Multiple personality disorder and borderline personality disorder. Distinct entities or variations on a common theme?

Personality disorder traits, maladaptive schemas, modes and coping styles in participants with complex dissociative disorders, borderline personality disorder and avoidant personality disorder

OBJECTIVE

The schema mode model offers a new conceptualisation of complex dissociative disorders (CDD) as it explains shifts between identities as shifts between schema modes. Furthermore, in this model CDD is conceived as personality pathology, incorporating core features of personality disorders. This study tested the assumptions of this schema mode model of CDD.

METHOD

Questionnaires measuring personality disorder traits, schemas, schema modes and coping styles were filled out by patients with CDD, borderline personality disorder and avoidant personality disorder (N = 210), and their scores on the various constructs were compared.

RESULTS

Participants with CDD were characterised by specific schizoid, schizotypal, borderline and avoidant personality traits and early maladaptive schemas in the domains of disconnection and rejection and over-vigilance and inhibition. The most pronounced schema modes were the dysfunctional parent modes, avoidant coping modes and the vulnerable child mode. For coping styles, no differences were found between the diagnostic groups.

CONCLUSION AND DISCUSSION

On all outcome measures participants with CDD scored at the level of personality disorders and showed a unique pattern different from participants with borderline and avoidant personality disorder. This suggests that CDD shows features akin to a personality disorder. A clinical implication is that an adapted form of schema therapy might present a viable treatment option for CDD.

Comparing the symptoms and mechanisms of "dissociation" in dissociative identity disorder and borderline personality disorder

A total of 75 patients were diagnosed with the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised as having dissociative identity disorder (DID), and 100 patients were diagnosed with the Structured Interview for DSM-IV Personality as having borderline personality disorder (BPD). Both groups were administered the Multidimensional Inventory of Dissociation (MID). DID patients had significantly higher MID scores than BPD patients, different distributions of MID scores, and different MID subscale profiles in 3 ranges of MID scores (0-15, 15-30, 30-45). The core MID symptoms-exhibited at all ranges of MID scores-for DID patients (the presence of alters, identity confusion, and memory problems) and BPD patients (flashbacks, identity confusion, and memory problems) were ostensibly similar but were considered to be mostly produced by different underlying processes. Multiple regression analyses showed that the core MID symptoms of DID patients had different predictors than did the core MID symptoms of BPD patients. Alter identities seemed to generate most-but not all-dissociative phenomena in DID patients, whereas only the 24% highest scoring BPD patients (MID ≥45) seemed to manifest alter-driven dissociative experiences. Most BPD dissociative experiences appeared to be due to 5 other mechanisms: (a) BPD-specific, stress-driven, rapid shifts of self-state; (b and c) nondefensive disruptions of the framework of perceptual organization with or without an accompanying BPD-specific, dissociation-like disintegration of affective/neurocognitive functioning; (d) a defensive distancing or detachment from distress (i.e., simple depersonalization); and (e) Allen, Console, and Lewis's (1999) severe absorptive detachment.

Parallel-Distinct Structures of Internal World and External Reality: Disavowing and Re-Claiming the Self-Identity in the Aftermath of Trauma-Generated Dissociation

The nature of consciousness and the autonomy of the individual's mind have been a focus of interest throughout the past century and inspired many theories and models. Revival of studies on psychological trauma and dissociation, which remained outside mainstream psychiatry, psychology, and psychoanalysis for the most part of the past century, has provided a new opportunity to revisit this intellectual and scientific endeavor. This paper attempts to integrate a series of empirical and theoretical studies on psychological consequences of developmental traumatization, which may yield further insight into factors which threaten the integrity of human consciousness. The paper proposes that an individual's experience of distorted reality and betrayal precipitates a cyclical dynamic between the individual and the external world by disrupting the developmental function of mutuality which is essential for maintenance of the integrity of the internal world while this inner world is in turn regulated vis-à-vis external reality. Dissociation -the common factor in all types of post-traumatic syndromes- is facilitated by violation of boundaries by relational omission and intrusion as represented by distinct effects and consequences of childhood neglect and abuse. Recent research conducted on clinical and non-clinical populations shows both bimodal (undermodulation and overmodulation) and bipolar (intrusion and avoidance) neurobiological and phenomenological characteristics of post-traumatic response. These seem to reflect "parallel-distinct structures" that control separate networks covering sensori-motor and cognitive-emotional systems. This understanding provides a conceptual framework to assist explanation of diverse post-traumatic mental trajectories which culminate in a common final pathway comprised of partly overlapping clinical syndromes such as complex PTSD, dissociative depression, dissociative identity disorder (DID), or "borderline" phenomena. Of crucial theoretical and clinical importance is that these maladaptive post-traumatic psychological formations are regarded as processes in their own right rather than as a personality disorder innate to the individual. Such mental division may perform in that internal detachment can serve to preserve the genuine aspects of the subject until such time as they can be reclaimed via psychotherapy. The paper attempts to integrate these ideas with reference to the previously proposed theory of the "Functional Dissociation of Self" (Şar and Öztürk, 2007).

Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder

Dissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.

Fighting the Whole System: Dissociative Identity Disorder, Labeling Theory, and Iatrogenic Doubting

This research examines how individuals diagnosed with dissociative identity disorder construe their experiences of being labeled with a contested diagnosis. Semistructured interviews were conducted in the United Kingdom with 5 women and 2 men diagnosed with dissociative identity disorder. A framework analysis was conducted. The analysis identified 2 overarching themes: diagnosis cross-examined and navigating care systems. The diagnosis appeared to be continually assessed by participants for its fit with symptoms, and the doubt among professionals seemed to be unhelpfully reflected in participants' attempts to understand and come to terms with their experiences. The findings are considered in light of labeling theory, the iatrogenic effects of professional doubt, and current debates concerning the reliability and validity of psychiatric diagnostic systems that have been reinvigorated by the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Meet Dr Jekyll: a case of a psychiatrist with dissociative identity disorder

OBJECTIVE

Dissociative identity disorder (DID) is a controversial psychiatric diagnosis. This case review presents a retired psychiatrist with a history of DID.

CONCLUSIONS

This case is used to illustrate current thinking about the characteristics and aetiology of DID. It also argues for the importance of being aware of both our personal and professional biases in our own clinical practice.

Dissociative amnesia in dissociative disorders and borderline personality disorder: self-rating assessment in a college population

Dissociative amnesia (DA) among subjects with a dissociative disorder and/or borderline personality disorder (BPD) recruited from a nonclinical population was examined. The Steinberg Dissociative Amnesia Questionnaire (SDAQ), the Childhood Trauma Questionnaire, and the self-report screening tool of the BPD section of the Structured Clinical Interview for DSM-IV(SCID-BPD) were administered to 1,301 college students. A total of 80 participants who were diagnosed with BPD according to the clinician-administered SCID-BPD and 111 nonborderline controls were evaluated using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) by a psychiatrist blind to diagnosis and scale scores. Internal consistency analyses and test-retest evaluations suggested that the SDAQ is a reliable instrument for the population studied. Of the participants, 20.6% reported an SDAQ score of 20 or above and impairment by DA. Those who had both dissociative disorder and BPD (n = 78) had the highest SDAQ scores. Both disorders had significant effects on the SCID-D total and amnesia scores in the variance analysis. On SDAQ scores, however, only BPD had this effect. There was a significant interaction between the 2 disorders for the SCID-D total but not for the SDAQ or SCID-D amnesia scores. BPD represented the severity of dissociation and childhood trauma in this study group. However, in contrast to the dissociative disorders, BPD was characterized by better awareness of DA in self-report. The discrepancies between self-report and clinical interview associated with BPD and dissociative disorders are discussed in the context of betrayal theory (J. J. Freyd, 1994) of BPD and perceptual theory (D. B. Beere, 2009) of dissociative disorders.

Validating female psychopathy subtypes: differences in personality, antisocial and violent behavior, substance abuse, trauma, and mental health

Recent empirical investigations utilizing male prisoners have begun to validate clinical conceptualizations of primary and secondary psychopathy subtypes. We extended this literature by identifying similar psychopathic subtypes in female prisoners on the basis of personality structure using model-based cluster analysis. Secondary psychopaths (n = 39) were characterized by personality traits of negative emotionality and low behavioral constraint, an early onset of antisocial and criminal behavior, greater substance use and abuse, more violent behavior and institutional misconduct, and more mental health problems, including symptoms of posttraumatic stress disorder and suicide attempts. Primary psychopaths (n = 31) exhibited few distinguishing personality features but were prolific criminals especially in regards to nonviolent crime, and exhibited relatively few mental health problems despite substantial exposure to traumatic events. The results support alternative etiological pathways to antisocial and criminal behavior that are evident in personality structure as well as gender similarities and differences in the manifestation of psychopathic personalities.

Associations among early abuse, dissociation, and psychopathy in an offender sample

Theorists have postulated that some variants of psychopathy result from childhood abuse and neglect. Dissociative symptoms are also thought to arise from abuse. To date, the conjoint associations among abuse, dissociation, and psychopathy have not been examined systematically. Some have hypothesized that abuse relates primarily to the affective symptoms of psychopathy, with dissociative experiences mediating this relationship. Others have suggested that abuse more directly affects the impulsive lifestyle features of psychopathy. The authors used structural equation modeling to examine these hypotheses in a sample of 615 male offenders who had completed a retrospective self-report measure of childhood abuse, the Dissociative Experiences Scale, and R. D. Hare's (2003) Psychopathy Checklist--Revised. Abuse exerted no direct or indirect effect on the core interpersonal and affective features of psychopathy but was directly related to the facet of psychopathy associated with an impulsive and irresponsible lifestyle. Implications for psychopathy subtypes are discussed.

An examination of the diagnostic validity of dissociative identity disorder

We review the empirical evidence for the validity of the Dissociative Identity Disorder (DID) diagnosis, the vast majority of which has come from research conducted within the last 10 years. After reviewing three different guidelines to establish diagnostic validity, we conclude that considerable converging evidence supports the inclusion of DID in the current Diagnostic and Statistical Manual for Mental Disorders. For instance, DID appears to meet all of the guidelines for inclusion and none of the exclusion guidelines; proposed by Blashfield et al. [Comprehensive Psychiatry 31 (1990) 15-19], and it is one of the few disorders currently supported by taxometric research. However, we also discuss possible problems with the current diagnostic criteria and offer recommendations, based on recent research, for possible revisions to these criteria.

Axis II pathology in outpatients with dissociative identity disorder

Forty-two outpatients with dissociative identity disorder (DID) and 16 outpatients with dissociative disorder not otherwise specified (DDNOS) were administered the Millon Clinical Multiaxial Inventory-II (MCMI-II), the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and the Dissociative Experiences Scale (DES). DID patients manifested severe personality pathology (BR > 84) on a mean of 4.0 MCMI-II scales: avoidant (76%), self-defeating (68%), borderline (53%), and passive-aggressive (45%). DDNOS cases had severe personality pathology on fewer MCMI-II scales (mean = 1.69): avoidant (50%) and self-defeating (31%). The DID and DDNOS groups differed in their scores on the DES (means = 54.9 vs. 25.9), the PK-PTSD scale of the MMPI-2 (means = 33.6 vs. 21.7), and in the incidence of severe borderline pathology (53% vs. 6%). These data on personality pathology in DID patients are virtually identical to those of seven previous studies of personality pathology in chronic PTSD patients (i.e., avoidant, self-defeating, borderline, and passive-aggressive). Such robust convergence of findings supports the construct validity of DID as a form of posttraumatic disorder and suggests that there is a quite predictable personologic core to the clinical picture of severely traumatized individuals.