heyjack70

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Who believes in this diagnosis? My perspective, having never seen a true case, and working with attendings who have worked for decades and claim to have never seen a case, is that it doesn't really exist. And that a better explanation is PTSD +/- personality disorder leading to dissociation symptoms.

I'm open to any opinions for or against.
 

Jorje286

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I've seen one case. I don't understand what do you mean though by "it doesn't exist". Ultimately it is defined purely based on presentation and symptoms like most of psychiatric diseases, rather than etiology. Even going by "PTSD +/- personality disorder", that seems to suggest that presentation is different from purely PTSD vs purely personality disorder, though that does provide more insight into the condition. I think the common belief that it is due to severe shock at a young age provides a decent explanation. Needless to say though, it is extremely interesting and more so for the fact that it seems to be confined to the Anglophone world.
 
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heyjack70

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I've seen one case. I don't understand what do you mean though by "it doesn't exist". Ultimately it is defined purely based on presentation and symptoms like most of psychiatric diseases, rather than etiology. Even going by "PTSD +/- personality disorder", that seems to suggest that presentation is different from purely PTSD vs purely personality disorder, though that does provide more insight into the condition. I think the common belief that it is due to severe shock at a young age provides a decent explanation. Needless to say though, it is extremely interesting and more so for the fact that it seems to be confined to the Anglophone world.
What I'm getting at is the possibility that a person's symptoms of DID are accounted for by severe PTSD with dissociation, or possibly PTSD and a personality disorder with dissociation. And that DID is not a separate diagnostic entity. I'm pretty sure this is a debated topic.
 

Jorje286

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What I'm getting at is the possibility that a person's symptoms of DID are accounted for by severe PTSD with dissociation, or possibly PTSD and a personality disorder with dissociation. And that DID is not a separate diagnostic entity. I'm pretty sure this is a debated topic.
Yes, but my point is that it's distinct enough in presentation from PTSD and even personality disorders that it does warrant its own category since after all of these diagnoses are based on symptoms and presentation. AFAIK, DID wouldn't fit at all with the common diagnostic criteria of PTSD (no necessary increased startle response or insomnia for example) despite the fact that shock is presumably important in the chain of events. From what I read, the skeptics base their arguments on that it's either psychotherapy induced or patients trying to fit the mold of the diagnosis rather than it being a genuine reaction to shock. The case of the patient I have seen was so severe that I really have a hard time believing the latter is true.
 

hamstergang

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I think this is a decent take on the issue: http://edition.cnn.com/2010/HEALTH/expert.q.a/02/23/dissociative.identity.disorder.raison/, by Dr. Charles Raison, a psychiatrist at Emory (I know nothing about him outside this article).

"There is no doubt that some people behave as if they have multiple personalities. And not all of them have been to therapists who have trained them to interpret their dissociative experiences in this way. Does this mean that dissociative identity disorder exists? In my opinion it depends on what we mean by 'exists.' Yes, dissociative identity disorder exists if by exists we mean there are people who complain of its symptoms and suffer its consequences. Do I think that some people have many biologically distinct entities packed into their heads? No. I think that some people dissociate so badly that either on their own or as a result of therapeutic experiences it becomes the case that the most convincing way for them to see their own experience is as if it is happening to multiple people."

I think the important question is, how does it affect treatment if we view DID as it's own entity vs PTSD + BPD? The same author continues from above: "I am personally less sanguine, however, about treatments that proceed as if each of the separate personalities really exists concretely and then work to integrate them again." But I personally don't know much about the treatment issues here so I'll leave that to others.
 
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heyjack70

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Yes, but my point is that it's distinct enough in presentation from PTSD and even personality disorders that it does warrant its own category since after all of these diagnoses are based on symptoms and presentation. AFAIK, DID wouldn't fit at all with the common diagnostic criteria of PTSD (no necessary increased startle response or insomnia for example) despite the fact that shock is presumably important in the chain of events. From what I read, the skeptics base their arguments on that it's either psychotherapy induced or patients trying to fit the mold of the diagnosis rather than it being a genuine reaction to shock. The case of the patient I have seen was so severe that I really have a hard time believing the latter is true.
Thanks for the reply. This is why it's interesting to me. I agree that on the surface DID and PTSD criteria seem very different, but it seems possible for DID to fit into the dissociative symptoms that occur with PTSD. Add to that the fact DID is thought to be a post trauma diagnosis. Perhaps DID is a less intense form of PTSD. This is just me babbling now. Ultimately, it boils down to me never seeing a real case where a patient had 'distinct personality states...with discontinuity in sense of self and agency" in the absence of borderline PD/PTSD diagnosis. So I'm skeptical that it's legitimate.
 

splik

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I have seen several cases. It is best to think of as an hysterical diagnosis which like other hysterical symptoms blurs the boundaries between consciously feigned and unconsciously feigned symptoms. Given that severe trauma history is present in cases, it is not surprising they all have PTSD +/- borderline personality disorder. we have had a few cases who have actually been admitted under different names/alters and then find themselves in the hospital stating, "I'm not x! I'm y! what am I doing here?" Whether we have agreed on them having DID, they clearly have a tendency to severe dissociation.

as far as I see it, DID is no more "real" or "false" than PTSD in that they are largely cultural constructions which didn't exist in the recent past and are both hysterical conditions and both are malingered very frequently, or imputed such.
 

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I've seen so many dissociative fugues with PTSD and one true DID (no history of specific trauma), and I'm not even a resident yet. In other words, I wouldn't agree that a DID is always a subset of PTSD.
 

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Personally I think it's culture bound. something like 80%-90% of diagnoses are in North America alone.

That's not say it isn't "real". We still have literature on other culture bound diagnoses and I certeinly would not tell someone with a culture bound disorder they were faking it.

The more interesting question is if culture bound disorders are a cultural specific presentation of an existing DSM diagnosis? Maybe people who suffer from DID have PTSD in North America, or amok is a unique manifestation of psychosis in Malay?
 
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heyjack70

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DID seems like it might just be adding to diagnostic confusion. If PTSD or Borderline PD, or panic d/o, or IED, could better explain it, why use DID. The issue is the distinct personalities and lost sense of agency. This idea just seems so far out there, that there are two or three or more alters within one person.

I mean, when I get angry, my personality changes, I don't remember things quite as clearly, and I act differently than when I'm calm. If the anger is enough, maybe I can't control myself the same as when I'm calm either. Is that an alter? Like can I say, "oh that's John, he's a real son of a bitch....I have DID. I just lose control and don't know what happens, and minutes can go by or I can find myself in a different place suddenly because he takes me over and I don't remember anything." Or could this be just as easily described as a dissociative component of one of the diagnoses above. "And when I get sad, that's when Tony shows up and it's the same thing with not remembering what I'm doing, just laying around all day, aimless and pretty soon 8 hours have suddenly been lost just sitting on the couch and I don't know what's happened."

If I were to come on to the board and question the existence of schizophrenia, everyone would think I was an idiot, or a scientologist, or that I had no experience because anyone who has worked for a month on inpatient psych has seen schizophrenia or schizoaffective disorder. The same certainly cannot be said for DID. So maybe it's just low prevalence of DID, or that it commonly travels with PTSD/borderline and gets missed, and if you're a cynic, the chances are low you would see that DID patient with a more pure (no other dx confounding) presentation and simply write it off as being from PTSD/borderline. Though uptodate says prevalence is 1.3% of population, which is slightly more than schizophrenia I believe; I'm not sure where these patients are. Perhaps if you're looking for DID, you will extend PTSD/borderline dissociation to fit the diagnosis.

Anyways, interesting topic.
 

splik

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well in the interest of sport, let me question the diagnosis of schizophrenia. who is this mythical beast that we all apparently know so well?
 

whopper

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I believe it exists because I've seen 3 people have it and had no reason to malinger, nor were they seeking attention so I don't believe they had factitious disorder. Those three I had for several months, so I was confident in their diagnosis.

That said, I also agree that if one sees a possible case of it to be very very suspicious and only use DID as a treatment of exclusion, ruling everything out first including malingering and factitious disorder.

There is a rather sad and established history of mental health providers creating false memories in someone of being raped/molested as a child. "Of course you were molested by your father, you just blocked it out. I know you love your father, but only someone who was molested would have bulimia. Here's a book, it'll convince you that you were raped. I'm going to put you in a group therapy session filled with other rape victims until you tell me you were raped."

Then to add insult to injury, some quack psychiatrists, if a patient started to entertain they may have been raped, told the patient they could do a sodium amobarbital interview (truth serum) and if they mentioned rape during the interview it'd be 100% proven they were raped.

Now this is despite the facts that a sodium amobarbital interview is nowhere close to 100% accurate, having an eating disorder doesn't mean one was molested, etc.

An epidemic of legal cases sprang up in the 80s with bogus lawyers, psychologists and psychiatrists charging top dollar claiming they could prove a person was molested using highly questionable methods such as sodium amobarbital, or having the person sit in a box with a blinking red light that'd help them to find memories submerged. When the courts finally became aware that submerged memory treatments were bogus, all of a sudden those cases just magically vanished.

So too did this sad practice go on with DID.

Again, I believe it exists, just that if you see it, be very suspicious.
 

Ceke2002

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There is a rather sad and established history of mental health providers creating false memories in someone of being raped/molested as a child. "Of course you were molested by your father, you just blocked it out. I know you love your father, but only someone who was molested would have bulimia. Here's a book, it'll convince you that you were raped. I'm going to put you in a group therapy session filled with other rape victims until you tell me you were raped."

An epidemic of legal cases sprang up in the 80s with bogus lawyers, psychologists and psychiatrists charging top dollar claiming they could prove a person was molested using highly questionable methods such as sodium amobarbital, or having the person sit in a box with a blinking red light that'd help them to find memories submerged. When the courts finally became aware that submerged memory treatments were bogus, all of a sudden those cases just magically vanished.
Sadly this sort of bogus therapy still takes place. Had an online support forum acquaintance, not particularly close or anything, but the dealings I did have with her she seemed to be a pretty standard BPD with PTSD case, and she was being treated as such. Then she found this new you beaut therapist who specialised in regressional hypnotherapy and memory retrieval through guided imagery type stuff, and all of a sudden she's remembering ritual abuse perpetrated by her Grandparents, and 12 or so 'alters' spring up out of nowhere. Haven't seen or spoken to her for ages, but I can only open she managed to get out of this quack's clutches and back to a decent therapist that can help her put her mind, and her family back together.
 

Jorje286

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I've seen 3 people have it and had no reason to malinger, nor were they seeking attention so I don't believe they had factitious disorder
In the case I saw it was quite impossible to fake the amnesia and all the complexities. If there was some form of exaggeration, then it's certainly all in the unconscious, but I don't think in the end that's quite relevant in regards to day to day management or that it lessens the strength of the diagnosis.
 
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