Neurological Disorders Papers (Dissociative Identity Disorder Book 1)

---

Smaller hippocampal volume in dissociative identity disorder could thus be related to stress exposure and could represent a neurobiological finding that dissociative identity disorder shares with other stress-related psychiatric disorders such as PTSD. The exact mechanism that could lead to smaller amygdalar volume in dissociative identity disorder is unclear. To our knowledge, the amygdala is not a target organ for glucocorticoids. In contrast to the volumetric assessment of the hippocampus, reliable measurement of amygdalar volume with MRI in human subjects has long been thought to be difficult to accomplish 29 , However, the use of MR cameras with good resolution, agreement on the structure boundaries, and the use of three-dimensional software packages enabled us to reliably measure both hippocampal and amygdalar volumes.

Smaller hippocampal and amygdalar volumes have been reported in three earlier studies in which patients with borderline personality disorder were compared to healthy subjects 18 — Tebartz van Elst et al. Early studies in PTSD patients did not show significantly smaller amygdalar volumes. These findings suggest that early abuse associated with a stress-related psychiatric disorder may be related to smaller amygdalar volume.

In addition, these findings are in contrast to findings from studies of depression that have shown no differences or larger amygdalar volume in depressed patients, compared with healthy subjects Genetic factors that could contribute to the smaller hippocampal and amygdalar volumes that are found in patients with dissociative identity disorder could increase the risk for the development of the disorder In an application of this argument to PTSD, stress may not cause hippocampal damage; rather, individuals who were born with smaller hippocampal volume would be at greater risk for development of PTSD Consistent with this hypothesis, abused subjects without dissociative identity disorder in the current study had larger hippocampal and amygdalar volumes than non-abused subjects without dissociative identity disorder.

Our finding that the ratio of hippocampal volume to amygdalar volume discriminated the patients from the healthy comparison subjects has not been reported in previous volumetric studies.

Case Example: Mary (As Mary, Edith, “Baby”)

This finding suggests that dissociative identity disorder is associated with relatively greater volume reductions in the amygdala than in the hippocampus. Our study had several limitations. As a group, the comparison subjects were significantly younger than the dissociative identity disorder patients. Age-related structural alterations in the hippocampus have been identified 56 ; however, there are no previous findings of a relationship between age and hippocampal or amygdalar volume in women in the 20—year age group 57 , 58 , the age group represented by the subjects in our study.

In a study of the effects on hippocampal volume of age and sex in early adulthood, Pruessner et al. In women no such relationship was found. No significant effect of age was found for amygdalar volume in either men or women. It is hypothesized that the estrogen level in young adult women protects against loss of volume of the hippocampus.

Dissociative Identity Disorder: A Pathophysiological Phenomenon

Changes in estrogen level associated with entering menopause could therefore have contributed to hippocampal volumetric alterations, and it is possible that a few of the dissociative identity disorder patients in our study could have entered menopause. These studies add support to an analysis in which dissociative identity disorder patients and healthy subjects are compared without adjustment for effects of age. Accordingly, we believe the significance levels for the between-group comparisons of both hippocampal and amygdalar volumes are valid without correction for this factor.

Yet the design would have been stronger if the groups were age-matched.

Post your comment

In addition, we did not perform volumetry of subcortical regions e. This step would have enabled us to correlate the volume measurements of structures of interest with those of brain regions that are presumed to be unaffected. However, we did use whole brain volume as a covariate. Another limitation was that the dissociative identity disorder subjects were so ill that they could not be safely included in the study as medication-free outpatients, whereas the comparison subjects were medication free during the study.

Medication has been shown to influence the volume of the hippocampus. In rodents, antidepressant treatment has been shown to increase neurogenesis in the hippocampus A single study in humans has also demonstrated an increase in hippocampal volume associated with treatment with paroxetine Therefore, it is possible that the differences in hippocampal volume and possibly in amygdalar volume for the dissociative identity disorder group could have been even larger if the patients had not been taking medication. Finally, a potential limitation of this study is that all of the patients with dissociative identity disorder also met the criteria for PTSD, which makes it impossible to establish that the findings are not related to the comorbid PTSD diagnosis.

However, patients with true dissociative identity disorder without PTSD essentially do not exist. We hope that the current study will promote a conceptualization of PTSD and dissociative identity disorder as related trauma-spectrum disorders These findings may have clinical implications for the treatment of dissociative identity disorder patients.

For example, an understanding of dissociative identity disorder as a trauma-related disorder that involves neural circuitry alterations in brain areas associated with memory that are also affected in PTSD may help clinicians better understand the symptoms presented by patients in treatment sessions. Neurobiological studies that support the validity of the diagnosis of dissociative identity disorder will help to advance research in this area. Findings that link dissociative identity disorder to other trauma-related disorders may help improve nosological approaches to this disabling disorder.

The authors thank Nancy Kristen Wilson, M. National Center for Biotechnology Information , U. Author manuscript; available in PMC Dec 8. Eric Vermetten , M. Douglas Bremner , M.

Author information Copyright and License information Disclaimer. Address correspondence and reprint requests to Dr. The publisher's final edited version of this article is available at Am J Psychiatry. See other articles in PMC that cite the published article. Abstract Objective Smaller hippocampal volume has been reported in several stress-related psychiatric disorders, including posttraumatic stress disorder PTSD , borderline personality disorder with early abuse, and depression with early abuse.

Method The authors used magnetic resonance imaging to measure the volumes of the hippocampus and amygdala in 15 female patients with dissociative identity disorder and 23 female subjects without dissociative identity disorder or any other psychiatric disorder. Results Hippocampal volume was Conclusions The findings are consistent with the presence of smaller hippocampal and amygdalar volumes in patients with dissociative identity disorder, compared with healthy subjects.

Method Subjects Fifteen patients with dissociative identity disorder were compared to 23 healthy subjects without psychiatric disorder. Open in a separate window. MRI Magnetic resonance images were acquired on 1. Data Analysis Repeated-measures analyses of covariance ANCOVA with side left or right as the repeated measure were used to analyze group differences in total volumes.

Results The mean of the left and right hippocampal volumes of the patients with dissociative identity disorder was Discussion Our study is the first to demonstrate smaller hippocampal and amygdalar volumes in female patients with dissociative identity disorder, compared to healthy female subjects. The dissociative disorders, in Comprehensive Textbook of Psychiatry.

Characteristics of patients with multiple personality and dissociative disorders on psychological testing. J Nerv Ment Dis. Diagnosis, epidemiology, clinical course, treatment, and cost effectiveness of treatment for dissociative disorders and multiple personality disorder: Putnam N, Stein M. Self-inflicted injuries in childhood: Clinical Pediatr Phila ; Abuse histories in cases of multiple personality disorder.

Clinical phenomenology of child and adolescent dissociative disorders. Boon S, Draijer N. Multiple personality disorder in the Netherlands: Frequency of dissociative disorders among psychiatric inpatients in a Turkish university clinic.

Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. Dissociation, development, and the psychobiology of trauma. An example of this is in children where an imaginary friend is not necessarily indicative of a mental illness. The symptoms are not due to the direct physiological effects of a substance such as blackouts or chaotic behavior during alcohol intoxication or a general medical condition such as complex partial seizures. The idea behind writing this mini review was to highlight the psychopathology behind DID.

Because not much has been published about the brain changes in the people exhibiting the symptoms of DID, this article will serve as a collection of some important studies discussing the pathophysiological mechanism associated with DID. Moreover, in this article we will address the changes in the amygdala; hippocampus and an involvement of orbitofrontal cortex OFC in DID patients, with reduction in functioning and the blood flow in OFC.

Furthermore, in the end we will point towards a need of more research in the future to gain more insight about a clear pathophysiology involving any possible brain changes in the DID. Because not much has been written about the pathophysiology of DID. Mostly we have been relying on speculations. In this review, we have attempted to compile some relevant studies discussing a possible pathophysiology of DID.

Some interesting studies have been found and included in this review. We found some studies about bipolar disorder, schizophrenia and their possible association with DID. These kinds of studies only point toward a possibility rather than claiming something with confidence. As we can see that in a recent study, Ross, et al. The attempts to study a possible pathology involved in DID is not new.

In , Ellason et al. The results indicated that the positive symptom and general psychopathology scores were worse in the dissociative identity group than the norms for schizophrenia, while the negative symptoms were remarkably more severe in schizophrenia. Enough evidences exist that schizophrenia patients have brain changes in almost all lobes including the occipital lobe [ 6 ].

Therefore, the co-occurrence of DID with either schizophrenia or Bipolar is an indication that in the future we will read more about similar studies, and possibly we will find some possible alterations in the brain in such patients. However, as of now it is premature to comment on any such brain changes. Similarly, various other personality disorders and types have been studied in relation to DID. This study inclined our attention towards the persona logic crux of DID [ 7 ].

Moreover, a preliminary study by Ross [ 8 ] was carried out in where he proposed the inclusion of possession experience in DSM V. This points toward a notion that a group of scientists has always been actively involved in trying to study, understand and treat DID as a pathophysiological phenomenon. In , Brunson et al. This further emphasizes upon our review demonstrating DID and its association with early stress and changes in volumes of stress regulating brain areas.

Many studies proposed childhood trauma as the most common precipitating cause of DID. But does childhood trauma tend to change volumes of hippocampus or amygdala?

Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder

Much neurological research in collaboration with radiology has to be done in order to get an answer. The emergence of neuroimaging and especially structural as well as the functional MRI revolutionized the world of neurosciences [ 10 ]. The discovery made it possible to study many neurological disorders including DID.

An MRI study by Vermetten, et al. They argued that DID arises from a substrate of borderline traits. The authors argued that the multiplicity of symptoms associated with DID, including insomnia, sexual dysfunction, anger, suicidality, self mutilation, drug and alcohol abuse, anxiety, paranoia, somatization, dissociation, mood changes, and pathologic changes in relationships, supported their view.

Although the alters described in DID are sometimes referred to as ego states , Watkins and Watkins 23 draw a distinction between the two concepts. In general, practitioners who accept the validity of DID as a diagnosis attribute it to the effects of exposure to situations of extreme ambivalence and abuse in early childhood that are coped with by an elaborate form of denial so that the child believes the event to be happening to someone else perhaps starting out as an imaginary companion.

In contrast, PTSD symptoms would more likely occur when trauma is experienced later in childhood or during adult life. Severe child abuse, a disorganized and disoriented attachment style, 25 , 26 and the absence of social and familial support seem to precede the development of DID.

The tendency to dissociate seems to be related as much to a pathogenic family structure and attachment disorder acquired early in the life of the child as to original temperament or genetics. Parenting style toward these patients was usually authoritarian and rigid, but paradoxically with an inversion of the parent-child relationship. DID patients showed increased vigilance, resulting in reduced habituation of startle reflexes and increased PPI.

This response is a voluntary process that directs attention away from unpleasant or threatening stimuli. The authors concluded that aberrant voluntary attentional processes may thus be a defining characteristic of DID. By contrast, one identity could recognize neutral words learned by the other identity. Huntjens et al 36 recommend that clinical models of amnesia in DID should exclude impairments for emotionally neutral material. Further research is needed to clarify whether or not the symptoms of DID actually perform a protective, defensive function neurologically by creating a neuroprotective environment that ameliorates the neurotoxic effects of traumatic stress.

This would be predicted by the adaptive hypothesis described by Stankiewicz and Golczynska. The typical patient who is diagnosed with DID is a woman, about age Typically by the time they are adults, DID patients report up to 16 alters adolescents report about 24 , but most of these will fade quickly once treatment is begun. There generally is a reported history of childhood abuse, with the frequency of sexual abuse being higher than the frequency of physical abuse.

Patients who have been diagnosed with DID frequently report chronic suicidal feelings with some attempts. Sexual promiscuity is frequent but patients usually report decreased libido and an inability to have an orgasm. Some patients report that they dress in clothing of the opposite gender or that they, themselves, are of the opposite gender.

These patients experience so much dissociation and also many somatic symptoms some cases resemble Briquet syndrome or somatization disorder 40 that they have a very inconsistent work history. Most DID patients come into treatment because of affective, psychotic-like or somatic symptoms. Patients who have been diagnosed with DID tend to possess extreme sensitivity to interpersonal trust and rejection issues, and this makes brief treatment in a managed care setting difficult.

Dissociative Identity Disorder

Patients tend to switch personality states when there is a perceived psychosocial threat. This switching allows a distressed alter to retreat while an alter who is more competent to handle the situation emerges. Kluft does not view the alters as obstacles, distractions, or artifacts to be bypassed or suppressed. In fact, he argues that he has found no evidence of improvement if the therapist does not work with these alternate personality states.

This can be enhanced by teaching relaxation exercises, suggesting breaks from the setting for a few minutes, and helping the patient gain control over cognitive distortions of the self and world. The therapist tries to model an appropriate relationship and model appropriate, calm, and considered reactions to crises. According to Kluft, large systems of alters usually collapse as the treatment moves forward and so it is not necessary to be overly concerned if the patient experiences a large number of personality states.

This would not be an appropriate goal of treatment. The personality state was created to defend the self against abuse and injury and can become a strong and important element when integrated more adaptively into the overall personality structure. National Center for Biotechnology Information , U. Journal List Psychiatry Edgmont v. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract A brief description of the controversies surrounding the diagnosis of dissociative identity disorder is presented, followed by a discussion of the proposed similarities and differences between dissociative identity disorder and borderline personality disorder.

She began to tell the psychiatrist about a crying voice she heard constantly: Baby cries all the time—Baby—I hear her. She is sad all the time. Her demeanor and posture were now so different the psychiatrist was startled. It really felt as though a different person was in the room. She is a wimp.

• Living in a Cardboard Box
• Over At The Frankenstein Place
• Socorro Saved Me:Socorro Smiled
• Life and Times of Charlie, the pomeranian dog who loved people (Life of Charlie Book 2)
• A Wisp in the Wind: In Search of Bull Trout, Bamboo, and Beyond