Dissociative Identity Disorders: Proposed Revisions, Essay Example

Many psychiatric disorders that have existed in the DSM-IV have been under consideration for revision in the new version of the Diagnostic and Statistical Manual in its fifth revision. The periodic revision of the DSM allows an opportunity to revisit the assumptions supporting certain diagnoses and the empirical support, or lack thereof, for the defining diagnostic criteria (Spiegel, 2011.) One of the diagnoses that have been accompanied by a great deal of debate is Dissociative Identity Disorder, formerly known as Multiple Personality Disorder. A majority of clinicians surveyed reported that they had received “moderate to extreme” reactions from colleagues regarding patients with this diagnosis (Gillig, 2009.) In addition, there is been a great deal of controversy over the meaning of the symptoms associated with dissociative disorders. This paper will discuss the changes that have been proposed for the DSM-5 for this diagnosis as well as the specific areas of controversy involved.

Dissociative Identity Disorder includes Depersonalization Disorder, or persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (Grohol , 2012); Dissociative Amnesia, a disturbance is which a person experiences one or more episodes of inability to remember significant personal information, often stressful in nature, and that is too far-reaching to be considered normal forgetfulness; Dissociative Fugue, which involves one or more incidents of amnesia in which the person is unable to remember parts or all of one’s past and experiences a sudden loss of one’s own identity or the formation of a new one; and Dissociative Identity Disorder, in which the person exhibits 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 (Grohol, 2012.).

The diagnosis of Dissociative Identity Disorder evokes significant reactions from mental health clinicians who have, at times, tried to refuse these patients admissions to hospitals, as well as forcing discharging of these patients prematurely, even when they were at risk for suicide. It has been speculated that the extreme responses to this diagnosis are based on anxiety that originates from the strange and unsettling clinical manifestation of this condition. Additionally, there is much disagreement in diagnosing the unusual symptoms and behaviors of DID which frequently go unobserved or ignored by clinicians (Gillig, 2009.) Another point of dispute is whether or not the symptoms of DID actually exist, or are simply malingering behaviors; other clinicians believe that these symptoms are created by practitioners who believe that a condition exists where it does not.

In fact, even the diagnosis of dissociative disorders has been under scrutiny because of various cases of this condition have been attributed to social contagion, hypnotic suggestion, as well as misdiagnosis; many of those who are skeptical about the diagnosis believe that the patients involved are highly suggestible, therefore easily hypnotized. There are several questions in the debate about how to address Dissociative Disorders in the new manual: should Depersonalization Disorder remain in the revised version, should be moved to another section, or should be considered as a cluster of symptoms that belong to another disorders such as anxiety disorder? Should Dissociative Amnesia continue in the category of Dissociative Disorders, or should it be moved to a section that is more related to trauma, such as Acute Stress Disorder or Posttraumatic Stress Disorder? Does the data supporting Dissociative Fugue suggest that it should be in its own category, or should this condition simply be eliminated? Should the diagnostic criteria for Dissociative Disorder been changed entirely?

Much of the controversy surrounding dissociative disorders and their place in the new DSM pertain to the issue of trauma: because several symptoms include shame and guilt which are the result of traumatic events, many clinicians believe that the diagnoses should be absorbed into the label of PTSD (Sar, 2011.) Both dissociative disorders and personality disorders have been highest rate of chronic traumatization in the early years of life, and therefore remain separate categories in the DSM-5. There are distinctions between the ways each manual describes traumatic events: in the DSM-IV, a traumatic event must contain actual or threatened death or serious injury, or a threat to the physical integrity of an individual and others. The person’s reaction must involve extreme fear, helplessness or horror; in the proposed revisions to the DSM-5, the response of the person is relatively insignificant, but rather ways of being exposed to these events take on more significance. For example, the person might have experienced the event himself or may have witnessed it happening to other people. In addition, another possibility is finding out that the event has occurred to a loved one or close friend; the last option is experiencing repeated exposure to repugnant details of the event. The revisions for the new manual are designed to clarify the criterion for dissociative disorder to draw a more distinct boundary between traumatic events and events that are distressing, but are not necessarily traumatic. For example, the new criterion omits the expression “physical integrity of self and others” and replaces it with “sexual violation.”

Further revisions suggested for Dissociative Identity Disorder in the new DSM-5 involve adding new diagnostic criteria called C. “Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning,” is a phrase that is present in various other diagnostic criteria and is part of the revisions suggested to merge Dissociative Trance Disorder with Dissociative Identity Disorder with the numerical designation 300.14. This would be included in order to help distinguish normative cultural experiences from psychopathology. The result would be, for example, that clinicians would be able to distinguish between voluntary hypnotic trances and mental illnesses.

My perception is that the controversy regarding this diagnosis is based on two factors: firstly, the difficulty those clinicians have in making the diagnosis because they are unsure if patients are malingering, trying to fool them, or actually suffering from a personality disorder that includes symptoms which suggest Dissociative Identity Disorder. Professionals do not like to be wrong, or deceived, like most people. I believe that the second issue for clinicians is what was described earlier, that is, the emotional reactions by practitioners upon even hearing about this diagnosis, let alone being confronted with it, face-to-face. I personally believe that Dissociative Identity Disorder should remain as is in the new DSM because it is divided up clearly into the four different presentations of the disorder, with the criteria explicitly listed for clinicians to be able to arrive at this diagnosis. My reaction to this change in the DSM-5 is similar to the other changes of which I have heard: those different conditions are being reclassified or eliminated when in fact nothing has really changed in the symptomatology or presentation. For example, my understanding is that the autism spectrum disorders are under consideration for revision or elimination, making it that much harder for parents to be able to secure funding for their children’s public school education. Changing the manual based on empirical evidence that a condition is nonexistent is one thing; eliminating diagnoses because of social or political pressures, economic factors, or an absence of actual data does a disservice to the profession of psychology.

References:

David Spiegel, R. J.-F. (2011). Dissociative Disorders in DSM-5. Depression and Anxiety , 824-852.

Gillig, P. (2009). Dissociative Identity Disorder. Psychiatry , 24-29.

Grohol, J. (2012, January 6). Symptoms and Treatment of Mental Disorders. Retrieved November 25, 2012, from Psych Central: http://psychcentral.com/disorders/

Sar, V. (2011). Developmental Trauma, Complex PTSD, and the Current Proposal of DSM-5. Retrieved November 25, 2012, from European Journal of Psycho-Traumatology