Dissociative identity disorder: recent developments.

In recent years Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder (MPD), despite the controversy that surrounds virtually every aspect of the phenomenology, diagnosis, and treatment of this condition, has been diagnosed and treated with increasing frequency. Careful studies using reliable and valid screening measures and structured interviews have demonstrated that previously undiagnosed DID is a rather common disorder, occurring in between 3-6% of psychiatric inpatients and 5-18% of patients in substance-abuse treatment settings (studies summarized in Ross [11 and Kluft [21). Although some have argued that DID is a North American culture-bound condition (3), the inpatient studies summarized above included cohorts from the United States, Canada, the Netherlands, Norway, and Turkey, and all demonstrated roughly comparable findings. Although cultural forces may have been prevalent in the North American cohorts, and, to a lesser extent, in the Netherlands patients, DID was not part of the popular or professional cultures of either Norway or Islamic Turkey. This offers a substantial challenge to the "culture-bound syndrome" and iatrogenesis hypotheses, because if DID were indeed culture-bound and determined by social psychological factors, and if the iatrogenic creation of DID symptoms were widespread, one would expect significantly more DID patients to be found in those nations in which it had become part of the professional and cultural idioms, and in which the clinicians were presumably more "adept" at inducing its features. The public health and ethical implications of these findings are profound, suggesting that in the interests of pursuing other agendas, we and our colleagues in many nations are failing to recognize and provide appropriate treatment to a considerable number of patients, further traumatizing a population of patients that is already deeply injured. Indeed, notwithstanding the undeniable vicissitudes of autobiographical memory in the traumatized (and the nontraumatized), excellent data demonstrates that trauma can be documented in 95 % of children and adolescents with DID and allied forms of Dissociative Disorder Not Otherwise Specified (4,5), and initial studies have demonstrated that many memories recovered in therapy by DID patients can be corroborated as time goes on (e.g., 6,7). Recent advances in treatment, many discussed by Kluft (8) in this special section of the American Journal of Psychotherapy, have made the psychotherapy of DID a more circumspect enterprise than it was in the early 1980s. Older emphases on aggressive trauma work and a march toward integration have given way to models consistent with the contemporary stage-oriented treatment of trauma victims (1,9). The use of containment-oriented hypnotic strategies has made it more possible to mitigate the pain and disruption of treatment between sessions (10). The more thorough development of various stances toward treatment, the emergence of knowledge about how to conduct the supportive psychotherapy of DID, and the identification of subgroups of DID patients with different degrees of psychological strength and comorbid psychopathology, have made it possible to individualize treatment planning and to more carefully match each DID patient with an appropriate psychotherapy (1). Sadly, however, it often is not possible to provide a given DID patient with the treatment appropriate to the needs of that patient, an issue to which we will return. After developing models of its own in relative isolation, the dissociative disorders field has been enriched by the building of bridges between dissociative disorders treatment paradigms and psychodynamic and cognitive-behavioral therapies, and the study of DID has the potential to enrich these fields in turn. Furthermore, the rise of increasingly sophisticated psychopharmacological approaches to victims of trauma has been helpful, as has been the rise of newer approaches, such as Eye-Movement Desensitization and Reprocessing (11). …