basis for long periods of time, often two to three years[4]. The tedious treatment has lead psychologists to seek a universal treatment strategy that includes both medicinal and psychotherapeutic approaches on individuals with DID.

2.1 Medicinal approach of DID

Most medicinal treatments target physiological conditions associated with dissociative identity disorder such as depression or other psychotic conditions such as schizophrenia. These medications’ main purpose is to reduce the frequency of symptom occurrence. Perospirone, an anti-psychotic drug, inhibits postsynaptic dopaminergic 5HT2 receptors while stimulate 5HT1A receptors to reduce the severity of hallucinations percept by auditory cortex of the patient and improve their mood, respectively. Several studies also have shown that stimulation of 5HT1 receptor is effective in treating anxiety[5],[6] Mirtazapine is another drug that acts on dopaminergic receptor to improve mood of the patient, and it is required at a very low amount, only 15mg per day. Whereas other SSRI (selective serotonin reuptake inhibitor) drugs such as Trazadone is required up to 400mg of dosage[7]. Large dosage may also leads to hypotension and anxiety caused by nightmares.[8]

2.2 psychotherapeutic approach of DID

The treatment of DID has always been heavily dependent on psychological consulting. Due to the varying nature of DID patients and comorbid psychological symptoms, different approaches have been used to bring DID patients out of their fragmented identities. Traumatic experience exposure was a common strategy of treating DID, psychiatrists viewed it as an escape from past experiences, and can be used as the primary target of treatment. Ivan Boszormenyi-Nagy founded contextual therapy, and it is widely used among psychological treatments[9]. It considers the immediate factors associated with the patient, i.e., background, ethics, social, and construct a preliminary understanding of the past experiences and established a accountability of patient towards the therapist. This therapy targets the fragmented identities and tries to rebuild relationship between each state of mind, to achieve a goal of bring integrity in the individual. This therapy combines many important aspects of other psychotherapies such as family therapy used in treating post-traumatic disorders, where the family members of the patient works along with therapist to bring well-being to the patient[10].
Relational therapy assumes therapist plays an important role in the enactment of the patient. It is intended to help patients to gain active control over their enactments during the course of treatment. The long term outcome of this therapy is to make the patient implicitly knowing to prevent their enactment of inappropriate behaviours with dissociated personalities[11].

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Mean GAF score increases as patient receives longer treatment period[14]

2.3 Phasic-oriented treatment model of DID

The international society for the study of trauma and dissociation has recently proposed a guideline for treating dissociative disorders, including DID. It proposes a phasic treatment model, which is widely used today, can be beneficial for patients with DID[14]. This systematic treatment approach combines both physiological and psychological aspects of previous treatments of DID. It outlines different stages of treatment approach a therapist should use. The overall goal is to assist the development of a safe and stable adaptation to daily life of a DID patient14. The first stage is to establish stabilized behaviour while reduce the symptoms of DID such as anxiety[14]. It is used to give the patient a general understanding of what is happening to him/her. Then build relational capacities and tolerance toward identity shifts while building a relational bond between therapist and patient[14]. Once a stable relationship has been established, the direction of treatment will shift toward working through traumatic past experiences with the patient, allowing him/her to express strong emotions associated with such memories and patient will benefit from a slow development of control over the emergence of past memory and to maintain it un-expressed. Some intervention from therapists are needed too, in order for patient to work with wide range of emotions and assist patient to be tolerance to effects of them such as horror and rage. Overall, the goal in phase 2 is to lead the patient to realize a whole sense of self, which the past has past already[14]. The last phase starts as the patient has a better sense of integrity among different identities[14]. The patient will continue to fuse identities and improve their daily functioning.

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Decreased frequencies of amnesia and identity alterations[14]

3.1 Effectiveness of treatments

Treatments of DID have received number of reports on successful cases of cure. Cases reported on cures resulting from both medication and therapeutic treatments. Perospirone was reported to treat a mid-aged woman out of DID after experiencing 13 years of dosage of antidepressant and other psychotic drugs. She was prescribed with perospirone, an anti-psychotic drug for schizophrenia. With increased dosage initially, her hallucination occurrences have gone down and eventually after 9 month of treatment, she does not experience symptoms of DID without maintenance by perospirone[13]. Naturalistic studies also revealed that prolonged phasic treatment time have significant improvement on normal functioning of DID patient. In a multi-case analysis by Brand also shows that phasic treatment model is beneficial for DID recovery. Patients experiences a decrease in frequencies of amnesia and hallucinations as well as improvement in GAF scores, which is a measurement of normal functioning of an individual through completion of multiple tasks[3].

1. Foote, B.; Park, J. (2008). "Dissociative identity disorder and schizophrenia: Differential diagnosis and theoretical issues". Current psychiatry reports 10 (3): 217–222. doi:10.1007/s11920-008-0036-z
2. International Society for The Study (2011). "Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision"Journal of Trauma & Dissociation 12 (2): 188–212. doi:10.1080/15299732.2011.537248
3. Brand, B.; Loewenstein, R. J. (2014). “Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative?” Journal of Trauma & Dissociation 15(1): 52-65. doi:10.1080/15299732.2013.828150
4. Jesse Fox and Hope Bell and Lamerial Jacobson and Gulnora Hundley (2013) “This qualitative study investigated the subjective experience of a female survivor of Dissociative Identity Disorder (DID)” .Journal of Mental Health Counseling, (10), Volume 35, Issue 4, p. 324.
5. Ishibashi T, Ohno Y. (2004) “Perospirone hydrochloride: the novel atypical antipsychotic agent with high affinities for 5-HT2, D2 and 5-HT1 receptors”. Biogenic Amines;(18): 307–317.
6. Gardner CR. (1998) “Potential use of drugs modulating 5HT activity in the treatment of anxiety”. Gen. Pharmacol. (19): 347–356
7. Foa EB. Keane TM. Friedman MJ. (1993) “Effective treatments for PTSD: posttraumatic stress disorder DSM-IV and beyond”. Washington DC; American Psychiatric Publishing; ; 147-169
8. Richard J Loewenstein (2005) Psychiatric Annals, Vol 35 (08), p. 666
9. Boszormenyi-Nagy, I., & Krasner, B. (1986). “Between give and take: A clinical guide to contextual therapy”. New York: Brunner/Mazel
10. Le Goff, J.F. (2001).”Boszormenyi-Nagy and Contextual Therapy: An Overview,” ANZJFT, 22 (3): 147–157
11. Patricia A. DeYoung, (2003) “Relational Psychotherapies”: A Primer p. 26
12. Bethany Brand, Catherine Classen, Ruth Lanius, Richard Loewenstein, Scot McNary, and Clare Pain. (2009) “A Naturalistic Study of Dissociative Identity Disorder and Dissociative Disorder Not Otherwise Specified Patients Treated by Community Clinicians” Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 1, No. 2, pp. 153–171
13. Gaku Okugawa, (2005) “Perospirone for treatment of dissociative identity disorder” Psychiatry and Clinical Neurosciences (2005), 59, 624
14. International Society for the Study of Trauma and Dissociation (2011) “Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision: Summary Version” Journal of Trauma & Dissociation, 12:188–212

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