Psychiatrist/Psychologist/Social Service needed -- Dissociative Identity Disorder

From a psychological point of view, it is not accepted in the mainstream that this kind of split personality even exists. Most documented cases are of people trying to get off death row for a murder they clearly committed.

Exir said:

1) Now, I need more information on how DID works. First of all, the conventional view is that DID, if it indeed exists at all, is a defense mechanism against trauma. Why would a girl develop an alter-ego that makes her own life a living hell? (The alter-ego only targets those who are dearest to her.) Also, is it possible for two personalities to be completely severed from each other (in effect, the girl can't remember ANYTHING about how she kills people, and can only follow physical clues if any were present)? And is it possible for such an alter-ego to be triggered so cleanly? (That's what I'm concerned about, it might become "feeling loved triggers the freak button" which is waaaay too simple compared to how the psyche really works.)

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Google is your friend. There are a lot of websites out there dedicated to providing information on various mental illnesses. MIND is a very good site. I'm not sure where your doubt over DID is from, most psychiatrists and health professionals i've encountered believe it to be a valid diagnosis. People don't have a choice over their own mental illness, so try to bear that in mind when asking why someone would develop an unpleasent alter-ego. Two personalities can be entirely severed, i remember one amusing case where a woman's alternate personality bought super-cars etc - she had no knowledge whatsoever of this happeneing. Disassociation in itself (without splitting of personality) can be an experience of which there is no recollection. Don't underestimate the mind, it is both more simple and complex than we can begin to imagine and triggers are not immune to that.

2) Secondly, after the girl tells her foster parents that she is dangerous, though they might not take her seriously they will at least whisk her to the nearest psychiatrist as quickly as possible. Of course, I can also count on the fact that not all psychiatrists believe the validity of DID, but still, at least they'd do something.It would be too irresponsible to say "oh well DID doesn't exist, I'm not gonna do anything about the girl". Even if the psychiatrist doesn't diagnose her as DID he'd probably still agree that she is in a very messed up state of mind right now. They'd probably transfer her to an institution under her insistence, if that's what's going to give her peace of mind. She'd be all for it; after all, feeling emotionally close to people triggers her alter-ego, so she'd be much happier staying as far away from her foster parents as she could.

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With psychiatrists, do as wish with them. They can react however you want them too. Thankfully there are many, many wonderful psychiatrists out there, unfortunately there are also a number of psychiatrists who are absolute twits (to put it mildly they can be more irresponsible than you could possibly imagine). Depending on where you are, being sectioned can be very hard.

3) Now the parents would be a different matter. They'd fight to keep the girl within their care. But if, based on the advice of the psychiatrist, social services decides to transfer the child to another place, that would override the foster parent's wishes, right? That's another question: how does Social Services operate, and how does that affect my plot?

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An involuntary section can have a number of advocates, so if a psychiatrist is insistent that someone should be sectioned, then they can have it done. Police can be involved if need be. Social services depends entirely on what country you're in.

4) How is Dissociative Identity Disorder cured? I know that's a very vague blanket question. Maybe some suggestions as to authentic case studies of DID being cured.

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Few mental illnesses are 'cured'; the symptoms may reduce to the extent that a person no longer fits a diagnosis but to my knowledge, DID can't be 'cured', however medications and therapies can help a number of conditions.

5) Medication. The girl's absurd-sounding claims could be easily seen as another disorder, such as child-onset schizophrenia or even attachment disorders. If the psychiatrist misdiagnoses her that way, and gives her such medication, how would that affect her?

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Misdiagnosis is feasible, but many medications have multiple uses; anti-psychotics are used for a number of condtions, varying from depression to schizophrenia. Your MC sounds a little old for early-onset schizophrenia however, from what i know, early-onset tends to be age 8 (ish) and under, however there's schizoaffective disorder and so on. So, with misdiagnosis, the difference in medication may not have a resounding effect because the same medication may be used for the 'true' diagnosis and false diagnosis.

I don't know if all that helps of not.

Exir said:

What am I to believe?

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That's up to you really; do research though, there is a heap of information out there. MIND as i mentioned before has a lot of information.

Exir said:

Any twit psychiatrist story to share? Thanks.

To all future posters: just in case you'd like to know, the story's set in the USA (California).

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Ah, the USA. From what i know, being sectioned in the US is easier than here in the UK but i may be wrong and i don't know how their social work departments operate.

However, twit psychiatrists? The one that springs immediately to mind was the case of an overdose involving my husband. He had taken a considerable OD (around 100 pills) and after being in hospital, saw his psychiatrist, who promtly prescribed him over a months worth of medication (any psychiatrist in his - or her - right mind would give no more than a one, at most two, weekly dispention of medication). Another one involved a GP but was amusing nonetheless: having read my husband's history minutes earlier, she found it appropriate to prescribe him 100 painkillers for an injury (where, again, the prescription should only have been minimal).

There are many, many other stories though and sadly the consequences aren't always so amusing (IE being flippant over raving psychosis etc).

Exir said:

Yeah, looking at Mind right now. Nice find -- much better than the www.healthyminds.org.

BTW, is it okay if I contacted them directly, stating that I'm a writer looking for more info? Specifically to ensure I'm not making any mistakes.

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I'm sure MIND would be more than happy to help; they have a facility for the media to contact them directly: http://www.mind.org.uk/media

From what I understand, effective treatment for DID revolves around "integration" of the different personalities.

Also from what you describe, this other personality would seem to be the caretaker of the original personality's rage and aggression. One of the most fascinating (albeit harrowing) stories of such a case is When Rabbit Howls by Truddi Chase -- although this deals with multiple personalities rather than just two.

Even cursory research will show that DID is a contraversial diagnosis. In my experience more scientific practitioners give it less credence, due to the fact that it is impossible to discriminate between what might be DID and malingering--and in almost all cases malingering as the simplest explanation. It is exceedingly rare even as a claimed disroder, and as I said mainly claimed under conditions of extreme self-interest (i.e. escaping the death penalty).

It is, at the very least, a controversial diagnosis rather than a routine and widely accepted one: "A one-page questionnaire was mailed to a random national sample of 367 board-certified American psychiatrists ... Only about one-quarter of respondents felt that diagnoses of dissociative amnesia and dissociative identity disorder were supported by strong evidence of scientific validity."

Alright.

DID is commonly misdiagnosed as Schizophrenia and vice versa. The difference is hearing voices in yer head and hearing voices in yer ears (which is where the confusion comes in). DID is extremely rare, extremely which is why it changed from Multiple Personality Disorder to Dissociative Identity Disorder. People have varying levels of their risk for DID, look it up and you'll find a lot of people who just got up one day and walked off, forgetting their entire life and starting anew usually in response to extreme stress.

Actual MPD is usually a child's response to extreme stress or a traumatic event. It is common in girls who have been sexually abused at a young age. The idea is that the abuse 'is happening to someone else'. MPD's are very self contained, not very social, and inner triggers cause stress (not outer ones) which causes the change of personality. Blank periods in memory are common. Since the other personality is a coping mechanism they often change during times of trauma or stress. When a personality that is not the main one is out, the brain looks to be sleeping when monitored (or it's the hypothalamus... can't remember it was so long ago). It's fascinating how different each personality can be. One can have an accent, one can be blind, one can have multiple sclerosis. And it's all in the head. Same thing when people get third degree burns from ice all because they've been told and shown that they're going to be touched with a hot poker.

Hmmm.. what else. Ah, yes, there are quite a few treatments for the 'cure' of MPD. There is a question over whether it really can be cured but the few documented cases use these. Either integrating all the personalities into the 'host' personality or integrating all the personalities into the personality that you believe is the 'real' personality. There is a lot of debate over the ethics of both. I mean, when one psychiatrist falls in love with a personality and decides to integrate them all into that one... baaad stuff.

Integrating is a very loooong process. The host has no idea it has different personalities. Usually the other personalities are aware of each other. Lots of therapy, hypnosis (popular in these cases), etc. that may take years. It is a huge danger that the counselor or patient will develop feelings for the other, sometimes mutual.

I would suggest going to your local college/university library and asking for the psychology section. You can also chat with professor's or ask a student, etc.

Um... that's all I can remember right now... I'll probably think of something after I post this anyways...

Exir said:

Okay, so I'm writing a story involving an orphaned girl with dissociative identity disorder. Basically, she discovers from the very beginning of the story that she has an uncontrollable alter-ego who murders her loved ones (she doesn't directly remember what her alter-ego does, but she finds out indirectly after following clues), and, having no memory or control over what her alter-ego does, tries to convince those around her that she is dangerous.

Nobody takes her seriously, especially since she has scant proof to back herself up.

Issues:

1) Now, I need more information on how DID works. First of all, the conventional view is that DID, if it indeed exists at all, is a defense mechanism against trauma. Why would a girl develop an alter-ego that makes her own life a living hell? (The alter-ego only targets those who are dearest to her.) Alternate personalities often do things which the base or core personality finds distasteful, including criminal acts. Also, is it possible for two personalities to be completely severed from each other (in effect, the girl can't remember ANYTHING about how she kills people, and can only follow physical clues if any were present)? Yes. The relationship between the different personalities in DID is often complex, but it's not at all unusual for one personality to have no idea what the other(s) do, or even realize that they exist. And is it possible for such an alter-ego to be triggered so cleanly? (That's what I'm concerned about, it might become "feeling loved triggers the freak button" which is waaaay too simple compared to how the psyche really works.) Alternate personalities are frequently triggered by emotional states. Having an alternate triggered by the feeling of being loved is perfectly realistic. Triggers often are fairly clearly defined in DID (for example, a 'protector' personality emerges only when the person feels threatened)

2) Secondly, after the girl tells her foster parents that she is dangerous, though they might not take her seriously they will at least whisk her to the nearest psychiatrist as quickly as possible. Of course, I can also count on the fact that not all psychiatrists believe the validity of DID, but still, at least they'd do something.It would be too irresponsible to say "oh well DID doesn't exist, I'm not gonna do anything about the girl". Actually, that sounds totally realistic to me. Some psychologists have no business practicing. Even if the psychiatrist doesn't diagnose her as DID he'd probably still agree that she is in a very messed up state of mind right now. They'd probably transfer her to an institution under her insistence, if that's what's going to give her peace of mind. Only if she has money (or excellent insurence), or it can be proven that she is a threat to herself or others. Getting committed is much harder than they make it look on TV; many institutions have long wait lists. She could, perhaps, get committed by making them think she's suicidal. She'd be all for it; after all, feeling emotionally close to people triggers her alter-ego, so she'd be much happier staying as far away from her foster parents as she could.

3) Now the parents would be a different matter. They'd fight to keep the girl within their care. But if, based on the advice of the psychiatrist, social services decides to transfer the child to another place, that would override the foster parent's wishes, right? That's another question: how does Social Services operate, and how does that affect my plot?

4) How is Dissociative Identity Disorder cured? I know that's a very vague blanket question. Maybe some suggestions as to authentic case studies of DID being cured. DID can be cured by integrating the personalities. This takes years of intensive psychotherapy focused on recovering the lost memories of abuse and accepting them.

5) Medication. The girl's absurd-sounding claims could be easily seen as another disorder, such as child-onset schizophrenia or even attachment disorders. If the psychiatrist misdiagnoses her that way, and gives her such medication, how would that affect her? The medication given completely depends on the misdiagnosis. If she were misdiagnosed with schizophrenia or another psychotic disorder she would be given anti-psychotic drugs which can have devastating side-effects if the person being treated isn't psychotic. It's also quite common for anti-anxiety drugs or tranquilizers to be given to anyone who is agitated, regardless of diagnosis.

Thanks in advance for your answers.

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Real-life stories of DID/MPD that I've read and recommend:
Sybil by Flora Rheta Schreiber
The Magic Castle by Carole Smith
When Rabbit Howls by Truddi Chase
Silencing the Voices by Jean Darby Cline
Broken Child by Marcia Cameron

Even cursory research will show that DID is a contraversial diagnosis. In my experience more scientific practitioners give it less credence, due to the fact that it is impossible to discriminate between what might be DID and malingering--and in almost all cases malingering as the simplest explanation. It is exceedingly rare even as a claimed disroder, and as I said mainly claimed under conditions of extreme self-interest (i.e. escaping the death penalty).

It is, at the very least, a controversial diagnosis rather than a routine and widely accepted one: "A one-page questionnaire was mailed to a random national sample of 367 board-certified American psychiatrists ... Only about one-quarter of respondents felt that diagnoses of dissociative amnesia and dissociative identity disorder were supported by strong evidence of scientific validity."

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DID is listed in the most recent edition of the DSM. Thus it is a valid diagnosis. I spent years studying it and firmly believe it is a real, though rare, disorder.

Your MC sounds a little old for early-onset schizophrenia however, from what i know, early-onset tends to be age 8 (ish) and under, however there's schizoaffective disorder and so on. So, with misdiagnosis, the difference in medication may not have a resounding effect because the same medication may be used for the 'true' diagnosis and false diagnosis.

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Actually, it sounds like his MC is probably right in the normal age range for early-onset schizophrenia. Often the onset of schizophrenia is divided into four categories: Childhood-onset (pre-puberty), early-onset (teen years), normal onset (20s to early 30s), and late onset (late 30s or older). Childhood-onset schizophrenia is extraordinarily rare, nearly as rare as DID. Early-onset is much more common.

Exir, I have spent a great deal of time studying psychology and DID in particular. You can feel free to PM me if you want more info.

ETA: crosspost. Sorry


How old is she?

If she could have some knowledge of her bad 'personality', it'd not be hard to do. She probably wouldn't get a consensus on her diagnosis for years, but it could certainly remind some of DID enough to think that.

It'd be more realistic if it weren't textbook Cybil. I don't know that children ever have 'multiple personalities' but they can surely have dissociative episodes/tendencies along with something like bipolar, maybe.

If you are interested in that angle, I can send you great links.

I had dissociative symptoms from childhood into my 20's, but not nearly enough for a Dx involving them [well, PTSD but that was standalone after specific events]. If you are interested in tales of how kids dissociate -- when they know they are doing it - I could help. I did even have memory loss with the PTSD. And fake memories. It's pretty fascinating how the mind works that way with trauma.

Still, full-on alter personalities are very, very rare; I agree. I definitely believe it, though.

Here is the article on bipolar kids I was especially thinking of:

http://www.jenniferegan.com/articles/2008_09_14_nyt_bipolar.html

It's more to give the flavor of kids and shrinks and parents that I suggest it, but I do think it might be a diagnosis a doc might consider for any kid that's unusually "good and bad".

I think you'll have no problem, really. The hardest part, imho, would be the 'not remembering' happening so often. Perhaps you can haze that up a bit and not make it 100% clear that she definitely doesn't remember a thing. If it's more like a drunken blackout, that's more common and believable. If she really is repressing it, she might screw up her memory, really out of guilt [and past trauma].

In other words, if she has flashes that she doesn't know if they're memories or fantasies, that would go a long way towards how most dissociative symptoms more commonly work.

I'd do the alter personality thing cos it's good and creepy , just haze it up a bit, imho.

Exir said:

actually. Let me ask the question this way: suppose you are a psychiatrist who thinks that DID is a load of waffle. One day a nine-year-old girl comes, kicking and screaming, insisting that she has a murdering psychopathic alter-ego and that no one would believe her. All she can offer is scant circumstantial evidence, but she is adamant that she is dangerous and wishes to be as far from her current (or ANY) foster family as possible.

What would you do?

ETA: Chasing The Horizons: thanks for your reply.

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1. It's unlikely that a girl would come along to a routine clinic appointment "kicking and screaming" so I'm going to assume I'm either in her house having been called as an emergency or in A&E (or ER for those across the pond)

2. I'm going to calm her.
This girl wants someone to listen to her and take her seriously, that's what I'm going to do. I might have to spend some time just sitting and chatting first. DID is not going to be on my mind at that precise moment, my thoughts won't be going further than "distressed and agitated girl"

3. If I really need to, I'm going to give her some medication to calm her. I won't do this quickly, but if I can't calm her within about an hour and she carries on "kicking and screaming" then the medication will probably come out. My aim would be to calm her though, not knock her out. I'd probably use a one off dose of lorazepam or diazepam. Neither of those is suitable for anything more than very short term use.

4. Once calm. I'm going to listen to her. Now, chances are that her story is going to sound delusional at first. The idea of having a second personality that makes her kill people is going to put psychotic illness rather than DID at the top of the list. Right or wrong, there's an old saying that if you hear hooves on the street behind you it probably isn't a zebra. DID is a zebra of a diagnosis, hell it's an albino zebra. Psychotic illness is rare in very young children but still more common than DID by a long way. I see on average two psychotic kids a year, I may never see DID in my whole career. I'm not going to make either diagnosis on day one but I'd probably work on an assumption of psychosis.

5. Once i know the story I'm going to try to make it safe. I'll probably consider this girl more of a risk to herself than anyone else, so i'll want someone with her pretty much all the time. If the family feel they can do this safely then I might explore treating her at home, but I'd guess that this would make my calm girl agitated again so I think there's a good chance this girl would end up in hospital on the same day I saw her. I can't see any easy way to send a girl home to foster carers she doesn't want to go home with, and hospital would seem less disruptive to this girl's life than any other options.

6. Medication wise, once I know this girl is safe then I can take my time deciding if she needs medication or not. I'm not going to jump to any conclusions on day one.

There are a couple of problems with some assumptions you've made in other posts.

a. Most psychiatry is voluntary. People are far too quick to assume that being sectioned is the automatic outcome of being ill. If we have a girl who wants to be in hospital and foster parents (more on that soon) who want her in hospital then not only would she not be sectioned, it would be illegal to section someone who was agreeing to treatment. Most people in psychiatric beds are admitted, not committed. I could even admit her under the Uk children's act so long as the responsible adults in her life allowed me to, even if the girl said "no"

b. There is no obvious reason from your scenario for anyone to want to take this girl away from her foster parents. The only hypothesis that comes to mind is that someone may think that this girl's desire to be away from them means they've harmed her in some way but she's not telling.

Foster parents have very few rights in English law. In england, something called "parental responsibility" dictates who is truely considered to have power over a child. Mums have it, most Dads have it, and if a child is taken into care on a care order then it is granted to a social services department. Foster parents do not typically have it. They can get it by applying to the court, or by adopting, but only a court can grant it. If I wanted to admit a child I need the permission of the person with parental responsibility, and that may not be the foster carer. If they said "no" and the child's social worker said "yes" then i could admit them.....you need a decision for you story about whether your foster carers have PR or not. (or the american equivalent). Now if a psychiatrist wanted to admit a child and foster carers said "no" then the social worker may not think them fit to carry on being foster carers.

Otherwise, your plan holds up.
Psychiatry might be able to help this girl but definately not quickly....and in the interests of humility, it would probably be a psychotherapist, not a psychiatrist or psychologist who would actually be able to help in the long term.
Her being prescribed an antipsychotic drug is very plausible.
....and as much as I might clench my teeth you're allowed to have a bad psychiatrist in your story if that helps your plot along.

Craig