Treatment of dissociative identity disorder: leveraging neurobiology to optimize success

INTRODUCTION

Dissociative identity disorder (DID) is a treatable mental health condition that is associated with a range of psychobiological manifestations. However, historical controversy, modern day misunderstanding, and lack of professional education have prevented accurate treatment information from reaching most clinicians and patients. These obstacles also have slowed empirical efforts to improve treatment outcomes for people with DID. Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes.

AREAS COVERED

In this narrative review, the authors discuss symptom characteristics of DID, including dissociative self-states. Current treatment approaches are described, focusing on empirically supported psychotherapeutic interventions for DID and pharmacological agents targeting dissociative symptoms in other conditions. Neurobiological correlates of DID are reviewed, including recent research aimed at identifying a neural signature of DID.

EXPERT OPINION

Now is the time to move beyond historical controversy and focus on improving DID treatment availability and efficacy. Neurobiological findings could optimize treatment by reducing shame, aiding assessment, providing novel interventional brain targets and guiding novel pharmacologic and psychotherapeutic interventions. The inclusion of those with lived experience in the design, planning and interpretation of research investigations is another powerful way to improve health outcomes for those with DID.

Dissociative Identity Disorder: A Review of Research From 2011 to 2021

ABSTRACT

Dissociative identity disorder (DID) has historically been one of the most controversial topics in the study of psychopathology. Building on a previous review of empirical research on DID from 2000 to 2010, the present review examined DID research from 2011 to 2021. The research output included 56 case studies and 104 empirical studies. Within the empirical studies, approximately 1354 new cases of DID emerged, which resulted in an average samples of approximately 20. Reanalysis of previous samples was standard in the literature with only 40% of reported cases being new. Studies emerged from dozens of countries across the world, but the majority of cases were from Western counties, especially the United States. Diagnosis primarily relied upon validated measures, but 74% of all new cases came from six research groups. Overall, research on DID is steady but methodologically limited in ways that make generalization, especially about etiology, difficult.

Firebug! Dissociative Identity Disorder? Malingering? Or …? An Intensive Case Study of an Arsonist

Courts struggle with questions of how to assess competency to stand trial (CTS) and not guilty by reason of insanity (NGRI) in dissociative identity disorder (DID). Concerns about CTS include dissociative amnesia and unpredictable switching behaviors that could cause inconsistent information transfer across self states, with the defendant unable to access important legal information about his/her defense and to collaborate with his/her attorney; DID defendants could not conform their conduct to the law or know right from wrong due to dissociative amnesia, the seemingly independent actions of self states, and the disruption of reality testing by switching. The author presents the case of a woman charged with both a witnessed and an unwitnessed burglary and arson, the latter at the home of her former therapist. The author was the fourth forensic evaluator in the case. Disagreements included whether the defendant met diagnostic criteria for DID or was malingering, and whether she was CTS and/or NGRI. In clinical work with DID, “the whole human being” is held responsible for all behavior, despite reported amnesia or lack of subjective agency. The Discrete Behavioral States (DBS) model of DID avoids reification of the DID self states and their conflation as separate “people.” This model supports evaluating the defendant at the level of specific self states, the self-state system, and that of the whole human being. The author concluded that the defendant met diagnostic criteria for DID and also was malingering its severity. She was competent to stand trial and legally sane.

Freud's Rejection of Hypnosis: Perspectives Old and New:Part III of III-Toward Healing the Rift: Enriching Both Hypnosis and Psychoanalysis

As Freud developed his own ideas, he abandoned the use of hypnosis. This change led to more than a century of disengagement between hypnosis and psychoanalysis, characterized, with notable exceptions, by mutual avoidance, dismissiveness, and incomplete appreciation of each by the other. Earlier communications challenged the foundations of Freud's rationales and their perpetuation. Here, contemporary instances in which hypnosis and psychoanalysis are used together are reviewed briefly before exploring possibilities/opportunities for their mutual enrichment and enhancement. The judicious incorporation of insights and assets from each into the other can be implemented without violating the standard approaches and practices of the modality into which they might be imported. Examples are offered as food for thought, stepping-stones toward a rapprochement long overdue.

REVISITING THE SAFE PLACE:Method and Regulatory Aspects in Psychotherapy when Easing Allostatic Overload in Traumatized Patients

Safe-place inductions are considered important altered states of consciousness (ASC) to be (re)installed during trauma-informed psychotherapy. Coregulation aimed at changing implicit relational knowing and increasing integration and coherence through relational work and hypnotic techniques is crucial, as clients' abilities to self-soothe and regulate have become seriously impaired. Thus, resource-oriented metaphors as inner strength imagery is advocated. Also, methods such as creative-arts therapy and neurofeedback will induce ASCs, as most methods used with complex traumatized clients, due to their high hypnotizability. When positive or soothing imagery or relationally held suggestions for changed attentional focus are added to both psychodynamic psychotherapy and CBT, a hetero-hypnosis will be induced-a prerequisite for phase-specific trauma therapy aimed at changing inner schemas and scripts.

Catching a Wave: The Hypnosis-Sensitive Transference-Based Treatment of Dissociative Identity Disorder (DID)

In this article, I will describe the way in which I work with enactment-prone dissociative patients in the transference. This approach requires an appreciation of the phenomena of hypnosis and the auto-hypnotic aspects of some forms of dissociation. Essentially, I learn from the patient and my interactions with the patient how hypnotic phenomena and auto-hypnotic defenses manifest themselves in the therapeutic relationship in order both to understand them and ultimately to bring them under conscious control. Because of the fluidity and turbulence of these states, I use the analogy of catching a wave, in which timing and balance are essential, albeit elusive factors in effecting a successful treatment. The importance of having experience with many patients, attending conferences, seeking supervision, and undergoing one's own therapy will be also discussed as important prerequisites for the clinician endeavoring to utilize this type of approach. This preparation, this quest for such a "balance," is modeled after the so-called tripartite model of training employed in psychoanalytic training institutes. I will offer clinical material to illustrate this approach, which I have described as "psychoactive psychotherapy." In such treatments, the clinician may be taken by surprise and is likely to be thrown "off balance" from time to time. The mutually shared understanding of such moments is essential to regaining clinical balance in the therapeutic setting, and can lead to if not create important turning points in the treatment process.

Reconsidering Hypnosis and Psychoanalysis: Toward Creating a Context for Understanding

Sigmund Freud developed what became psychoanalysis in the context of his experiences with hypnosis and the treatment of the grand hysterics of his era, conditions largely classified among the dissociative disorders in contemporary systems of diagnosis. He rapidly constructed understandings of the human mind and human distress that replaced the concept of dissociation and a model of pathology that was passive (associated with reduced psychic cohesion), with the paradigm of an active defensive process he termed repression, and an understanding that psychological discomfort was the outcome of intrapsychic conflict. In short order Freud repudiated hypnosis, initiating the schisms that subsequently separated the study and practice of hypnosis from the study and practice of psychoanalysis. It is timely to reexamine these schisms anew, challenge the basis of the arguments thought to justify them, and explore whether these schisms have deprived psychoanalysis and hypnosis alike of the potentially helpful ideas and approaches each might offer the other. This contribution invites students of hypnosis and psychoanalysis alike to put aside both traditional and stereotypic notions of each other's field of endeavor, revisit the origins, rationales, and outcomes of these schisms that have divided them, and explore their commonalities and their differences from fresh perspectives.

Promoting Safety in Hypnosis: A Clinical Instrument for the Assessment of Alertness

Hypnosis has long demonstrated its power to facilitate various approaches to psychotherapy. Like other potent modalities, hypnosis may produce unwanted effects. Although its negative sequelae are usually mild and transient, more serious complications may occur. Recently, attention has been drawn to the powerful role of failures of dehypnosis or alerting/realerting in producing unwanted effects. Traditionally, alerting has been viewed as a relatively uncomplicated process that requires little more than the simple suggestion that the subject will return or awaken from trance, and exiting from trance has generally been considered the cessation of the phenomena suggested during induction and thereafter. Newer findings challenge these assumptions and suggest that restoring the subject to a prehypnotic baseline level of alertness is of equal or greater importance. Here, I describe the Howard Alertness Scale (HAS), with which subjects can be made aware of their baseline levels of alertness to help them understand the unique ways that their trance states differ from their normal alert states, and assess and measure their subjective perception of alertness before and after hypnosis. Furthermore, regular use of the HAS holds potential to enhance both the therapeutic alliance and the patient's sense of safety and mastery. The development and use of the HAS is discussed along with three vignettes illustrating its clinical application.

The Wounded Self in Trauma Treatment

The potential role of hypnosis in the treatment of trauma is both venerable and underappreciated. This article underscores the importance of the wounded-self concept by proposing a Kohutian perspective complimentary to the cognitively-driven model of Alladin (2014a, 2014b) discussed elsewhere in this issue. It explores selected topics that demonstrate (1) the importance of considering the wounds to the sense of self experienced by trauma victims and their implications for individualization of treatment in planning a psychotherapy; (2) the possibility of enhancing access to memories using shame alleviating techniques with minimal suggestive properties; (3) the use of hypnosis to facilitate less disruptive processing of traumatic materials; and (4) the importance of hypnosis in enhancing the safety of the trauma patient between sessions. Absent contraindications, the circumspect use of hypnosis as a facilitator of trauma treatment deserves consideration for inclusion in the mainstream of contemporary trauma treatment.