Disorder: A Case Study
Dissociative identity disorder, commonly referred to as DID, has intrigued the general public for many years now. The disorder was popularized by the release of the movie "The Three Faces of Eve" in 1957, which was based on the story of Eve White, a young woman with DID (Aldridge-Morris, 1989). The movie was so popular that Joanne Woodard, who played Eve, won the Academy Award for best actress (http://www.eonline.com/Facts/Movies/ 0,60,22049,00.html). However, this is Hollywoods version of the life of a DID patient, which may lead one to ask what DID is really like outside of the movie theatre. This paper will describe the diagnostic criteria for a clinical diagnosis of DID and give an illustration of the disorder through a case study of an actual DID patient.
Dissociative identity disorder, as is suggested by its name, is based on the psychological defense mechanism called dissociation. The majority of DID patients have experienced an extremely traumatic event in their childhood, usually either physical or sexual abuse. Hornstein and Putnam (cited in Kluft, 1996) found that 95.3% of the DID patients they studied reported some type of abuse during their childhood. Alternate personalities are formed in order to protect the host personality from having to face the traumatic events of their past. Usually only two or three personalities are formed, but there have been cases in which more than one hundred personalities were discovered (Kluft, 1996).
The DSM-IV diagnostic criteria for dissociative identity disorder includes:A ) The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B) At least two of these identities or personality states recurrently take control of the persons behavior.
C) Inability to recall important information that is too extensive to be explained by ordinary forgetfulness.
D) The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, these symptoms are not attributable to imaginary playmates or other fantasy play (American Psychiatric Association, 1994).
Once the patient is diagnosed with DID, the therapist needs to develop a plan to get the alters to form an alliance with each other to form one integrated personality, which can prove to be an incredibly difficult process. Different alters have very different personalities, and some are more cooperative than others. It is important to make the alters understand that they are all living in the same body at the same time. Each alter "lives" in the time period that they were originally created in, so the therapist has to convince the alters to live together in the present. For example, if a thirty-year-old DID patient has a five-year-old child alter, the alter has no concept of the amount of time that has passed in his or her life. Any abuse the patient suffered as a five-year-old is still very much a reality to the alter, even if the abuse stopped twenty-five years ago. It is important to make all of the personalities live in the present so that they can deal with the problems that caused the alters to be created without feeling threatened. Once this is accomplished, the therapist can work with each alter individually to help them resolve whatever issues the alter has and teach them how to communicate with each other. When the alters learn communicate freely with each other, they are able to merge into one unified alter, which was the goal of the therapy (Ross, 1997). The following case study provides an excellent illustration of the course of therapy in DID patients.
Paula was raised in the country by two extremely strict Baptist parents who never spared the rod when disciplining her. Paula recalled being physically abused on several occasions, especially by her mother, who submerged Paulas hands in boiling water on a regular basis. In addition to being physically abused by her mother, Paula was also sexually abused by her father regularly throughout both her childhood and adult life. When Paula was five years old, her father began fondling her genitals when there was no one else at home. The abuse continued on this level until Paula turned eleven and her father caught her kissing a boy in their barn. He told Paula that if she desired love and affection, she would have to get it from him, and then her forced her to have intercourse with him. The sexual abuse suddenly turned violent when Paula turned fifteen. In therapy, Paula recalled an incident in which her father dragged her into his bedroom, tied her to his bed, and raped her while their neighbor watched. Afterwards, her father watched while he let his neighbor rape her too.
Paulas subsequent relationships with men were also very unhealthy. When Paula was sixteen, she met a thirty-one year old man named Cal, who also took advantage of her sexually. Despite Cals promise that he would marry Paula, he married another woman instead. However, Paula still continued to engage in a sexual relationship with Cal, even after she finally married her husband, Roger. Paulas relationship with Roger was far from healthy also. When she met Roger, he was married to another woman, but he got a divorce when Paula became pregnant with his child. Roger was in the Air Force and was stationed overseas, so Paula had to stay with her parents and raise her baby by herself, out of wedlock, which her parents strongly disapproved of. Two years after their first child was born, Paula and Roger finally got married when he came home on leave, and Paula became pregnant again. Roger went overseas again only to return home one time in three years, so Paula decided to file for divorce.
Paula began taking night classes at a local university while working as a secretary when she was thirty-eight years old. She was doing exceptionally well in her human sexuality course, receiving As on her first two exams, until she failed to come to class for her third exam. When her professor questioned her about missing the exam, Paula swore that she had no idea where she was the day she was that day. Her professors concern escalated when she wrote a paper about being sexually abused by her father, and her referred her to a psychologist for counseling.
Paulas therapist, Dr. Harpin, originally diagnosed Paula as having borderline personality disorder due to her pattern of highly fluctuating mood states, apparent alcohol abuse, and highly volatile personal relationships. Paula reported feeling depressed, and even attempted suicide on a number of occasions. During these episodes, Paula claimed that she felt dizzy and experienced extremely intense headaches. She also began experiencing periods of temporary amnesia.
It wasnt until over a year later that Dr. Harpin was able to officially diagnose Paula with dissociative identity disorder. Dr. Harpin had just concluded a hypnosis session in an effort to help Paula regain her memory from one of her episodes of amnesia when Paula complained of an intense headache. Suddenly Paula seemed very disoriented. She did not know where she was, but she claimed that her name was Sherry and that she was thirty years old. It was later discovered in therapy that "Sherry" was created in order to protect Paula from suffering from the emotional trauma of her fathers sexual assaults. Sherry was aware of the other alters within Paula, and she told Dr. Harpin of another alter, named Janet. Janet was an extremely angry teenager. She admitted that she was responsible for Paulas alcohol abuse and her extramarital affair with Cal. Later on in therapy, Sherry told Dr. Harpin that she and Janet were very concerned for a fourth personality named Caroline. Caroline was only five years old, but she was very depressed. When Dr. Harpin was able to speak to Caroline, he noticed that she had a completely different voice from the other personalities. Both her speech and tone of voice sounded like that of an actual five-year-old child. Dr. Harpin quickly realized that he could not learn much from Caroline because she was too afraid to betray her parents, so Caroline was rarely ever summoned during therapy.
Several months later, Paula came to Dr. Harpin with a new concern. She kept finding one of her fathers loaded guns in her house. Every time she found the gun, she would return it only to find it back in her house the next day. Stealing a loaded gun was out of character for Paulas other personalities, so Dr. Harpin decided to hypnotize Paula to see if there were any more alters that he had not spoken to. A fifth personality, Heather, emerged. Heather was in love with Cal, and when Cal would not leave his wife for her, Heather stole Paulas fathers gun in order to kill herself. Having a suicidal alter put the pressure on Dr. Harpin to be more aggressive in initiating the integration of the alters.
In an effort to begin the integration process, Dr. Harpin asked Paula to read Sybil, a well-known book about a woman with dissociative identity disorder. Paula still completely unaware of her alters, so she could not understand why Dr. Harpin asked her to read a book on DID. His logic became painfully clear when Dr. Harpin showed Paula a videotape of a therapy session in which he was able to speak to all of her alters. Paula did not accept what she saw on the videotape as the truth initially, but eventually she gave in, accepted her disorder, and agreed to cooperate with Dr. Harpins plan to integrate her alters.
Dr. Harpin tried to make the alters face the sexual abuse that Sherry endured by Paulas father, but this technique was unsuccessful. Both Paula and Sherry cried uncontrollably when confronted with the rape. Dr. Harpin decided to focus strictly on preventing any more alters from being formed and integrating the alters that already existed. However, Sherry soon became the dominant alter, and she would not allow Dr. Harpin to make any progress with the other alters. She engaged in destructive behaviors, such as running away with the intention of drinking as much alcohol and sleeping with as many men as she possibly could, on several occasions. Dr. Harpin was finally forced to admit Paula to a mental institution against her will. At the time in which this case study was written, Dr. Harpin was still not able to integrate Paulas alters successfully (Oltmanns, Neale, & Davison, 1995).
Aldridge-Morris, R. (1989). Multiple personality: An exercise in deception. Hillsdale: Lawrence Erlbaum Associates.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Kluft, R.P. (1996). The diagnosis and treatment of dissociative identity disorder. In the editorial boards of Directions in Mental Health Counseling, Directions in Clinical Psychology, & Directions in Rehabilitation Counseling (Eds.), The Hatherleigh guide to psychiatric disorders (pp. 49-96). New York: Hatherleigh Press.
Oltmanns, T.F., Neale, J.M., & Davison, G.C. (1995). Case studies in abnormal psychology. New York: John Wiley & Sons, Inc.
Ross, C.A. (1997). Dissociative identity disorder: Diagnosis, clinical features, and treatment of multiple personality. New York: John Wiley & Sons, Inc.