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Introduction

Multiple personality disorder, or MPD, is a mental disturbance classified as one of the dissociative disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It has been renamed dissociative identity disorder (DID). MPD or DID is defined as a condition in which “two or more distinct identities or personality states” exist.
MPD is an incredibly creative defense mechanism to protect the host from the trauma of the past and the present. Full blown DID or poly- fragmented DID (more than 100 personalities) is characteristically a result of severe, and prolonged occurrences of physical, sexual, or emotional abuse occurring before the age of 12 (and often before the age of 5). The female to male ratio for DID is about 9:1, but the reasons for the gender imbalance are unclear.
NOTE- “Split Personality is not an accurate term for DID and should not be used as an acronym for schizophrenia.

Symptoms of MPD

About 90% of multiples are completely unaware that they are MPD/DID. Some know that there is something wrong with them, some fear they are going mad, but most are unaware of even the existence MPD/DID. If you suspect that a friend or family member is MPD/DID, there are a few signs to look out for:

Depersonalization : Depersonalization is a dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of their body, or as watching a movie of themselves.

Amnesia : Amnesia in DID is marked by gaps in the patient’s memory for long periods of their past, in some cases, their entire childhood. Most DID patients have amnesia, or “lose time,” for periods when another personality is “out.” They may report finding items in their house that they can’t remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

Derealization: Derealization is a dissociative symptom in which the patient perceives the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail to recognize relatives or close friends.

Identity disturbances: Identity disturbances in DID result from the patient’s having split off entire personality traits or characteristics as well as memories. When a stressful or traumatic experience triggers the reemergence of these dissociated parts, the patient switches-usually within seconds-into an alternate personality. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Patients vary with regard to their alters’ awareness of one another.
Depression, hallucinations, multiple mannerisms, attitudes and beliefs that are dissimilar to each other, headaches and other body pains, distortion or loss of subjective time, schizophrenia, epilepsy, anxiety, mood disorders, fugue states, nightmares and sleepwalking, repeated self-injury, chronic suicidal tendencies, emotional dysregulation, phobias, post traumatic stress, personality and eating disorders are other symptoms.

Causes

A child, suffering unspeakable, life-threatening sexual/ physical/ emotional abuse is most prone to MPD.
Overwhelming stress, trauma, insufficient childhood nurturing, iatrogenic cases, etc may also lead to MPD.

Mechanism

MPD being a psychological disorder, the exact mechanism of occurrence is unclear. However, certain postulated theories give first hand information about the occurrence.

CEREBRAL CHANGES:

Regional cerebral blood flow (rCBF) was studied with single photon emission computed tomography (SPECT) with Tc99m-hexamethylpropylenamine (HMPAO) as a tracer. Compared with findings in the control group, the rCBF ratio was decreased among patients with dissociative identity disorder in the orbitofrontal region bilaterally. It was increased in median and superior frontal regions and occipital regions bilaterally.
Many experts believe that temporal lobe epilepsy may lead to a dissociative disorder. Other physical conditions which can lead to some level of dissociation are sleep loss, sensory deprivation, strokes, encephalitis, and Alzheimer’s disease.
Even more interesting, the unity of self can be disrupted when the corpus callosum (the commissure that joins the two hemispheres of the cerebral cortex) is severed
Recent neuroimaging studies have supported this clinical observation. During provocation of traumatic memories, it has been reported that activity in Broca’s area (a portion of the central nervous system that is involved in the transformation of subjective experience into speech) is markedly suppressed. Simultaneously, the areas in the right hemisphere that are thought to process visual images and intense emotions were highly activated.
It has been determined that stress is related to the increased production of several neurotransmitters, neuropeptides, including nor epinephrine, corticotropin releasing factor, as well as cortisol, opiates, dopamine and serotonin. Although the marked increase the release of these substances in beneficial for short-term survival, the long term or chronic effects of these substances are detrimental. Most generally, chronic stress related substance secretion causes the death of neurons.
In many cases, cortico-steroids released chronically and continuously due to frequent exposure to stressful events can act as neurotoxins, causing the death of neurons specifically in the hippocampus. Interestingly, it is the hippocampus that serves to unify memory elements from diverse neocortical areas.

PSYCHOLOGICAL ASPECT:

The small circle, the Conscious Mind, sits on a larger one, the Unconscious Mind.  When awake, the personality, indicated by the green dot, is in the smaller circle.  It is in executive control.  When asleep, control is relinquished and the personality slips into the Unconscious.
In MPD the situation is more complicated.  Alter personalities take turns to have executive control.  One alter may have control for minutes, hours or days before being replaced by another alter.  Switching may occur either through the intention of another alter, or in response to some role demand or following an external stimulus.
Around the Core Personality are False Front alters, Persecutor alters and Rescuer alters.  Ralph Allison introduces a revolutionary concept, a spiritual being called the Inner Self-helper (ISH).  It is an intellectual, non-emotional spiritual companion and guide that has been present since birth and claims to have a complete recall of every aspect of the person’s story.

ALTERS:
Alters is the name given to the distinct personalities which form. The number of alters varies from person to person, but seems to depend on a number of factors such as the severity of the abuse and the time period of the abuse, (e.g. from the age of 2 to age 16 is likely to lead to many alters). My SO – who we shall call Snowflake – has 25+ that we know of so far.

Each alter has a job within the system. Most alters protect the host personality from the memories of the trauma. It is common for each personality to guard a particular memory.

Some multiples are co-conscious – others are not. Not all alters are co-conscious. This means that within some systems the alters can communicate among themselves, share information and so there is a lesser degree of time loss for the host.

Each multiple sees their mind of alters in a different way – a place where alters go when they’re not out (i.e. not in control of the body). Some multiples have houses, tunnels, castles and levels, Snowflake has a series of rooms – the most popular being a lobby-type room called the “special room”.

Most alters do not see themselves in the physical body that they live in – they have their own perception of themselves. The children see themselves as 4 ft, small children; the girls see themselves as girls; the boys as boys. Some alters do not understand that they are sharing one body.

Alters may be different nationalities and races. Some may speak different languages. One of Snowflake’s alters speaks Flemish!?! Alters can also be biologically different. One of Snowflake’s alters has cystic fibrosis, another is blind and another cannot speak. The sight of the different alters varies from 20:20 vision to eeding glasses. All of Snowflake’s alters have very different handwriting. I remember reading about an experiment done by handwriting experts on the handwriting of a particular multiple’s different alters’ handwriting. The experts concluded that no two samples of writing were from the same person.
Alters can also come from different time periods. One child alter in Snowflake’s system, believes it is still the 1960’s and Kennedy has just been shot, and is amazed by colour TV. If anyone else has any experience of this, or an explanation for this I would love to hear from you.
Alters often look different. They have different facial expressions and different mannerisms.

There are many different kinds of alters and all systems are different, but there are some main groups, which seem to be present in most systems:

Host
This person can either be the original birth child, or can be an alter that is the main personality presented to the outside world.

Original Birth Child
This person may be awake and functioning, or said to be asleep. This person is sometimes referred to as the core personality.

Child Alters
Child alters (or littles as they are affectionately called), can range from the age of an infant upwards. These are the alters that took much of the abuse, and often carry a large number of memories. They display behaviour that is appropriate for their age. Often child alters carry much pain, both physical and emotional. They have been through horrifying suffering and need and deserve all the love we can give them. They need to be allowed o be children – as their own childhood was taken from them. These child alters have guarded many brutal memories so the system could survive. They should be credited with saving the life of the multiple. Without them, who knows what way things would have ended.

Teens
Most systems have teen alters. These alters were often the ones who went to school, and were out for those years.

Gatekeepers
Some systems have a gatekeeper, who directs who has control of the body. They may also control the length of time an alter is in the body. They do not often come out themselves, but just seem happy to observe and direct the others.

Internal Self Helpers
These internal self helpers keep the alters safe. They usually know all the alters and the details of the abuse the alters endured. They are very helpful in therapy, and also to the SO, to help them to understand why a particular alter feels the way they do, or to explain the action of a particular alter. They also decide what information is passed to other alters and to the host.

Protectors
Protectors protect (!) the system from outside threats. They can usually talk hard, or fight, or do whatever is necessary to keep the system safe. They often use anger as a defense. They are especially protective of the child alters.

Fully-fledged personalities
This phrase is used to describe any of the alters who is able to function in society on a day to day basis. They are out quite often and have their own beliefs, interests, talents and skills which can be different from the hosts. These alters can have their own groups of friends and are often the reason for the host being called by another name by these friends (who are strangers to the host).

Fragment alters
These are sometimes called task specific alters. These alters were created to carry one specific memory or deal with a particular situation.

Most alters, especially the child alters, do not age. They stay at the emotional age that they were created in. Some alters, usually adults, do age with the body.
It is important for friends and family of a multiple to realize that for them, each of the alters are different people, and they should be treated as such. One alter may say or do something that another may not. You should not blame one alter for the actions of another.

Triggers

A trigger is something which upsets an alter (usually a stressful situation) and causes another alter (often the protector) to come out unexpectedly. For each multiple the triggers will be different, but the following are some common ones:
–          Things people say
–          A certain touch
–          Shouting
–          Seeing the abuser
–          A certain object
–          Certain times of the year – especially holidays
–          Certain smells
–          Certain sounds
–          An unexpected touch
–          Someone coming up behind you
–          A colour or texture
–          Certain songs/music
–          Arguments, anger and aggression
–          Loud noises
–          Having sex
–          Making decisions

Diagnosis

The diagnostic criteria in DSM-IV Dissociative disorders section 300.14 require:

• 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.
• At least two of these identities or personality states recurrently take control of the person’s behavior.
• Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
• The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g. complex partial seizures). In children, the symptoms are not attributable to imaginary playmates or other fantasy play. A patient history, x-rays, blood tests, and other procedures can be used to eliminate symptoms being due to traumatic brain injury, medication, sleep deprivation, or intoxicants, all of which can mimic symptoms of DID.

Diagnosis should be performed by a psychiatrist or psychologist who may use specially designed interviews (such as the SCID-D) and personality assessment.

Diagnostic Tests

I. DISSOCIATIVE EXPERIENCE SCALE (DES): This is a 28-question self-test about experiences that you may have in your daily life. Following are the questions:
1. Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don’t remember what has happened during all or part of the trip.
2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said.
3. Some people have the experience of finding themselves in a place and having no idea how they got there.
4. Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on.
5. Some people have the experience of finding new things among their belongings that they do not remember buying.
6. Some people sometimes find that they are approached by people that they do not know who call them by another name or insist that they have met them before.
7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person.
8. Some people are told that they sometimes do not recognize friends or family members.
9. Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation).
10. Some people have the experience of being accused of lying when they do not think that they have lied.
11. Some people have the experience of looking in a mirror and not recognizing themselves.
12. Some people have the experience of feeling that other people, objects, and the world around them are not real.
13. Some people have the experience of feeling that their body does not seem to belong to them.
14. Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event.
15. Some people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them.
16. Some people have the experience of being in a familiar place but finding it strange and unfamiliar.
17. Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them.
18. Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them.
19. Some people find that they sometimes are able to ignore pain.
20. Some people find that that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time.
21. Some people sometimes find that when they are alone they talk out loud to themselves.
22. Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they were two different people.
23. Some people sometimes find that in certain situations they are able to do things with amazing case and spontaneity that would usually be difficult for them (for example, sports, work, social situations, etc.).
24. Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that this (for example, not knowing whether they have just mailed a letter or have just thought about mailing it).
25. Some people find evidence that they have done things that they do not remember doing.
26. Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing.
27. Some people sometimes find that they hear voices inside their head that tell them to do things or comment on things that they are doing.
28. Some people sometimes feel as if they are looking at the world through a fog so that people and objects appear far away or unclear.
The answer is rated on the following scale:
(Never)

(Always)

II. Structured Clinical Interview for DSM-IV: An Axis I SCID assessment with a psychiatric patient usually takes between 1 and 2 hours, depending on the complexity of the past psychiatric history and the subject’s ability to clearly describe episodes of current and past symptoms. A SCID with a non-psychiatric patient takes 1/2 hour to 1-1/2 hours. A SCID II personality assessment takes about 1/2 to 1 hour.
The instrument was designed to be administered by a clinician or trained mental health professional, for example a psychologist or social worker. Ideally, this would be someone who has had experience performing unstructured, open-ended question, diagnostic evaluations.

III. The Dissociative Disorders Interview Schedule (DDIS): Is a structured interview, has been developed to make DSM-III diagnoses of the dissociative disorders, somatization disorder, major depressive episode, and borderline personality disorder, Additional items provide information about substance abuse, childhood physical and sexual abuse, and secondary features of multiple personality disorder. These items provide information useful in the differential diagnosis of dissociative disorders. The DDIS has an overall inter-rater reliability of 0.68. For the diagnosis of multiple personality disorder it has a specificity of 100% and a sensitivity of 90%.

Treatment

I. PSYCHOTHERAPY:
Several stages:

• an initial phase for uncovering and “mapping” the patient’s alters;
• a phase of treating the traumatic memories and “fusing” the alters;
• And a phase of consolidating the patient’s newly integrated personality.I. Psychoanalysis:

Psychoanalysis is the first practice to be called a psycho therapy. It is a body of ideas developed by Austrian-Jewish physician Sigmund Freud and his followers, which is devoted to the study of human psychological functioning and behavior. It has three applications: 1) a method of investigation of the mind; 2) a systematized set of theories about human behavior; and 3) a method of treatment of psychological or emotional illness.
The basic method of psychoanalysis is interpretation of the patient’s unconscious conflicts that are interfering with current-day functioning – conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions.
When the patient reclines on a couch with the analyst out of view, the patient tends to remember more, experience more resistance and transference, and be able to reorganize thoughts after the development of insight – through the interpretive work of the analyst.

Variations in technique:
There is what is known among psychoanalysts as “classical technique.”
It comprises of instructions (telling the patient to try to say what’s on their mind, including interferences); exploration (asking questions); and clarification (rephrasing and summarizing what the patient has been describing).
The analyst then uses a variety of interpretation methods, such as dynamic interpretation (explaining how being too nice guards against guilt, e.g. – defense vs. affect); genetic interpretation (explaining how a past event is influencing the present); resistance interpretation (showing the patient how they are avoiding their problems); transference interpretation (showing the patient ways old conflicts arise in current relationships, including that with the analyst); or dream interpretation (obtaining the patient’s thoughts about their dreams and connecting this with their current problems). Analysts can also use reconstruction to estimate what may have happened in the past that created some current issue.

II. Rorschach inkblot test:
The Rorschach inkblot test is a psychological projective test of personality in which a subject’s interpretations of ten standard abstract designs are analyzed as a measure of emotional and intellectual functioning and integration. The test is named after Hermann Rorschach (1884-1922) who developed the inkblots, although he did not use them for personality analysis.
The test is considered “projective” because the patient is supposed to project his or her real personality into the inkblot via the interpretation. The inkblots are purportedly ambiguous, structure less entities which are to be given a clear structure by the interpreter. Those who believe in the efficacy of such tests think that they are a way of getting into the deepest recesses of the patient’s psyche or subconscious mind. Those who give such tests believe themselves to be experts at interpreting their patients’ interpretations.
The time it takes you to provide a verbal response is carefully noted, along with any other secondary comments you may make. Hand gestures and some body movements may also be noted. In the classical test protocol the psychologist is never supposed to “hurry you along” or ask you to respond. Again, tape recordings often serve the examiner well in this regard since they can time the responses later (and with more accuracy) at their leisure pond. Again, tape recordings often serve the examiner well in this regard since they can time the responses later (and with more accuracy) at their leisure.

For e.g. this is a black and white card, often described as looking like a mask or the face of a fox or wolf by the patient.
Possible Sexual Imagery:  Breasts, primarily the rounded areas at the top of the image.

III. Cognitive behavioral therapy:
Cognitive behavioral therapy (or cognitive behavior therapy, CBT) is a psychotherapeutic approach that aims to influence problematic and dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure. CBT can be seen as an umbrella term for therapies that share a theoretical basis in behavioristic learning theory and cognitive psychology, and that use methods of change derived from these theories.
Group therapy: Cognitive behavioral group therapy is a group therapy approach, developed by Richard Heimberg for the treatment of social phobia.
Computerized CBT: There are cognitive behavioral therapy sessions in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face to face with a therapist. This can provide an option for patients, especially in light of the fact that there are not always therapists available, or the cost can be prohibitive. For people who are feeling depressed and withdrawn, the prospect of having to speak to someone about their innermost problems can be off-putting. In this respect, computerized CBT (especially if delivered online) can be a good option.

Medication

Medication is usually for symptomatic treatment of MPD.

Antidepressants:
Some core personalities, or alters, may genuinely be depressed, and may benefit from antidepressant medications.Antidepressants are classified as:

• Reversible inhibitors of Mono Amine Oxidase- A (RIMAs): e.g. Moclobemide, Clorgyline
• Tricyclic antidepressants (TCAs): e.g. Imipramine, Clomipramine
• Selective serotonin reuptake inhibitors (SSRIs): e.g. Fluoxetine, Sertraline
• Atypical Antidepressants: Trazodone, Venlafaxine

Anti anxiety drugs:
These are drugs used to treat anxiety.

• Bezodiazepines: e.g. Diazepam,
• Azapirones: e.g.  Buspirone,
• Sedative antihistaminic: e.g. Hydroxyzine,
• β blocker:  e.g. Propranolol, etc are used.

Tranquillizers:
These are drugs that treat the psychosis like symptoms.

• Phenothiazines like Chlorpromazine,
• Atypical neuroleptics like Clozapine,
• Butyrophenones like Haloperidol,
• Thioxanthenes like Flupenthixol, etc are used.

Alternative treatment: Alternative treatments that help to relax the body are often recommended for DID patients as an adjunct to psychotherapy and/or medication. These treatments include hydrotherapy, botanical medicine (primarily herbs that help the nervous system), therapeutic massage, and yoga. Homeopathic treatment can also be effective for some people. Expressive therapy like Art therapy and the keeping of journals are often recommended as ways that patients can integrate their past into their present life. Meditation is usually discouraged until the patient’s personality has been reintegrated.
Eye Movement Desensitization and Reprocessing (EMDR) is used if appropriate. It is the imaging of the traumatic memory with saccadic eye movements guided by the therapist. A subjective unit of distress scale (SUDS) was used to measure distress where 0 was no distress and 10 was the maximum distress created when an image of the phobic event was recalled. A validity of cognition (VOC) scale was used to assess the patients’ level of confidence.
All these lines of treatment prove to be useful only if the patient accepts the presence of this disorder. Hence self help is the best possible help for an MPD patient.

History

Books: MPD has been the topic of interest for many novelists;

• Robert Louis Stevenson’s Strange Case of Dr Jekyll and Mr. Hyde,
• Sydney Sheldon’s Tell me your  Dreams

Movies influenced by reality:

• Sybil,

MPD in fiction:

• Bhool Bhulaiyaa and Aparichit(Hindi), etc.

Epidemiology

The occurrence of MPD is low in India as compared to other countries.

INDIA	0.015%
SWITZERLAND	0.05- 0.1%
CHINA	0.4%
GERMANY	0.9%
NETHERLANDS	2%
U.S.A.	~6-10%
TURKEY	14%

References

• www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp
• http://deltabravo.net/custody/rorschach.php
• http://en.wikipedia.org/wiki/Psychoanalysis
• http://en.wikipedia.org/wiki/Systematic desensitization
• http://www.w3c.org/TR/1999/REC-html401-19991224/loose.dtd
• http://skepdic.com/inkblot.html
• http://en.wikipedia.org/wiki/Rorschach_inkblot_test
• http://en.wikipedia.org/wiki/Psychotherapy
• http://serendip.brynmawr.edu/bb/neuro/neuro99/web3/Sancar.html
• http://skepdic.com/mpd.html
• http://en.wikipedia.org/wiki/Hypnotherapy
• http://www.ncbi.nlm.nih.gov/pubmed/17961993?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed
• http://counsellingresource.com/quizzes/des/index.html
• http://en.wikipedia.org/wiki/Computerised_CBT
• http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
• Essentials of Medical pharmacology – K. D. Tripathi.
• Principles of anatomy and Physiology – Tortora and Derrickson.
• Gale Encyclopedia of Medicine