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Dissociative Identity Disorder
Dissociative Identity Disorder Treatment
The main goal of the treatment for patients with dissociative identity disorder is to help the individual achieve a better integrated functioning and increase the degree of communication and coordination between the alternate identities. Although most clinicians target the fusion of all the alternate identities as the most desirable and stable treatment outcome, some patients only achieve an optimally integrated and coordinated functioning among the alternate identities that allows them to function in good conditions. Unfortunately, these patients are more vulnerable to decompensate in florid DID and/or posttraumatic stress disorder when encounter stressful events than those that gained a stable fusion.
Studies conducted on the efficiency of treatment revealed that patients with DID can have a very successful treatment outcome, especially when the treatment focuses "on the direct work with alternate identities and trauma material." The clinician's requirements when treating patients with DID are: (1) to focus on the patient as a spectrum of alternate identities which "together make up the identity or personality of the human being with DID" and not as the "host" or a collection of separate people sharing the same body, and (2) to foster the idea that all alters represent adaptive attempts to cope or master problems that were faced in the past.
A poor prognostic indicator is associated with the presence of other mental or psychotic disorders, substance abuse, eating disorders, or significant antisocial personality features. (4)
Individuals affected by DID
can be classified in three distinct categories:
1. Individuals with a clinical picture dominated by dissociative symptoms and posttraumatic symptoms, who generally function well and can completely recover with treatment.
2. Individuals with a clinical picture dominated by dissociative symptoms combined with other disorder symptoms (mood disorders, eating disorders, substance abuse disorders, or personality disorders), who can benefit from treatment with a slow recovery.
3. Individuals with a clinical picture dominated by dissociative symptoms combined with coexistent mental disorders, who can benefit from long-term type of treatments in controlling and managing the symptoms, rather than recovering. (8)
The main form of treatment for patients with DID is psychotherapy.
According to the Guidelines for treating Dissociative Identity Disorder in adults, one of the most effective forms of individual psychotherapy for patients with DID is the phase or stage orientated approach. The phase orientated approach focuses on three phases: (1) safety, stabilization, and symptom reduction, (2) working directly and in depth with traumatic memories, and (3) identity integration and rehabilitation. However, this approach requires a range of psychotherapeutic interventions such as cognitive cognitive, behavioral therapy, hypnotherapy, and psychodynamically orientated psychotherapy.
|The first phase of the treatment focuses on (1) establishing a therapeutic alliance, (2) addressing the self-destructive behaviors that can jeopardize the physical and psychological safety of the patient through so called "safety contracts" or "safety agreements", (3) manage and control the symptoms, and (4) educate the patient about the nature of the disorder. Patients with DID have a rich history of suicide attempts and self-destructive behaviors and when present for treatment, they exhibit a wide range of behaviors that can be dangerous to themselves and others. Such behaviors include: alcohol and/or substance abuse, enmeshment in violent or exploitative relationships, eating disorder symptoms, violent or aggressive behavior toward others, lack of food, clothing or shelter, fugues or wandering in dangerous neighborhoods or environments, driving recklessly, engaging in unsafe sexual practices, and/or failure to attend medical problems. The treatment success depends on how efficient the safety problems are addressed and resolved.||
Symptoms management is a complex task that requires several interventions, such as: psychoeducation concerning the disorder, techniques to improve internal communication and co- consciousness among alternate identities, and strategies for them to have safe ways of communicating as well as containing their symptoms. One of the essential components when learning about the nature of the disorder is addressing the issue of alternate identities. The patient learns how to understand, accept, and access these alternate identities.
The second phase of the treatment focuses on addressing the patient's memories of traumatic experiences by remembering, tolerating, and integrating them in a unified picture. During this phase, the patient gains a sense of control over past and present experience and their reactions to them, and built a better understanding of their personal history and sense of self. As a result of the process, alternative identities may start to experience themselves as less separate and distinct and can start fusing. The internal coordination, integration, and fusion continues during the last phase of the treatment when the patient achieves a more solid and stable sense of who they are, how to related with other and to the outside world. During this phase, the patient's focus shifts from past trauma to how to deal efficiency with current problems.
Group therapy is not a viable primary treatment, rather adjunct to the individual psychotherapy, and patients with DID seem to benefit only from "certain types of time-limited groups for selected patients with DID or complex posttraumatic stress disorder." Task orientated, educational, and skill building groups can help educated the patients about trauma and dissociation, assist them in developing specific strategies and skills, and reinforce its members that are not alone in their struggle with the disorder. (9)
Family (or couple) therapy
Family therapy addresses pathological family and marital processes common in families with a member affected by DID. One of the goals is to educate the family about the disorder and provide support and strategies to cope more effectively with the symptoms and manifestations of the disorder. In some cases, sex therapy can be an important part of the couple therapy, due to the fact that patients with DID may become intensively phobic of intimate contact for periods of time and create marital discomfort or problems.
Medication is not a primary treatment for patients with DID and is usually prescribed to control and manage specific symptoms of co-morbid disorders such as posttraumatic stress disorder and affective disorders. Medication can cause different responses among alternative identities (due to their different levels of neuropsychological activation) and is more effective if the targeted symptom is present in the hole spectrum of identities rather than one or few.
Some of the groups of drugs prescribed in patients with DID include:
1. Antidepressant medication (selective serotonin re-uptake inhibitor - SSRI, monoamine oxidase inhibitors - MAOIs, and the tricyclic antidepressants - TCAs) is usually prescribed to treat depressive and/or posttraumatic stress disorder symptoms.
2. Anxiolytics are used on a short-term basis to treat anxiety.
3. Atypical neuroleptic or antipsychotic medication is effectively used to treat overactivation, thought disorganization, intrusive posttraumatic stress disorder symptoms (chronic anxiety, insomnia, irritability).
The treatment can be carried in outpatient or inpatient settings and the length can vary. Treatment in an inpatient setting is usually required when the patient is at higher risk to harm themselves or others and the posttraumatic or dissociative symptoms are overwhelming or out of control. However, hospitalization is usually brief and only for the purpose of stabilization.
There is little information regarding those individual with dissociative identity disorder that are not diagnosed and treated. It is believed that such individuals get involved in abusive relationships and/or violent subcultures and die by suicide or as a result of a risk-taking lifestyle.
Article by Alina Morrow
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