Dissociative Identity Disorder Clinical Presentation

Because children normatively exhibit age-related differences in levels of dissociative behavior, exhibiting fantasy play and displaying various parts of their personalities in various settings, the clinician must determine if a particular behavior deviates from that of other children of the same age and if a child is exhibiting dissociative symptoms.

Children have a much poorer sense of continuity of their behavior and the flow of time than adults do. Symptoms such as the sense of loss of time are not easy for children to discern. Even well into adolescence, children may not recognize loss of time or discontinuity of experience as unusual or abnormal experiences. In fact, discontinuity of experience is probably the norm for young children; it is consistent with the cycle through sleep and drowsy states and is developmentally appropriate for children to find themselves in new or changed surroundings without awareness of passage of time. This is qualitatively distinct from the loss of time of dissociation, during which the individual is awake.

Dissociation reflects disruptions in the integration of memories, perception, and identity into a coherent sense of self. Disruptions in identity may assume the blurring of boundaries between a child's self and fantasy characters. Important to note, however, is that in young children, dissociation is often viewed as a normative process related to imagination and fantasy capacity.

Dissociative phenomena are divided into 2 categories: detachment and compartmentalization. These 2 factors have diverse natures and manifest as conversion disorder, hypnosis, dissociative amnesia, and dissociative identity disorder.

• Dissociative identity disorder is characterized by the existence of 2 or more personalities within the individual. Clinically, only one of the personalities is present at any given moment, and one of them is dominant most of the time.
• The various personalities are almost always quite discrepant and often seem to be opposite. The original personality usually has no knowledge of the other personality. When a given personality is dominant and interacting with the environment, the other personalities may not perceive all that is happening.
• Each personality is well integrated and is a complex aggregate of unique memories, behavior patterns, and social relationships that control each individual's function during its dominant intervals.
• Transition from one personality to another is sudden, often dramatic, and usually precipitated by stress.
• Patients with dissociative disorder have associated borderline personality disorder, somatization disorder, major depression, PTSD, and history of suicide attempt more often than other psychiatric patients. Childhood sexual abuse, physical neglect, and emotional abuse are strongly associated with dissociative disorders.
• Other, more subtle, signs of dissociation may be present, such as episodes of amnesia or blackout in the absence of substance abuse, the patient referring to himself or herself as we, the patient being told by others of behavior he or she does not recall, or the patient being greeted by people he or she does not know. A patient may miss objects that cannot be accounted for or find objects or samples of strange handwriting.
• Fugue states, sleepwalking, and automatic writing may represent dissociation.
• A child who is experiencing dissociative symptoms may appear withdrawn, frightened, or uninvolved.
• Frequently, the child is identified as being "different" from other children, although referring clinicians, caseworkers, foster parents, and teachers are often at a loss to characterize the differences.
• Children with dissociative disorders exhibit a plethora of fluctuating abilities, moods, fears, and anxieties; shifting preferences; inconsistent knowledge; and other evidence of erratic access to information and skills.
• Auditory hallucinations are present in most children and adolescents with dissociative disorder; however, "phobic" hallucinations in severely stressed children and young adolescents do not necessarily indicate an enduring psychotic disorder and may be transient phenomena.
• Initial or short-term effects of abuse include early reactions occurring within the first 2 years of termination of abuse.

  • Emotional reactions and self-perceptions
    • In 1981, Anderson et al reviewed clinical charts of 155 female adolescent sexual assault victims and reported psychosocial complications in 63% of them.^[11]
    • Tuft's researchers found differences in the amount of pathology reported for different age groups.^[12] The highest incidence of psychopathology was found in children aged 7-13 years. Of the group aged 4-6 years, 17% met the criteria for clinically significant pathology. The following reactions are found to be common among patients who have been abused: breaking down emotional impact into specific reactions, anger and hostility, and guilt and shame.
  • Effects of sexual abuse on sexuality: Reactions of inappropriate sexual behavior in patients who have been sexually abused are well documented. Patients with dissociative disorder are more likely to have experienced childhood physical abuse and childhood sexual abuse than patients with other psychiatric conditions.
  • Effects on social functioning: People who have experienced sexual abuse are also found to have problems in social functioning, including the following:
    • School difficulties
    • Truancy
    • Running away from home
    • Delinquency
• Long-term effects are noted in the same areas.

  • Emotional reactions and self-perceptions: Depression, anxiety, and tension are the most commonly reported long-term problems among adults who were molested as children.
  • Impact on interpersonal relations
    • Difficulty in parenting and responding to their own children
    • Difficulty trusting others
    • Fear, often undifferentiated
    • Hostility
    • Sense of betrayal
  • Effects on sexuality
    • Problems with sexual adjustment
    • Promiscuity (increased level of sexual behavior)
  • Effects on social functioning
    • Prostitution
    • Substance abuse

• Suspect physical abuse when a child who presents with possible dissociate disorder has an injury is unexplained, unexplainable, or implausible.
• Bruises are the most common manifestation of child abuse and may be found on any body surface.
• Approximately 10% of cases of physical abuse involve burns. A burn's shape or pattern may be diagnostic when it reflects the pattern of an object or method of injury.

• No evidence suggests any biological cause for dissociative identity disorders.
• Traumatic experiences in childhood may enhance the individual's ability to dissociate. In 1986, Putnam et al reported the highest correlative figures; 97% of patients with MPD were reported by their clinicians to have a history of abuse in childhood.^[13] Sexual abuse, usually incest, was reported in 75% of those cases.
• Middleton provided early photographs and school reports that provided further suggestive evidence of childhood disturbance.^[14]
• In 2001, Macifie documented that maltreated children, especially children who were physically and/or sexually abused, demonstrated more dissociation than did normally treated children.^[15] Maltreated children are at higher risk to develop dissociation compared with well-treated children. In a study of children from low-income families, authors concluded that maltreated children have illogical thought processes considered to be in the pathological range compared with well-treated children. In another study, maltreated children had less inhibition of event memory compared with well-treated children.^{[16, 17]}
• Gast reported high prevalence of traumatic experiences during childhood.^[18] Of the participants in this study, 85% reported some sort of childhood trauma.
• In Sar et al's 2004 study, the rates of reported childhood physical and sexual abuse were 44.7% and 26.3%, respectively.^[19]
• MPD tends to have its origin in early childhood, from age 2.5-8 years, and issues arise during adolescence. Traumatic childhood experiences, especially of physical abuse and neglect, are reported to be common in people who develop MPD. How these traumatic experiences lead to a presentation of MPD in later life is unclear.
• The effects of exposure to situations of extreme ambivalence and abuse in early childhood may be coped with in a psychodynamic formulation by an elaborate form of denial so that the child believes the event to be happening to someone else. This process may be facilitated in childhood, a time with a rich fantasy life that often includes imaginary companions.
• Foster children are at higher risk to develop dissociative identity disorder in their middle childhood if there is history of early maltreatment experiences. A study by Hulette et al showed that foster children were more dissociative than others who had experienced physical and emotional abuse. They also found that dissociation is related to the number of foster placements.^[20]
• Dissociation is also common among college students who report abusive behaviors. In a recent study, a Spanish-speaking population sample at the University of Puerto Rico was enrolled and authors identified that dissociation fully mediates the relationship between childhood abusive experiences and the Anxious Arousal and Dysfunctional Sexual Behavior scales of the Trauma Symptom Inventory.^[21]
• Men with alcohol dependency are also at higher risk to develop dissociation and lifetime posttraumatic stress disorder if they have a history of childhood trauma.^[22]