Did

[zenman]

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21 yr old Africian American male soldier originally presented with what we thought was just an internal dialogue such as "go to Walmart" and "don't go to Walmart" type of argument. Further eval shows there are 4 distinct personalities present.He has hx of ADD and treament with multiple stimulants which didn't work and PTSD from early gang involvement. He has been a martial artist and golden gloves boxer so has also taken a few blows to the head. I know psychotherapy is treatment of choice but do you ever give antipsychotics to quieten things down?

 

[nitemagi]

21 yr old Africian American male soldier originally presented with what we thought was just an internal dialogue such as "go to Walmart" and "don't go to Walmart" type of argument. Further eval shows there are 4 distinct personalities present.He has hx of ADD and treament with multiple stimulants which didn't work and PTSD from early gang involvement. He has been a martial artist and golden gloves boxer so has also taken a few blows to the head. I know psychotherapy is treatment of choice but do you ever give antipsychotics to quieten things down?

What is this "further eval?" Sounds to me like the iatrogenic BS that led to this explosion of DID in the 80's, all of which was later disproved. All later found to have malingering, borderline PD, etc. Including the index cases like Sybil. All disproven.

Patients are very suggestible, and anyone with any dissociative sx's (which is a borderline PD subtype) even moreso. Questioning in itself may be leading to endorsement of "personalities," that may better be explained otherwise. Read some books on Ego State Therapy, False memory syndrome ("Try to Remember: Psychiatry's Clash over Meaning, Memory, and Mind"). Don't reinforce the DID dx, but treat the distress, the depression. And get the pt. another therapist (2nd opinion).

DID is a zebra at best, IF it exists at all. No one should be thinking about this except as a diagnosis of exclusion.

 

[toothless rufus]

What is this "further eval?" Sounds to me like the iatrogenic BS that led to this explosion of DID in the 80's, all of which was later disproved. All later found to have malingering, borderline PD, etc. Including the index cases like Sybil. All disproven.

Patients are very suggestible, and anyone with any dissociative sx's (which is a borderline PD subtype) even moreso. Questioning in itself may be leading to endorsement of "personalities," that may better be explained otherwise. Read some books on Ego State Therapy, False memory syndrome ("Try to Remember: Psychiatry's Clash over Meaning, Memory, and Mind"). Don't reinforce the DID dx, but treat the distress, the depression. And get the pt. another therapist (2nd opinion).

DID is a zebra at best, IF it exists at all. No one should be thinking about this except as a diagnosis of exclusion.

What!? No way! My program has a dedicated 30 bed DID unit! When the unit is full we can actually bill for (Patient )X (number of personalities), so at a minimum we bill for 60 patients! It's great!

 

[kugel]

what!? No way! My program has a dedicated 30 bed did unit! When the unit is full we can actually bill for (patient )x (number of personalities), so at a minimum we bill for 60 patients! It's great!

 

[SuperSoccer19]

21 yr old Africian American male soldier originally presented with what we thought was just an internal dialogue such as "go to Walmart" and "don't go to Walmart" type of argument. Further eval shows there are 4 distinct personalities present.He has hx of ADD and treament with multiple stimulants which didn't work and PTSD from early gang involvement. He has been a martial artist and golden gloves boxer so has also taken a few blows to the head. I know psychotherapy is treatment of choice but do you ever give antipsychotics to quieten things down?

If he's a soldier, how many of his personalities are trying to get out of a deployment, NJP, etc?

 

[notdeadyet]

If he's a soldier, how many of his personalities are trying to get out of a deployment, NJP, etc?

Well said...

 

[zenman]

If he's a soldier, how many of his personalities are trying to get out of a deployment, NJP, etc?

Athough he doesn't particulary like the military he says his problems started before joining up. He's going for psychological testing with a few psychologists who don't believe in the diagnosis, as well as sleep and neuro consult. His answers to a lot of DID questions are positive, he never veers off of his original story, and seems in much distress over it. We'll see.

 

[billypilgrim37]

Athough he doesn't particulary like the military he says his problems started before joining up. He's going for psychological testing with a few psychologists who don't believe in the diagnosis, as well as sleep and neuro consult. His answers to a lot of DID questions are positive, he never veers off of his original story, and seems in much distress over it. We'll see.

What are his PTSD and BPD screens like? If those aren't present, I'd be shocked if the symptoms were credible. The symptoms of DID probably exist within those contexts (rarely), but treating like it's own disorder and something distinct from the sequella of personality pathology probably isn't helpful.

 

[vistaril]

21 yr old Africian American male soldier originally presented with what we thought was just an internal dialogue such as "go to Walmart" and "don't go to Walmart" type of argument. Further eval shows there are 4 distinct personalities present.

LOL....this is why we are seen by so many as lacking credibility.

First, what was the need for a 'further eval'? You didn't do a good job of describing his initial presentation. My guess is he didn't require any more of a 'further eval' in the first place, and certainly not one that 'shows there are 4 distinct personalities present'......

 

[zenman]

What till psych testing is over.

 

[Scorcher31]

To me DID is BPD with severe dissociation or malingering until proven otherwise. The few cases I've seen were never anything else.

 

[zenman]

LOL....this is why we are seen by so many as lacking credibility.

First, what was the need for a 'further eval'? You didn't do a good job of describing his initial presentation. My guess is he didn't require any more of a 'further eval' in the first place, and certainly not one that 'shows there are 4 distinct personalities present'......

Actually I gave enough...even more than enough...as I was only asking the one question at the end.

 

[DebDynamite]

The therapy this patent needs is supportive debunkng of his multiple personalities. Figure out which is most prevalent and go from there: BPD, PTSD, and/or malingering. Acceptable meds would be the ones we use for BPD or PTSD... so to your original question an antipsychotic is not really indicated.

I have a defendant coming to see me later this who has been diagnosed for many years with DID. It's generally harder to work with individuals once they have identified with that diagnosis. They get attached to the multiple personalty theory and don't want to trade it in for insight.

 

[OldPsychDoc]

.... They get attached to the multiple personalty theory and don't want to trade it in for insight.

Beautiful phrasing...
👍

 

[zenman]

The therapy this patent needs is supportive debunkng of his multiple personalities. Figure out which is most prevalent and go from there: BPD, PTSD, and/or malingering. Acceptable meds would be the ones we use for BPD or PTSD... so to your original question an antipsychotic is not really indicated.

I have a defendant coming to see me later this who has been diagnosed for many years with DID. It's generally harder to work with individuals once they have identified with that diagnosis. They get attached to the multiple personalty theory and don't want to trade it in for insight.

So far this guy seems pretty distressed about it...and embarrassed.

 

[kugel]

Maybe I missed this somewhere in the discussion, but what does he want out of treatment? What exactly does he want to be different 6 or 12 or 24 months from now? Then maybe you can start planning how his behaviour would have to be changed to accomplish those goals.

 

[DebDynamite]

Thanks OPD.
🙂

Zenman- if he really seems distressed, then take the time to get to know his understanding of his diagnosis because there is a lot you can help him with. If you have the time, that is. Start with the suggestions kugel put out because you will get a better idea of where to go next.

 

[Psychiatrized]

Agree with posters who are thinking more along the borderline spectrum and suggesting not to reinforce the symptoms too much. In this case not knowing more about the patient I would think of borderline more in the psychoanalytic sense as on the borderline of neurotic and psychotic, trauma could definitely soften this boundary. The "DID" patients I have met tend to be very suggestible and the positive attention they get from treaters who are interested in this much fabled diagnosis reinforces their reporting of DID symptoms which I do think they start to believe.

Without more info about these four distinct personalities it is hard to get to the true root of the situation. Also realizing that questions trying to elucidate more information should be as open ended as possible so as not to lead or suggest symptoms to the patient and cause false positives.

Other thoughts - sometimes people with OCD or anxiety features will ruminate and get stuck between decisions which can sometimes be rather paralyzing.

I wonder what is underlying his difficulty in deciding whether to go to Walmart - what is the conflict playing out in his head.

As far as treatment I would probably start with treating the PTSD and see what happens with the possible distinct identities if you don't pay much mind to them.