All the Pieces of Me: Childhood Dissociative Identity

All the Pieces of Me:
Childhood Dissociative
Identity Disorder
Developed by
Lindsay Hope-Ross, M.Sc., R. Psych.
Clinical Lead
Healthy Minds/Healthy Children Outreach
Services
1
Outline
• What is Dissociative Identity Disorder (D.I.D.)?
• What causes D.I.D.?
• Signs and symptoms of D.I. D.
¾ D.I.D.-specific symptoms
¾ PTSD symptoms
• How caregivers can help
• What professionals can do
• References and resources
• Contact information
2
What Is D.I.D.?
“Despair stares out of a little child’s eyes as her
mind switches places so another can absorb
what she cannot bear.
Robbed of purity, given no security; robbed of trust, given only
lust; robbed of care, given pulls on the hair.
Open-eyed and vulnerable she waits – for that feeling of dread,
for footsteps, for the touch, for the smell.
‘Please God, will you save her this time? Don’t you listen? Why
won’t you put an end to her hell’?
Sorrow stares out a little child’s eyes as her mind switches gears
and she wishes for butterfly wings so she can escape”.
©1/12/95 kellen&co/kate(17)
3
What Is D.I.D.?
• dissociation is a psychological
process that occurs when
experiences are not integrated into
the usual sense of self, resulting
in discontinuities in conscious
awareness
• in severe cases, disconnection
occurs in the functions of
consciousness, memory, identity,
and/or perception
4
What Is D.I.D.?
• in children, there is a
developmental disruption in the
integration of adaptive memory,
sense of identity, and the selfregulation of emotion
• that is, the “on-going process by
which the mind continues to make
increasingly organized connections
that allow adaptation” are disrupted
(ISSD Task Force, 2004)
5
What Is D.I.D.?
How dissociation changes the way one experiences life:
1. depersonalization
2. derealization
3. dissociative amnesia
4. identity confusion
5. identity alteration
6
What Is D.I.D.?
Depersonalization
• is the sense of being detached
from, or “not in”, one’s body
• may include
¾ profound alienation from one’s body
¾ a sense of not recognizing oneself in a mirror
¾ feeling disconnected from one’s body but unable to
explain this to others – “I’m just not there”
7
What Is D.I.D.?
Derealization
• is the sense of the external world not being real
• may include perceptions that
¾ everything is phoney or fake
¾ everything is foggy
¾ everything is far away
¾ everything is being seen through a
veil
¾ the world is detached
¾ “it is like watching a movie”
8
What Is D.I.D.?
Amnesia
• is the inability to recall important personal/life
information so extensive that it is not due to ordinary
forgetfulness, for example, forgetting attending one’s
graduation ceremony
• may include
¾ the “loss of time”; that is, a
block of time from minutes
to years is missing
9
What Is D.I.D.?
¾ forgetting that a discussion or
activity has occurred
¾ being unable to recall the
content of a conversation or
activity from one moment to
the next
• characterized by the need to
cover for oneself all the time
10
What Is D.I.D.?
“My memories of childhood are sketchy at best. It isn’t just the
scary stuff I don’t remember. A lot of the things I don’t remember
are family outings, learning to water ski ... I remember always trying
to figure out what was going on around me ... New toys in my
bedroom and not knowing where they came from ...
I said I forgot all the time and it
got me into trouble ... I would
hide … My entire life has been
geared toward staying invisible or
blending in or hiding.” (Anonymous)
11
What Is D.I.D.?
Identity Confusion
• is a sense of not knowing
who the self is; for example,
when a teen gets a thrill
from drinking alcohol, when
at other times this would be
repugnant to her/him
12
What Is D.I.D.?
Identity Alteration
• is the sense of being markedly different from another
part of oneself
• may include
¾ shifts to alternate personalities,
sometimes with different
names, ages, and/or genders
¾ severe confusion
13
What Is D.I.D.?
¾ distortion of time, place and/or
situation
¾ regression
¾ changes in emotional expression
¾ changes in tone of voice
¾ use of different accents
¾ changes in range of language or
language norms
14
What Is D.I.D.?
¾ changes in facial expression and mannerisms
¾ changes in world view, belief systems and/or values
¾ different abilities
¾ different physiologies
• most often unaware of the
dissociated parts of the
self
15
What Is D.I.D.?
• Dissociative Identity Disorder (D.I.D.) used to be known
as Multiple Personality Disorder (M.P.D.)
• DSM-IVR (American Psychiatric Association, 2000)
criteria for D.I.D. diagnosis include:
¾ 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 the self, and
16
What Is D.I.D.?
¾ at least two of these identities
recurrently take control of the
individual’s behaviour, and
¾ an inability to recall important
personal information that is too
extensive to be explained by
ordinary forgetfulness, and
¾ in children, the symptoms are
not attributable to imaginary
playmates or other fantasy play
17
What Is D.I.D.?
• the different dissociated states are not fully formed
personalities; rather they represent a fragmented
sense of identity
• the amnesia of D.I.D. is called asymmetrical, since
the different personality states hold the memory of
different aspects of the individual’s experiences
18
What Is D.I.D.?
• there is usually a “host”
personality who
identifies with the
child’s real name and
who is typically unaware
of the other alters
19
What Is D.I.D.?
• sudden shifts to
alter personalities
are usually
triggered by
environmental
events
20
What Is D.I.D.?
• the different personalities often serve
distinctive roles, such as the student,
the “good” girl, the “bad” girl, the
creative one, the athletic one, etc.
• in adults seeking help in the U.S.A.,
on average there are 2 to 4 alters
present at the time of diagnosis, with
13 to 15 more emerging over the
course of treatment
21
What Is D.I.D.?
• while acknowledged by many that
D.I.D. can occur in children, childspecific criteria have yet to be
included in the DSM
• children are most often diagnosed
with Dissociative Disorder Not
Otherwise Specified (D.D.N.O.S.)
instead, although this category also
lacks child-specific criteria
22
What Is D.I.D.?
• amongst professionals there is no
agreement on a typical presentation
for childhood D.I.D. and, therefore, no consensus
about appropriate diagnostic criteria
• the International Society for the Study of
Dissociation (ISSD) has developed guidelines for the
assessment and treatment of dissociative symptoms
in children and adolescents (ISSD Task Force, 2004)
23
What Causes D.I.D.?
• stems from a combination of
biological and environmental factors
that impact the caregiver-child
attachment system and disrupt the
development of self-regulation of
emotion
• no evidence of a genetic link
• most common environmental factors
are repetitive childhood physical
and/or sexual abuse and/or other
forms of trauma
24
What Causes D.I.D.?
• may also develop when there is
severe neglect and emotional abuse
without physical or sexual abuse
• as well, may occur in families
where parents are frightening, are
unpredictable, are dissociative
themselves, or make highly
contradictory demands
25
What Causes D.I.D.?
• can be considered an adaptive coping
skill because dissociation reduces the
overwhelming distress in traumatic
situations, allowing the child to
survive extreme psychological blows
• core issue is lack of ability to tolerate
and regulate intense emotional
experiences
26
What Causes D.I.D.?
Reasons for this inability to self-regulate include:
¾ research linking maladaptive attachment patterns to
dysfunctional brain development that may inhibit
integrative connections in a developing child’s brain
(Stein & Kendall, 2004)
27
What Causes D.I.D.?
¾ having had little opportunity to
learn to self-soothe or modulate
feelings due to growing up in
an abusive and/or neglectful
environment where regulation
skills were not modelled or
taught
¾ the sudden intrusion of
traumatic memories and their
accompanying overwhelming
emotions
28
What Causes D.I.D.?
• we need to remember - each child’s reaction to life
experiences is idiosyncratic
and what overwhelms one
child may not overwhelm
another and responses vary
from situation to situation
29
What Causes D.I.D.?
• severe dissociation during a
traumatic experience increases the
likelihood of generalization of this
coping mechanism to subsequent
situations
• the experience of on-going trauma
in childhood significantly increases
the probability of developing
dissociative disorders in adulthood
30
Signs and Symptoms
D.I.D.-Specific Symptoms
A. Trance States or “Black
Outs”
• range from momentary
absences of attention (as in all
children), to longer periods of
non-responsiveness, to
excessive sleeping or fainting,
to coma-like states
31
D.I.D.-Specific Symptoms
B. Amnesia and Transient
Forgetting
• true amnesia is rare and
diagnostic of severe dissociation
• loss of memory for traumatic
events is more common
• transient forgetting, which
disappears with minimal
intervention, is most common
32
D.I.D.-Specific Symptoms
¾ for example, a caregiver may report
the child has no memory of an event
or the child may use “I forget” as a
distraction from focusing on the
trauma, out of guilt or shame over
what occurred, or because of
discomfort with the person with
whom he/she is talking
• forgetting positive events, not just
misbehaviour or anger outbursts, is
indicative of true amnesia
33
D.I.D.-Specific Symptoms
C.Imaginary/Fantasy Friends
• important to differentiate between normal “imaginary
friends” and fantasy from pathological dissociative
symptoms
• a dissociative disorder is
suggested when:
¾ fantasy interferes with
normal activity
34
D.I.D.-Specific Symptoms
¾ when the child feels the behaviour is out of his/her control
¾ when imaginary playmates are experienced as real
¾ when the imaginary entities are perceived as being in
conflict with one another
35
D.I.D.-Specific Symptoms
D.Identity Alteration and State
Changes
• child may report feeling the
presence of others/alters/ego
states/personalities internally or of hearing conversations
going on ‘inside’
• child may visibly shift behaviour and/or affect
• important to determine:
¾ what stimuli elicit shifts in state, mood, ability, or
perceived identity
36
D.I.D.-Specific Symptoms
¾ what purpose the state shift serves (e.g.
expression of anger, elicit nurturing of
caregivers, allow helplessness,
avoidance, etc.)
¾ what the child’s memories are of the
shift
¾ what the child’s subjective sense is of
the discontinuity and what occurred
after the shift. Children often
experience shifts as dramatic,
uncontrollable, and puzzling
37
D.I.D.-Specific Symptoms
¾ whether the child is able to make internal connections
between states (have “co-consciousness”)
• sudden regression, rageful behaviour, apparent loss of
consciousness, or suddenly talking about oneself in the
third person (“he/she”, “him/her”, “we”, “they”, “us”), by a
different name, or as a different age or gender are highly
suggestive of D.I.D.
38
D.I.D.-Specific Symptoms
E. Depersonalization and Derealization
• depersonalization is the sense of being detached
from one’s body
• derealization is the sense of the external world not
being real
39
D.I.D.-Specific Symptoms
• need to ensure that substance abuse
is not a confounding factor
• also, self-harming behaviours may
be used to make the self be
present in the body and confirm
one’s existence
40
D.I.D.-Specific Symptoms
F. Somatic Complaints
• may complain of or display:
¾ headaches and other body aches and pains, and
“body memories”
¾ stomach aches/
digestive problems
¾ dizziness
¾ ringing in the ears
41
D.I.D.-Specific Symptoms
¾ exaggerated startle response
¾ visual disturbance
¾ tiredness due to not sleeping,
nightmares, lack of restorative
sleep, and/or insomnia
¾ loss of physical sensation
42
D.I.D.-Specific Symptoms
¾ agitation or restlessness
¾ visual-motor coordination
difficulties
¾ unusual pain tolerance or
sensitivity
¾ sensory-perceptual anomalies,
such as smelling unusual odors
inconsistent with the
environment or situation
43
D.I.D.-Specific Symptoms
G.Post-Traumatic Stress Disorder (PTSD) Symptoms
• any of the physical, cognitive,
emotional, and/or behavioural
symptoms associated with PTSD
may also be present in a child
with D.I.D. at any given time and
depending on the self that is present
and the situation
44
PTSD Symptoms
• in addition to the somatic symptoms noted previously,
the following is a list of PTSD signs and symptoms one
might encounter when assessing for D.I.D.:
a) Physical (in addition/instead of those listed previously
under Somatic Symptoms)
• increase or decrease in appetite,
with or without associated weight
gain or loss
• palpitations
45
PTSD Symptoms
•
•
•
respiratory difficulties
lethargy and lack of energy
oral discomfort (sensitive gag
reflex, sensation of choking)
dyspareunia (painful sexual intercourse)
dysmenorrhea (painful menstruation)
erectile dysfunction
enuresis/encopresis (wetting/soiling oneself)
•
•
•
•
46
PTSD Symptoms
•
•
•
•
•
•
•
chills
sweating
unexplained rashes/bruises
tremors
seizures
changes in care of physical appearance/hygiene
changing food sensitivities and allergies
47
PTSD Symptoms
b) Cognitive
• profound psychic
numbing
• inability to concentrate
• indecisiveness
• difficulty problemsolving
• slowed thinking
• paranoia
48
PTSD Symptoms
•
•
•
•
•
distrust
nightmares/night terrors
physical/auditory/visual hallucinations
memory gaps/poor short-term memory
confusion
49
PTSD Symptoms
•
•
•
•
•
disorientation, particularly regarding time and space
preoccupation with thoughts of the event(s)
changes in personal belief and value systems
sense of a severely limited future
belief that self is flawed or “damaged”
50
PTSD Symptoms
• belief that the self is worthless, useless, and/or
unlovable
• lack of empathy for self
• suicidal/homicidal ideation
51
PTSD Symptoms
c) Emotional
• persistent, intense fear and
anxiety
• strong feelings of vulnerability
• feeling “out of control”
• feeling lost/abandoned/alienated
• feeling damaged, worthless,
and/or unlovable
52
PTSD Symptoms
•
•
•
•
•
•
•
feeling numb or detached
intense feelings of guilt
feeling irritable
feeling agitated or restless
feeling angry/intense rage/homicidal
feeling worried, particularly regarding others
feeling sad
53
PTSD Symptoms
•
•
•
•
feeling grief
feeling hopeless
feeling depressed
feeling inadequate/not
good enough
• feeling suicidal
54
PTSD Symptoms
d)
•
•
•
•
•
•
•
Behavioural
regression
intense, “wired” appearance
hyper-vigilance
fearful of specific people, places, things, or situations
flat affect (that is, unexpressive/unemotional)
ritualized behaviours
issues/rituals regarding eating
55
PTSD Symptoms
• clingy/difficulty separating
from caregivers
• crying easily
• ritualized and/or repetitive reenactment of trauma in
play/art
• “dark” themes in
play/writing/drawing/music
• social isolation/withdrawal
56
PTSD Symptoms
• lack of participation in activities once
found pleasurable
• cutting and other self-harming
behaviours to regulate emotion, to
facilitate dissociation, or to interrupt it
• self-medicating with alcohol or drugs
• “out-of-character” risk-taking
behaviours
• interest in Satanism and/or cults
57
PTSD Symptoms
• mood swings
• defiant and oppositional behaviours
• inability to get along with others, particularly in close
relationships
• anger outbursts/increased aggression or violence
or
• extreme passivity
• failure to thrive in infants/small
children
58
PTSD Symptoms
• sexually reactive or offensive
behaviours
• selective mutism
• poor school attendance
• decline in grades at school
• talking/writing/drawing about
death, suicide, or homicide
• suicide or homicide
attempt/successful suicide or
homicide
59
How Caregivers Can Help
• safety is of primary concern.
Protection of the child from further
traumatization and dissociation must be the first priority.
• whenever possible, participate in family therapy to:
¾ learn about dissociation and D.I.D.
¾ develop parenting strategies that will facilitate the child’s
healing
¾ learn to accept all aspects of the child
60
How Caregivers Can Help
¾ correct inter-active patterns that encourage dissociation
¾ process feelings of guilt or
denial regarding the child’s
trauma, which may require
the acknowledgement of trauma
that occurred within the family
and an apology for the lack of protection given the child
¾ build trust and open communication between family
members
61
How Caregivers Can Help
Caregivers need to
• recognize that the parts belong to
the whole child and, therefore, to
interact with the entire person, not
a specific part
• hold the whole child responsible
for behaviours
62
How Caregivers Can Help
• consistently set and enforce limits on behaviour,
despite the child’s frustration at this, as the
frustration leads to awareness (co-consciousness)
and then to change and integration
63
How Caregivers Can Help
• be cognizant of the context in
which the child may be
triggered and set designated
times/places to discuss
unpleasant experiences so that
the child is not likely to
experience a flashback or so
that such discussions do not
interfere with day-to-day
functioning
64
How Caregivers Can Help
• learn to recognize the child’s triggers and encourage the
child to use positive methods of affect regulation in place
of dissociation or other maladaptive coping skills such as
self-harming or substance abuse
• develop code words to use as cues for the child that a
shift has occurred, thereby increasing the child’s
awareness
65
How Caregivers Can Help
•
•
foster the appropriate
expression of feelings
within the home by all
family members
model healthy self-care. It
will give you the energy
and calm needed to help
your child, as well as teach
your child coping skills and
instil hope for the future.
66
What Professionals Can Do
“Vengeance stares out of a teenager’s eyes as her mind switches
faces and vents anger on the woman and child she has found.
End the silence, let them tell of the violence; end the lies, let
them remove the disguise; end the shame, let them redirect
blame.
Never! Screams that scared, angry teenager who’s guarded all
the secrets down through the years.
Send her a message God, if you’re there, if you care. Let her
know it’s okay to open the gates of her soul and release the
pain stored in her unshed tears.”
©1/12/95 kellen&co/kate17
67
Assessment
• an assessment for D.I.D., at a minimum, must include
¾ an extensive exploration of the child’s history as told
by the child, caregivers, and any other relevant
persons
¾ exploration of co-morbid
conditions
¾ a thorough medical evaluation
• may also include screening tests and/or psychological
testing
68
Assessment
History
• needs to include enquiry about:
A.Child’s and Caregivers’ Perceptions of Her/His
Difficulties
¾ trauma history
¾ imaginary friends and transitional objects
¾ hallucinations (auditory, visual, physical, olfactory)
¾ puzzling forgetfulness
69
Assessment
¾ intrusive thoughts and feelings
¾ numbing
¾ flashbacks
¾ anxiety
¾ nightmares
¾ self-injury
¾ somatic concerns
70
Assessment
¾ sexual concerns
¾ depersonalization
¾ derealization
¾ identity alteration/confusion
B. Family Environment
¾ physical/emotional safety
¾ dysfunctional family patterns
71
Assessment
¾ family history of mental illness
¾ family secrets impacting the child
¾ sources of external support
¾ practices/beliefs that are
unusual for the family’s
culture/ethnicity
72
Assessment
C. Knowledge of Dissociation
¾ familiarity with information
from books, movies, the internet,
and family conversations
¾ family’s investment in/interest
in/understanding of dissociation
¾ multi-generational history of
dissociation
73
Assessment
D.
¾
¾
¾
Child’s Functioning
in school
in the community
with peers
E.
¾
¾
¾
Other Contributing Factors
predisposing factors
precipitating factors
perpetuating factors
74
Assessment
Co-Morbidity
• co-morbidity is common with
D.I.D.
• disorders often co-morbid include:
¾ PTSD
¾ Obsessive-Compulsive Disorder
(OCD)
¾ eating disorders
¾ Reactive Attachment Disorder
(RAD)
75
Assessment
¾ Attention-Deficit
Hyper-Activity Disorder
(ADHD)
¾ affective disorders
¾ substance abuse
disorders
¾ specific developmental
disorders
76
Assessment
Medical Evaluation
• Must rule out medical disorders that mimic
dissociative symptoms, including:
¾ seizure disorders
¾ other neurological conditions
¾ allergies
¾ exposure to toxins
¾ legal/illegal drug effects
77
Treatment
•
•
•
physical/emotional safety
supersedes all other work
any treatment for
dissociation in children
must include consideration
of developmental issues
a safe, empathic, nonjudgemental and consistent
therapist and therapeutic
environment are key
78
Treatment
• therapy needs to be directed toward
providing new inter-personal
relationships that foster integration
and coherence of the self, and that
improve adaptation/flexibility in
managing affect
• a team approach employing all
significant people in the child’s world
is very important
79
Treatment
• a combination of play, expressive arts
(drama, dance, visual arts, music), and
cognitive behavioural techniques, perhaps also including
Eye Motion Desensitization and Reprocessing (EMDR)
and/or hypnosis by very experienced clinical
practitioners to access feeling states and encourage safe
integration or for the containment of intense affect, for
ego strengthening, for education, or for support (but
NOT for memory retrieval), together with family
therapy whenever possible, are noted as being effective
80
Treatment
• a behaviour modification treatment model is, in most
cases, inadequate for the treatment of D.I.D. as it
does not address identifying the feelings, trauma
triggers, or internal states that lead to maladaptive
behaviours
81
Treatment
• Goals of therapy for D.I.D.
include:
¾ helping the child to acknowledge
previously disowned emotions and
experiences and to learn
increasingly adaptive, flexible
ways to manage affect
¾ decreasing the child’s use of selfdestructive and disruptive
behaviours
¾ increasing personal responsibility
82
Treatment
• eventually, achieving developmentally-appropriate
integration of past, present, and new experiences so
normal development can proceed
83
Medication
• Medications tend to be used to
treat specific symptoms,
particularly those of PTSD,
depression, anxiety, and
perhaps ADHD
84
Medication
The medications most often prescribed are
• an SSRI anti-depressant for anxiety, depression,
avoidance behaviour, and intrusive recollections;
• a beta-adrenergic-blocking agent for hyper-arousal;
• an alpha-adrenergic agonist for inattention and
hyperactivity; and/or
• a mood stabilizer for
arousal, impulsivity, and
dissociation.
85
“. . .
You want to know why you can’t feel.
I’ll tell you why when you ask,
Because it’s been part of my task.
Find the words that are buried deep.
Tell the reasons we can’t weep.
It all started long ago
When we first learned we couldn’t say no.”
©3/28/06 kellen&co/Rhyne - 12
86
References
Alexander, D.W. 1999. Children changed by trauma: A healing
guide. Oakland, CA: New Harbinger Publications, Inc.
American Psychiatric Association. 2000. Diagnostic and
statistical manual of mental disorders, fourth edition, text
revision. Washington, DC: American Psychiatric Association.
Bryant, D., J. Kessler & L. Shirar. 1992. The family inside:
Working with the multiple. New York, NY: W.W. Norton &
company, Inc.
Carion, V. 2007. Severe PTSD damages children’s brains: Study.
Bio-Medicine, April 3, 2007. (see www.bio-medicine.org)
87
References
Gil, E. 1996. Treating abused adolescents. New York, NY: The
Guildford Press.
International Society for the Study of Dissociation (ISSD). 2004.
Guidelines for the evaluation and treatment of dissociative
symptoms in children and adolescents. Journal of Trauma &
Dissociation. 5(3):119-150.
James, B. 1994. Handbook for treatment of attachment-trauma
problems in children. New York, NY: The Free Press.
Kluft, R.P. 1984. MPD in childhood. Psychiatric Clinics of
North America. 7:9-29.
88
References
Putnam, F.W. 1997. Dissociation in children and adolescents.
New York, NY: Guilford Press.
Schore, A. 2001. The effects of early relational trauma on right
brain development, affect regulation, and infant mental
health. Infant Mental Health Journal. 22:201-269.
Shirar, L. 1996. Dissociative children. New York, NY: W.W.
Norton & Co.
Silberg, J.L. (Ed.). 1998. The dissociative child: Diagnosis,
treatment, and management, second edition. Lutherville,
MD: Sidran Press.
89
References
Stein, P. 7 J. Kendall. 2004. Psychological trauma
and the developing brain: Neurologically-based
interventions for troubled children. Binghamton,
NY: Haworth Press.
Williams, D.T. & L. Velazquez. 1996. The use of
hypnosis in children with dissociative disorders.
Child & Adolescent Psychiatric Clinics of North
America 5:495-508
Web Sites
www.childtrauma.org
www.isst-d.org
90
Contact Information
Lindsay Hope-Ross, M.Sc., R. Psych.
Clinical Lead
Healthy Minds/Healthy Children Outreach
Richmond Road Diagnostic and Treatment Centre
1047 – 1820 Richmond Road S.W.
Calgary, AB T2T 5C7
Phone: 403-955-8644
Fax: 403-955-8184
E-mail: lindsay.hope-ross@albertahealthservices.ca
91
Community Education Service
To register for notification or an upcoming
education session go to:
www.fcrc.sacyhn.ca
For general CES enquiries Email:
ces@sacyhn.ca
Call: 403-955-7420
92