Dissociative Identity Disorder in the DSM 5 TR | Symptoms and Diagnosis

CEUs are available at AllCEUs.com/DSM5TR-CEU hey there everybody and welcome to  this presentation on the dissociative   disorders in the dsm-5tr i'm  your host dr donnelly snipes   in this video we're going to learn about the  diagnostic criteria for dissociative identity   disorder as well as other disorders in that  category we'll explore differential diagnosis   identify some common co-occurring issues and  discuss current evidence-based treatment options dissociative disorders are characterized by a  disruption of and or discontinuity in the normal   integration of consciousness memory identity  emotion perception body representation motor   control and behavior so that's a lot of things  and we're going to talk as we go through this   more specifically about what that means  dissociative disorders are frequently found in   the aftermath of a wide variety of psychologically  traumatic experiences in children adolescents   and adults it's important to remember that  dissociative disorders can be diagnosed at any age symptoms are experienced as unwanted  intrusions into awareness and behavior   with accompanying losses of continuity in  subjective experience what does that mean   well positive dissociative symptoms now  remember positive and negative are like   positive and negative and schizophrenia positive  means the addition of something negative means the   subtraction of something we're not saying it's  a good thing that's not what positive means but   positive dissociative symptoms include division  of identity so going from having one identity   one personality to two or more depersonalization  and derealization so maybe you're not going from   having one personality to multiple  but you're going from being one entity   to being a body and then sort  of a fly on the wall if you will   negative dissociative symptoms such as inability  to access information amnesia or control mental   functions that are normally readily amenable to  access or control you may freeze when the person   switches into a dissociative disorder they  may unhook if you will from their body in dissociative amnesia there's an inability to  recall important autobiographical information   usually of a traumatic or stressful nature that is  not better explained by just ordinary forgetting   you know you may forget some things that happened  when you were five or six years old but what we're   talking about are significant events and and  or aspects of events that you probably wouldn't   normally normally forget dissociative amnesia may  be apparent to others for example the person does   not recall something that others witness or maybe  the person can't recognize significant others now   we want to differentiate and i'm going to talk in  differential diagnosis we do want to differentiate   this dissociative amnesia from what we see as  blackouts in substance use for example so there   are a lot of times when people who heavily use  substances will get to the point of intoxication   where they have a blackout they don't remember  what they did and they wake up the next morning   and people tell them oh let me tell you that's  not dissociative amnesia that's substance use   the dissociative amnesia is not attributable  to a medical condition a substance disorder   or other mental health issue including  ptsd in ptsd there is going to be some   forgetting of particular events of the trauma  so we want to rule out or differentiate between   ptsd where the amnesia is specifically  associated with a trauma and other aspects   dissociative amnesia causes clinically significant  distress or impairment and may or may not   include dissociative fugue in dissociative fugue  the person leaves their home for example or maybe   goes to a different place in their home but has  no memory of the movement they get from one place   to another and then they kind of snap out of  it in that new place they don't remember how   they got there they don't remember wanting to go  there again we want to separate this from normal   maybe what someone might call highway hypnosis or  autopilot where you're driving for example to work   and you don't think about where you've got to turn  you don't think about you know what street you're   on you know this so you get from your house to  your office and you may not really remember the   drive but that's because you were lost in your  own thoughts you weren't completely checked out   you weren't in an amnesic state you were   dealing with monkey mind so we do want to  separate the um typical from the diagnostic issues in depersonalization or derealization disorder  there's persistent or recurrent experiences of   depersonalization or derealization in  depersonalization there's a detachment   or being outside of one's own thoughts feelings  or actions so the person may feel more like a   fly on the wall they don't feel like they're part  of that person anymore they've somehow separated   in d realization the person has a detachment  from their surroundings it may feel dreamlike   foggy lifeless or sort of visually distorted now  you may see some of these depersonalization or   derealization symptoms for example after  the use of hallucinogenic type drugs   not terribly uncommon however the  depersonalization and derealization   is attributable to that substance when  there is no history of substance use then   obviously we've especially hallucinogens then  obviously we need to look for other explanations   during these experiences in depersonalization and  derealization reality testing remains intact they   recognize that the world is not actually foggy  they recognize that they're not actually outside   of their body it just feels that way it's not  attributable to a medical condition substance use   or another mental health issue including ptsd  and it causes clinically significant distress   people with ptsd with borderline personality with  although it's not an official dsm diagnosis cptsd   often experience episodes of depersonalization and  derealization as well as they may experience some   elements of dissociative amnesia so we  do want to recognize those symptoms exist   and figure out do they have the other criteria for  example of borderline personality or do they have   the other criteria for ptsd or is it i hate to  say simply but is it are the symptoms confined to   what is present in depersonalization or dear or  dissociative amnesia so dissociative amnesia and   derealization are very symptom-specific disorder  presentations when we get to dissociative identity   disorder in a minute you're going to see elements  of depersonalization derealization dissociative   amnesia plus some more things likewise in  ptsd borderline personality and a lot of   these other disorders we're going to talk about  in differential diagnosis there may be elements of   dissociative amnesia and or depersonalization or  derealization and there are additional symptoms so   there's you have to meet a lot more criteria for  example for a ptsd diagnosis a lot of people with   cptsd which again is not a official diagnosis of  the dsm-5tr a lot of people with cptsd experience   for example depersonalization derealization  and maybe even some dissociative amnesia so let's talk about the big one dissociative  identity disorder and i say the big one because   there are a lot more symptoms in this and it  is the one that people talk about more often   whereas dissociative amnesia and  depersonalization are often somewhat   more common dissociative identity disorder is the  one that gets a lot more attention in this group   so for did this used to be called multiple  personality disorder way back in the dsm   3 maybe maybe even the dsm-4 i don't remember  when it changed but now it's called dissociative   identity disorder the individual has  two or more distinct personality states   observed by others or by the individual the other  people don't necessarily have to perceive it so   the individual may experience it they experience  themselves as a 30-something year old adult   but they also at times experience themselves as a  five-year-old child they feel like they're in the   they feel like they are that five-year-old child  so they're actually switching it's not like it's   not that they want to act like a five-year-old  child they feel like they are a five-year-old   child they have two distinct personalities and  they have done um brain scans on people with   dissociative identity disorder and with  each personality their different aspects   of the brain light up and the brain lights up  in different ways so there is definitely some   a neurological differentiation between the  different alters if you will so the individual has   two or more distinct personality states observed  by others or experienced by the individual   characterized by alterations in sense  of self so who they are how old they are   and personal agency what they have control of  when they switch to an altar a lot of times the host for example may not feel like they've  got control where they can pull back   and become themselves akin they can't  just switch back to being the host   they lose a sense of personal control when  that other alter when when the altar takes over   affect behavior memory perception cognition and  or sensory motor functioning may also change   so in people with two alters or two different  personalities a host and an alter which is   obviously the simplest form they may write very  neatly they may be very organized they may be very   professional in their host personality  when they're in their alter they may have   sloppier writing they may be more  argumentative and aggressive they may be more   reactive they they act and perceive the world  very very differently and interestingly enough   there's been a theory proposed that each  personality each alter develops its own schema   because they experience remember and  encode the world through their eyes so the   four-year-old alter is going to have different  schema and it's going to react differently to   the world than the 34 year old altar which is  kind of interesting so whenever those alters are   engaged that means that they are forming new  schemas that may or may not be beneficial to the   recovery process the individual may have a feeling  that they suddenly become depersonalized observers   of themselves and feel powerless to stop mention  that already they may have perceptions of voices   we're going to talk in a little while  and on and off about differentiating   dissociative identity disorder from schizophrenia  spectrum disorders the perception of voices could   be a child's voice they may hear a child's voice  talking to them persecutory voices or command   hallucinations so these are common now remember  i said you have to have the symptom and all the   other symptoms for schizophrenia in schizophrenia  you typically don't have the two personalities   and in dissociative identity disorder you don't  have a lot of the other characteristics of   schizophrenia so when you sit down and you look at  them on paper you can more clearly differentiate i   find uh looking at them on paper i like checklists  and comparisons you can more clearly differentiate in some cases the person reports multiple  independent thought streams over which they   feel they have no control think  about going to a cocktail party   or a luncheon whatever you go to and  you are in the middle of a conversation   and there are multiple people talking and you  have no control over what they say you're just   kind of you're almost invisible to them and that's  what it may be like to some people that's one way   it's been described to me for from people who have  been diagnosed with dissociative identity disorder   they may also have hallucinations  in all sensory modalities they may have strong emotions impulses thoughts  and even speech or other actions that suddenly   materialize without a sense of personal ownership  or control the person suddenly starts acting a   certain way and they're not sure why they're  acting this way they feel like they are   being driven by a remote somewhere conversely  thoughts and emotions may unexpectedly vanish   and speech and actions are abruptly inhibited  so if their altar for example is very talkative   and gregarious and then they switch back to  the host or they switch to a different altar   they may find that they are they become abruptly  inhibited they go from being that gregarious   personality to one that is not so much   attitudes outlooks and personal preferences  including food activities and their perception   of gender identity and and i want to be  very clear on this this is from the dsm-5 a person's gender identity may change  when they are in an alter they can have what they define as male alters they can have  what they define as female alters they can have   what they define as any you know other  permutations so it's important to recognize   that you may not have all female alters  in someone who is biologically female they may also report that their bodies feel  different they suddenly feel like a small   child a different gender or different  ages simultaneously they feel like a kid   and an adult or even an adult and  an older person all at the same time   dissociative fugues with amnesia for  travel are also common in people with   dissociative identity disorder where they  will enter into this dissociative state   so maybe an altar will take over they go somewhere  or maybe they even if an altar takes over maybe   it's the small child altar that was abused and  they hide under their bed and then the host   may come back and be hiding under the bed and not  remember how they got there why they got there   etc individuals may report suddenly finding  themselves in another city at work or even at home   in the closet under the bed or even running out  of the house those things are important to explore   if the person remembers you know when they came  to what were they doing a lot of times not always   a lot of times that may give you some clues as  to traumas that may need to still be processed in criterion b for dissociative identity disorder  the person has frequent gaps in the recall of   daily either ordinary or traumatic events  they may not remember going to work that day   or if there's a traumatic event they may not  remember aspects of that event or the event itself   they may not remember important personal  information and this is also inconsistent   with ordinary forgetting it's not something that  they just can't recall most of us don't know   our driver's license number for example so you  wouldn't expect somebody to be able to recall that   you would expect someone someone to be able  to recall their birthday gaps in any aspect of   autobio autobiographical memory may be present so  the person may not remember important life events   their birthday the birth of their child their  wedding or they may lack a recall of all school   experiences before high school they try to  remember junior high or elementary school or any of those times and it's just blank there's  nothing there they may experience lapses in memory   of recent events or well-learned skills this is  another thing that's important to take a look at   a lot of times there are memory problems in people  with dissociative identity disorder in both recent   memory as well as long-term memory there may  be gaps especially around that traumatic time   but there also may be gaps in the present that  represent when one or more of the alters took over   and well-learned skills could be for  example one of the alters may know   how to type and another one may not one may  know how to play the piano another may not   and there may be a discovery of possessions that  the person has no recollection of ever owning they   go into their jewelry box and they've got a  necklace there they don't remember ever getting   they go into their closet and there are  clothes there they don't remember buying   we also again we need to differentiate this and  make sure that there's no other explanation for   it there's ordinary forgetting with early  onset dementia with alzheimer's disease   the majority of time remote memory stays intact  recent memory becomes more difficult people get   have more confusion in what's going on asking  them what they did today is more problematic than   tell me what happened when you were in high school  50 years ago or even for early onset 20 years ago these experiences are frequently reported  as ego destonic and puzzling now one of the   things that i found puzzling was in the dsm-5 tr  they seem to contradict themselves the criterion   b very clearly says they're egodistonic so the  person recognizes that something is not quite   right it doesn't make sense what's going on  or when they experience the depersonalization   it's they recognize their reality testing  is intact so they recognize that this is not   um typical i always try to avoid using the word  normal uh they realize it's not typical to feel   like they are a fly on the wall so that's  ego-dystonic and they're not sure why they're   experiencing it however in another place in this  same write-up in the dsm-5 tr in the associated   features it says individuals with dissociative  identity disorder often conceal or are not fully   aware of disruptions in consciousness  amnesia or other dissociative symptoms   it's hard for them to be ego-dystonic and puzzling  and for the person to not be aware of them at the   same time so i was a little confused by that  but i figured i would put that out there um   i personally have not directly worked with  anybody with dissociative identity disorder   i've talked to people who have been diagnosed  with it who have worked with other therapists   but i have not personally worked with it in  in my practice minimization or rationalization   of amnesia is really common if somebody finds  something in their possession that they don't   remember ever getting they can often make a  rationalization for how it got there or why   it must be there oh somebody must have given this  to me and i just put it aside and forgot about it the symptoms in criterion a and b cause clinically  significant distress or impairment in one or   more areas of functioning if it didn't  they probably wouldn't be in your office   so okay so if they're presenting then  likely it's causing them problems the   experience is not a normal part of broadly  accepted cultural or religious practice   in children symptoms are not better explained  by imaginary playmates or other fantasy play in the possession form of dissociative identity  disorder there was a caveat in the dsm-5tr   for cultural um explanations and in certain  cultures there may be times in which the person is possessed for example by a by a spirit  or an entity however it doesn't cause   clinically significant impairment or distress  it is culturally recognized and embraced in   uh whatever format they're in for example  speaking in tongues or in in seances for example   when someone from the uh from the beyond  i don't know what to call it is speaking   through the medium that would be considered  culturally sanctioned it's not something that   happens just kind of willy-nilly if that's a  technical term the symptoms are not attributable   to the effects of a substance or another medical  condition additionally symptoms worsen during   times of internal or external stress so internal  stress could be pain it could be illness it could   be a variety of different substances that may  especially disinhibitors like alcohol that may   make it harder to suppress some of the memories  which increase internal stress or external stress   such as being too tired and or having a lot of  environmental demands that are impairing them most individuals with non-possession did do  not overtly display or only subtly display   their discontinuity of identity so most people  with d.i.d are not going to be like what you   would think of like what hollywood portrays it as  is going to often be relatively subtle you're not   going to have somebody who at who is talking  to you and drinking coffee one moment and then   all of a sudden has regressed into a four-year-old  altar just spontaneously that rarely happens now   could it happen yes but it rarely happens and the  person is often has often developed compensatory   strategies to kind of be able to keep things under  control in a lot of cases they are distressed by   their discontinuity of identity they recognize  that this doesn't happen in other people they know   many people did have dissociative  flashbacks and subsequent amnesia for   the content of the flashback so they may have  a flashback to something that their altar did   and then when they come out of the flashback  when they're when they get regrounded   they won't remember they know they had a flashback  but they can't really remember the content of it you want to differentially diagnose dissociative  identity disorder from dissociative amnesia   in dissociative amnesia the person  maintains a continuity of personality   and that is going to be the predominant   feature that differentiates dissociative  identity disorder from everything else we're   fixing to talk about in depersonalization and  derealization the person does not experience   the presence of different personality states nor  do they typically report dissociative amnesia   so if you've got depersonalization and  dissociative amnesia but only one personality   then you may have somebody who has both of  these or ptsd i would probably look at that too   but they're not going to have did unless  they have at least two distinct personalities   in bipolar disorder the relatively rapid shifts in  behavioral state in individuals with did usually   within minutes or hours are atypical even for  the most rapid cycling individuals with bipolar   disorder that is something to really pay attention  to there's a lot of misdiagnosis of people   with bipolar 2 who actually have dissociative  identity disorder from what the research says   so we want to pay attention to this  rapid cycling if somebody is going in   several hours or even a couple of days between  depressed and hypomanic we want to take a look   at that because that is really really really  really fast even for cyclothymia or or bipolar 2. and fictitious disorder or malingering relatively  the person is relatively undisturbed by or may   even seem to enjoy having the disorder and become  angered if you try to rule out the diagnosis of   dissociative identity one of the first things you  want to ask yourself if they're presenting in your   office with dissociative identity is there  a material gain to it are they trying to   excuse themselves from a violent outburst  are they trying to excuse themselves from   theft or for some from something  else they did so that's the first   question to try to differentiate it a  little bit now it's possible somebody   with dissociative identity may have a bad actor  if you will in their uh in their alters but we do want to consider most of the time that's  not the case we do want to consider is there a   gain that the person hopes to  achieve by having this diagnosis   remember i said that most people  with dissociative identity disorder   recognize that it is not typical of most other  people and therefore are greatly distressed by it   and they don't want to have the disorder  and they'd be thrilled if you could say   no it's this over here and here's this easy  peasy treatment but we can't a person who   is malingering or has factitious disorder may ask  clinicians to find traumatic memories most people   with dissociative identity disorder they don't  want to remember the did developed as a way to   block those memories is to help them survive and  to cope they don't want to go there so somebody   who is curious and really wants the therapist  to dive in again may have an ulterior motive   people who are have factitious disorder create  limited stereotyped identities and feigned amnesia   is often related only to the events for which the  gain is sought so the only time they have amnesia   is when they engaged in this violent episode  or when they did this other thing and sometimes   it'll be generalized a little bit like they  may talk about having dissociative fugue where   they go they end up going from one place  to another they totally don't remember   getting there they don't remember doing  whatever they did during that period of   time and they may say it's frequent but the  other episodes of amnesia are related to or   additional instances of the one that they  are trying to excuse or mitigate if you will increased knowledge evidently um impacts uh  dissociative identity disorder presentation   now this isn't from the dsm-5 tr this is from an  article i read that if somebody it does not have   have did they have fictitious disorder um then the  more they start to learn about did their the more   they're going to embrace it the more symptomatic  they're likely to become and for the person   who is malingering fragmented personality is often  important an important topic of discussion they   want to talk about all of their alters they want  to talk about what's going on and how curious it   is people who have did often don't want to they  don't want to acknowledge it they don't want to   that's just too painful and  too stressful to think about in terms of ptsd depersonalization and  derealization symptoms in dissociative identity   disorder may occur not only in response to ptsd  reminders but also in an ongoing fashion in daily   life including in response to stressful situations  so in ptsd a lot of times the depersonalization   or derealization happens in response  to a trauma trigger totally get that in   dissociative identity disorder the degree of  emotional dysregulation is so intense that   any stressor of a certain level depending  on the person will often trigger the emergence of the altars the emergence  of depersonalization or derealization   so we want to identify when the  depersonalization or derealization is happening   is it in response to trauma triggers now you  might be able to argue that ongoing traumatic   events in someone's childhood may have coded  pretty much everything to be a trauma trigger   so especially if you're talking about cptsd then  we we may need to be a little cognizant of that borderline obsessive-compulsive personality  disorder anti-social personality disorder   and narcissistic personality disorder  have a lot of features in common with dissociative identity disorder but personality  disorders according to the dsm are more stable   and pervasive whereas the person with did  switches personalities the person with   borderline may have an unstable sense of self and  they may alternate from valuation to devaluation   but it is a relatively cohesive  package and there is not as much   um deep non-trauma related depersonalization or  derealization it was interesting in one article   i found that said up to 17 of dissociative  identity disorder patients are initially   diagnosed with borderline personality disorder  let that sink in for a second how many people   have you diagnosed or have you come across that  are diagnosed with borderline personality disorder   seventy percent of those seven out of ten of them  may likely have dissociative identity disorder   not borderline personality interesting fact  in terms of schizophrenia spectrum disorders   the symptoms in schizophrenia are ego syntonic  if you if a person is having hallucinations in   schizophrenia if they're the way they're  experiencing the world makes sense to them   they don't understand why you don't see it the  same way whereas in dissociative identity disorder   the reality testing is intact they recognize that  what they're experiencing is not really how it is   and it's schizophrenia spectrum disorders there's  often not the dissociative amnesia amnesia is not   one of those big things in schizophrenia now  i added hallucinogen persisting perception   disorder i always hate saying that one because  i get tongue-tied because people who have taken   hallucinogens particularly lsd may have sporadic  hallucinations years after the initial substance   dose however there is no splitting of personality  there is no amnesia so you would differentiate   hallucinogen persisting perception disorder  from depersonalization disorder and and or dissociative amnesia but more the  depersonalization and derealization disorder   in addiction we want to examine are the symptoms  caused by a blackout are the symptoms of the   two distinct personalities if you  will caused by or do they occur   one when the person is using or using a  particular type of substance and one when   they're using a different type of substance  or when they're detoxing or in withdrawal remember in dissociative identity disorder  the personalities switch pretty rapidly so   but in addiction there's definite triggers  if you will there's definite precursors   to the presentation of one personality  somebody may be get very angry and   hostile for example when they drink but when  they're not drinking they are susie sunshine   and as i mentioned in dementia and delirium  people start having more difficulty processing   information understanding what's being said  and their near memory and their ability to   learn new things is compromised but a lot of  times their historical memory if you go back   you know a few years that is not as compromised  as much if there is a rapid onset of   cognitive symptoms it's really important  to get them evaluated by a physician to   make sure that they're not experiencing  weirnike korsakov syndrome or early onset   alzheimer's or dementia we certainly want  to rule out any of the organic causes in terms of comorbidity anxiety is  very common in people with dissociative   disorders not just dissociative identity disorder  but dissociative disorders in general and you know   that makes sense if their condition whichever one  we're talking about if the condition developed as   a result most commonly to trauma then that means  they were stripped of a sense of feeling safe a   stripped of a sense of personal empowerment and so  they're going to continue to be anxious until they   can feel safe and empowered once again and what  did i keep saying in depersonalization for example   they feel like their body is just kind of gone off  on being remote controlled from somewhere else and   they have no control over it they may feel like  their emotions or their actions or their thoughts   do the same thing so yeah that would make just  about anybody anxious addiction is not uncommon   because people are trying to quell silence  suppress the distress that's caused by the   fragmented personalities or the dissociative  experiences and or they may be trying to   self-medicate to cope with the memories of  the trauma depression remember depression   mainly is the key features a sense of hopelessness  helplessness and even anhedonia difficulty really   feeling much of anything or and low motivation  and people who are experiencing these switches   or depersonalization may feel depressed  they may feel exhausted that's not uncommon   ptsd is of course often very common   because the cause or trigger for the  development of dissociative disorders   is often trauma itself so we we can diagnose  ptsd and one or more dissociative disorders   self-injury unfortunately is also very common  in people with dissociative disorders for some   people they use it as a tool to try to help them  stay grounded and not dissociate for others it's a   coping mechanism to deal with the distress that's  caused by the caused by the dissociation but it   is very very common and very very problematic  it needs to be a focus of clinical attention   brief psychotic symptoms are not uncommon  hallucinations and delusions we talked about those   and it's important to help the person recognize  them for what they are and develop tools to deal   with them atypical antipsychotics have been found  to be hopeful for people who are having a lot   of or frequent psychotic symptoms that can help  however atypical antipsychotics also tend to be   very sedating so not everybody wants to take them  all the time it may be one of those things that   people take when they're having an exacerbation  that is between the person and their psychiatrist   interestingly of all of the personality  disorders avoidant personality disorder   is most commonly co-occurring with dissociative  disorders it makes sense though i mean you would   think it might be borderline or anti-social  um but avoidant also makes sense because if   the person has been exposed to severe trauma then  they may not trust other people they may not trust   the world they may not have the energy or desire  to engage with other people it's just they're   over it eating disorders and obsessive-compulsive  disorder are also common co-occurring issues in   dissociative identity disorder and you can  hypothesize for quite a while about why that   might be but in each individual presentation  and i emphasize this a lot in each individual   presentation it's important to look at that person  as an individual look at that person's symptoms   and say what are these symptoms communicating  behavior is communication what are these symptoms   communicating what function are these symptoms  serving for this person at this point in time now prevalence very interesting uh in the  u.s the prevalence is for dissociative   identity disorder is identified to  be 1.5 so 3 out of every 200 people   and for some reason the dsm-5tr also highlighted  that women in turkey uh the prevalence is 1.1   not exactly sure why they just plucked that out of  thin air however i mentioned before that more than   70 percent of people with dissociative identity  disorder are initially diagnosed with borderline   personality disorder now this doesn't even  include all the people that are misdiagnosed with   uh borderline with bipolar 2. but if we just  take into account 70 of the people the people   who are diagnosed with borderline personality  disorder that means that in the general population   the prevalence of dissociative identity may be as  high as 2.62 percent so almost 3 out of every 100   and in the clinical population it  could be as high as almost 32 percent   and that is just taking into account the misdiagnosis of people with bpd um  not any other diagnosis out there so   wow if those researchers are right then  we are missing the boat in a big way   because treatment is somewhat different  for dissociative identity disorder than   other disorders very different  than bipolar disorder for example in terms of development and course children  usually don't present with identity shifting   instead they may present with an independently  acting imaginary companion or as personified   mood states in adolescence dissociative identity  commonly comes to clinical attention because   of externalizing symptoms suicidal  self-destructive behavior or rapid   behavioral shifts now think about adolescents  they have a lot of rapid behavioral shifts   anyway developmentally their hormones are all  over the place they are going through ericksonian   psychosocial development crises there's a lot  of stress teenage years are really difficult   so we do want to differentiate expected behavioral  shifts from unexpected ones and what we're looking   at really is the frequency the rapidity the  how quickly they happen and the intensity   the generally in dissociative identity disorder  in adolescence you're going to see a more intense demarcation between the altars remember i  said in adults a lot of times it's pretty   um the shift is pretty mild  according to the dsm-5 tr   but in adolescence it may be  more pronounced because they have   even fewer emotional regulation skills and because  that prefrontal cortex is still developing they   have more difficulty with impulse control so a lot  of the things that may come out in an altar may be highlighted more exaggerated more in an  adolescent 90 percent of individuals with   dissociative identity disorder report early  neglect and childhood abuse often extending   into late adolescence so this isn't a one-time  traumatic event this is ongoing abuse or neglect   maltreatment may occur in the in or  outside of the family and may include   severe bullying whether it's at school or even  by siblings multiple painful medical procedures   i've known children and adults who've had to  have for example multiple open heart surgeries   and that is extraordinarily painful children who  have had to go through cancer treatment that can   be extremely painful children who've experienced  war and or terrorism or being trafficked well   those you know definitely are significant  additionally the dsm-5 goes on tr goes on to   state after prolonged and often transgenerational  exposure to dysfunctional family dynamics so we   have this dysfunctional family that's been  dysfunctional from multiple generations   and they're passing down the dysfunctional  interactions and the dysfunctional behaviors and which also means that it there's no no one  to go to for the child they can't go to grandma   and say you know things are really  bad at home because grandma was   behaved the same way towards mom or dad so  there's prolonged transgenerational exposure   to dysfunctional family dynamics including  over controlling parenting insecure attachment   and emotional abuse even if these behaviors  do not rise to the level of clear neglect   or sexual or physical abuse the ongoing  and um inescapable nature of the dysfunction may precipitate enough of a crisis to trigger  the development of dissociative identity disorder another interesting but disturbing disheartening  fact is over 70 percent of outpatients with   dissociative identity disorder have attempted  suicide not have had ideation they've attempted   it if you're working with somebody who was  diagnosed with d.i.d who has dissociative symptoms   who has trauma who has borderline personality or  bipolar 2 especially if you haven't ruled out that   it's a dissociative identity disorder  it's important to be extremely aware   of how frequent and common suicide attempts  are in this particular population multiple   attempts are common and other self-injurious  and high-risk behaviors are highly prevalent in terms of diagnosis the dissociative experiences  scale the des the structured clinical interview   for dissociative disorders revised or the scid d-r  or the dissociative disorders interview schedule   are some of the most common diagnostic tools  but more instruments if you're looking for   self-reports or screening tools you can go to the  dissociative identity disorder diagnostic guide   the link is in the powerpoint but you can also  just search for that online and it comes right up in terms of treatment direct engagement  with dissociative identity self-states   to repair the identity fragmentation and decrease  dissociative amnesia needs to be according to   the literature one of the treatment goals so  reintegration is going to be really important   one of the strategies to do this and one  of the important strategies in a trauma   focused approach is to allow the alters to be  heard remember i said each alter has their own   experience and perceptions of what happened  and what the world is so it's important for   every alter as well as the host to receive  support and be able to feel safe and be   able to tell their story as they see it as they  experienced it so they can process their trauma   once that happens then it is it can be easier  to integrate those think about at a crime scene   when officers interview multiple different  bystanders each bystander has a slightly different   account of what happened and the officer takes  all of those accounts and can put it together   to get a better picture of exactly what happened   or if you want to think about cameras cameras  from different aspects different angles are   going to get different perspectives in order  to get a 3d image you need to put together   multiple different aspects and that's really  what integration is about it's about hearing   the different experiences and integrating them  so all parts of the person can feel safe again   trauma-focused psychotherapy that includes  dialectical behavior therapy and even emdr   can be very helpful for the older alters those  alters that are able to participate in emdr each   one of them may benefit from participating in emdr  now that is not something that's really common for   emdr practitioners to work with so it would take  some time to find one that is trained in actually   and capable competent and actually handling that  you don't want just any old emdr practitioner uh working with an altar for example and and not  able to handle if there's a switch in the middle   a session in terms of medication i mentioned  atypical antipsychotics can be very helpful   for hallucinations and delusions those psychotic  symptoms and opioid antagonists like naltrexone   have been found to be somewhat helpful for  reducing dissociative symptoms now that can   be helpful but i also want you to remember that  dissociative symptoms when somebody dissociates   they have become all of their systems have  gotten overwhelmed they are in system shut   down and if you prevent them from shutting down  they need to have some way to cope that can be   terrifying and painful and overwhelming if they  can't dissociate but they don't have a way to deal   with what they're experiencing so it is important  to have an integrated approach to treatment   dissociative identity often represents a survival  strategy developed to cope with overwhelming   stress or trauma the defining feature of did is  the presence of two or more distinct personalities   potentially twice as common as  currently diagnosed and treatment   involves trauma processing with the host and  the alters in a safe supportive environment

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Keywords: Dawn Elise Snipes, Cheap CEUs, NCMHCE, unlimited ceus, hpcsa, crcc, lcsw ceus, lcdc ceus, lmft ceus, lmhc ceus, ce broker, addiction ceus, LADC CEU, counseling skills, online counseling, yt:cc=on, donnelly snipes, doc snipes, counselor education, mental illness, allceus, all ceus, cognitive behavioral, certificate programs, counselor certification, online course, dissociative disorder, dissociative identity disorder, depersonalization, dsm 5 tr, dsm 5

Id: G4TA2JEWSnU

Length: 56min 30sec (3390 seconds)

Published: Wed Jul 13 2022