Dissociative Identity Disorder Case Study

 

Case Summary/Case Conceptualization

Identifying Information:  Kevin is a thirty-something-year-old, single, Caucasian male; referred to Gibson Center for Wellness mandated by the court system as part of his sentencing.  Kevin reports living alone underneath the Philadelphia Zoo, where he works, in the basement of the maintenance building. Kevin states he has never been married and does not have a relationship with his mother or father.  Kevin is dressed neatly in khakis pants, turtle next shirt and cardigan sweater.  His shoes appeared clean and slightly worn for normal wear and tear.  He is currently unemployed due to emotional stress related to an incident which involved two female students that visited his place of employment.

Background, Family, Information, and Relevant History:   Kevin reports a history of childhood abuse by his mother; she suffered from obsessive-compulsive disorder (OCD).  Kevin states his father abandoned his as a child aboard a train.  Kevin says his mother would demand him

Goals for Counseling and Course of Therapy:  Kevin reported to agency counselor conducted the initial Comprehensive Clinical Assessment to determinate appropriate clinical diagnosis.  Additionally, Kevin and therapist will collaboratively devise treatment plan as well as goals for treatment.

Summary

Kevin sought treatment after recognizing his alter personalities has been in the light for some time.  Most recently, he states further that recently he kidnapped three female teenagers and held them captive underneath the Philadelphia Zoo, where he works, in the basement of the maintenance building.  He reports he has evidence of 23 alternative personalities and there is a discussion of a superhuman 24 “The Beast.”  He states each of his alternative personalities has their distinct characteristics and psychological profiles.  In the past, he has been stable able to keep the personalities under control.

In the past, Kevin saw a psychiatrist, Dr. Karen Fletcher regularly who believed he was stable compared to others with same concerns.  Barry is one of Kevin’s multiple personalities, this particular personality is a sketch artist and has a prevalent Boston accent. He meets with Dr. Fletcher usually during a therapy session.  Another personality is known as Patricia, a friendly British woman. Finally, another prominent personality is Hedwig, who present mannerisms of a 9-year-old boy. He tells the prisoners that Patricia and Dennis are upset at him and that he is in trouble.

Kevin discuss his father, who abandoned him as a child aboard a train, which he believes led the other personalities eventually “The Beast” is significant inside a train car. Kevin recognizes the personalities began manifesting to help cope with the abuse he experienced to by his mother, who he states suffered from obsessive-compulsive disorder. Kevin says there are times certain characteristics are displayed and will pretend to be another.  For example, “Dennis” typically who usually show features of OCD but sometimes attempt to convince therapist he is Barry. The collaboration of numerous factors together with overwhelming stress; the capability to disconnected one’s recollections, observations, or identity from mindful awareness; irregular psychologic development; and inadequate protection and nurture during childhood have been identified in the formation of DID (Pais, 2009).

Kevin reports the police reports describes how “The Beast” first killed and ate Marcia, and then Claire human flesh. Later, Casey found Dr. Fletcher’s corpse, and it is believed “The Beast” crushed killed her as well.  Dr. Fletcher left a note stated to call “The Beast,” “Kevin Wendell Crumb.” At that time, Kevin says he felt like waking from a horrific dream and was shocked by his actions, then asked Casey to kill him before his other personalities begin to take over.   Then her states, Casey reported Kevin switched from several different personalities until “The Beast” returns and corners Casey after she gets the shotgun. Casey attempts to shot him at point blank range, to which she was unsuccessful.”  Finally, “The Beast” prepares to consume Casey when he notices numerous scars on her trunk and rejoices in the fact that she is “untainted.”  Finally,  “The Beast” leaves and spare Casey.  At that point, Kevin states he wakes in a jail cell distraught over all that he has done.

Diagnosis

Based on the information provided by the client, his primary diagnosis is Dissociative Identity Disorder 300.14 (F44.81).  The client was given the diagnosis due to meeting the following criteria (Association, 2013):

• 300.14 (F44.81) Dissociative Identity Disorder (DID)
  • Criteria A: The client has evidenced 23 different personalities, each with various characteristics.  Kevin’s body chemistry changes with each personality, finally revealing the 24^th character, some listed below:
    • “The Beast,” a personality that presents superhuman levels of strength, speed, mobility, and a practices cannibalism.
    • “Hedwig,” a personality who behaves as a nine-year-old boy
    • “Patricia,” a personality that claims to be a well-mannered British woman and wears a skirt and high heels.
    • “Dennis,” a personality that he enjoys to watch young girls dance naked, and he has both violent tendencies and obsessive-compulsive disorder. “Barry,” a personality that is a sketch artist with a thick Boston accent.
  • Criteria B:  There was evidence of significant gaps in Kevin’s recall.
  • Criteria C:  The symptoms cause clinically significant distress or impairment in social, occupational, or important areas of functioning.  This is evident in the job loss, inability to have interpersonal relations.
  • Criteria D:  The client symptoms are not attributed to cultural or religious practices.
  • Criteria E:  The client’s symptoms are not attributable to the physiological effects of a substance or another medical condition.

Additional contributing factors:

• V62.29 (Z56.9) Other Problems Related to Employment
  • Kevin is currently unemployed after an incident with two female students.  Client had difficulty overcoming the emotions related.
• V40.31 (Z91.83) Wandering Associated with a Mental Disorder
  • The customer’s reports wandering when the alter personality “The Beast,” is in the light and the client is unable to recall the events.
• V15.41 (Z62.810) Personal history (past history) of physical abuse in childhood
  • The client was a victim of childhood abuse by his mother who suffered from obsessive-compulsive disorder. Then his father abandoned him as a child aboard a train.

Differential Diagnosis

The clinician working with this client may consider factitious disorder and malingering.  However, per American Psychological Association (2013) individual who pretends DID do not report the subtle symptoms of intrusion features of the disorder; instead, they tend to overreport well-publicize symptoms of the disorder, such as dissociative amnesia, while underreporting less-publicized comorbid symptoms, such as depression.  Additionally, individuals who attempt to fake dissociative disorder tend to be relatively undisturbed by or may even appear to enjoy “having” the disorder.  On the other hand, individuals who malinger DID usually creative limited, stereotyped alternate personalities, with pretend amnesia, related to events (2013).

Case Note

Purpose

The purpose of today’s session was to develop a level of trust through consistent eye contact, active listening unconditional positive regard, and warm acceptance (Jongsma A. E., 2014).  The client began to express feelings more freely as rapport and confidence level have been increased.  The client will improve his overall emotional and behavioral functioning by actively participating in the therapeutic process.

Intervention

Today’s clinical contact focused on building the level of trust with the client through consistent eye contact active listening, unconditional positive regard, and warm acceptance (2014). The client was asked to describe the various personalities that take control of him and the circumstances under which this occurs.  A functional analysis was conducted with the variables associated with the client’s dissociative states.  The customer’s level of insight toward presenting problems was assessed.  The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.

Assessment

Psychological testing was administered to assess the presence and strength.  The client has been evaluated for evidence of research-based correlated disorders.  The severity of the customer’s impairment has been evaluated to determine the appropriate level of care.  The feelings and circumstances that tend to trigger the customer’s dissociation state were explored.  The customer’s sources of emotional pain/trauma and feelings of fear, rejection, inadequacy, or abuse were explored.  The client was assisted in making an insightful connection between his dissociation disorder and the avoidance of facing unresolved emotional conflicts.  As the customer stayed focused on reality, rather than escaping through dissociating, he was reinforced.  The client was taught several different relaxation techniques to be used to reduce muscle tension and assist in anxiety management.

Treatment Goals and Objectives

Short-term

1. Kevin will identify each personality and have each one tell its story.
   • The therapist will actively build the level of trust with the client in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his ability to identify and express feelings.
2. Kevin will identify the key issues that trigger a dissociative state.
   • The therapist will explore the feelings and circumstances that trigger the client’s dissociative state.  The therapist will assist the customer in accepting a connection between his dissociating and avoidance of facing emotional conflicts/issues.
3. Kevin will practice relaxation and deep breathing as means of reducing anxiety.
   • The therapist will train the client in relaxation and deep breathing techniques to be used for anxiety management.
4. Kevin will verbalize acceptance of brief of dissociation as not being the basis for panic, but only as passing phenomena.
   • The therapist will teach the client to be calm and matter-of-fact in the face of brief dissociative phenomena so as to not accelerate anxiety symptoms, but to stay focused on reality.

Long-term

1. Integrate the various personalities.
2. Reduce the frequency and duration of dissociative episodes.
3. Resolve the emotional trauma that underlies the dissociative disturbance.
4. Reduce the level of daily distress caused by dissociative disorders.

Evidence-Based Best Practices (EBBP)

The primary treatment modality for DID is individual outpatient psychotherapy. The best treatment approach includes psychotherapy, group therapy, expressive therapies such as creative art therapy, family therapy, clinical hypnosis, psychoeducation, and pharmacotherapy. The frequency of sessions and interval of treatment may depend on some variables, including the patient’s characteristics, the abilities and preferences of the therapist, and external factors such as insurance and other financial resources and the availability of skilled therapists. DID patients vary widely in their motivation, resources for treatment, and comorbidities, all of which affect the course of therapy (Harper, 2011). Treatment methods depend on the individual and the severity of their symptoms and usually includes some mixture of the previously stated modalities. The minimum frequency of sessions for many DID patients weekly 45- 50-minute session. However, some therapists have found extended sessions (e.g., 75-90 minute) to be beneficial (Dissociation, 2011).

EMDR has many potential benefits in the treatment of DID. EMDR has the ability change trauma based distortions in self-representation, increasing associative linkages to the adaptive material, and facilitating the incorporation of processed traumatic material into alternate identities.  Also, EMDR enhances the creation of new behaviors by enabling individuals to process previous traumatic experiences and their current triggers and then develop new patterns of desired skills or behaviors (Dissociation, 2011).

The focus of psychotherapy is to help the customer recognize what may have caused this illness and find new ways of coping with stressful situations that can activate dissociation (Pais, 2009).  The primary approach to treatment interventions utilized for DID are phase-oriented (Harper, 2011).  There are three phases to the phase-oriented treatment of structural dissociation, and in all phases, it is crucial. The phases do involve periodic returning to earlier phases as an essential component of the treatment is that clients must learn skills to tolerate strong affect, thoughts, and sensations, rather than avoiding them.  Phase 1 involves symptom reduction and stabilization which dealing with the phobia of trauma-related mental actions.  Overcoming the phobia of trauma-related psychological effects means helping an individual with emotions, thoughts, body sensations, and memories they may have avoided (2011).

Next, Phase 2: treatment of traumatic memories This step that involves overcoming the phobia of traumatic memories is complicated and full of potential pitfalls. The actual treatment of traumatic memory includes both guided synthesis and guided realization. Guided synthesis involves controlled exposure to the traumatic memory so that it is not experienced as overwhelming.

Then Phase 3: Integration and rehabilitation involes the final phase begins when the majority of a survivor’s traumatic memories have become autobiographical narratives. The survivor is encouraged to let go of unhelpful beliefs and behaviors and to engage in the world with new coping skills.

For the treatment of DID and other dissociative disorders, the most well-known CBT intervention is the Tactical-Integration model which has a foundational blueprint which is a modified cognitive therapy module

Patients with DID do poorly in unspecified treatment groups that include individuals with complex diagnoses and clinical problems. Many DID patients have difficulty tolerating the strong effects elicited by traditional process-oriented psychotherapy groups or those that encourage dialogue, even in a limited way, of participants’ traumatic experiences. Some such therapy groups have resulted in symptom exacerbation and dysfunctional relationships among group members.

Medication

Currently, there are no listed drugs to treat dissociative disorders individually. However, individuals with dissociative disorders, particularly those with associated depression and anxiety, may benefit from treatment with antidepressant or anti-anxiety medications.  According to (Gentile, 2013), the following are Pharmacologic Treatment of DID:

• Antidepressants/anxiolytics (e.g., selective serotonin reuptake inhibitors, non-selective reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors) treat comorbid symptoms, stabilize mood, and reduce unpleasant symptoms, hyperarousal, and anxiety. For example, sertraline is a SSRI used for depression.  The usual adult dose of Sertraline initial dose: 50 mg orally once a day and maintenance dose: 50 to 200 mg orally once a day.  According to Drug.com, list the following commonly reported side effects of sertraline include: diarrhea, dizziness, drowsiness, dyspepsia, fatigue, insomnia, loose stools, nausea, tremor, headache, paresthesia, anorexia, decreased libido, delayed ejaculation, diaphoresis, ejaculation failure, and xerostomia (Publications, 2016).
• Benzodiazepines use with caution to decrease anxiety; this medication class may exacerbate dissociation. Xanax XR is a common drug used to treat anxiety disorders.  (Publications, 2016), list the following as common side effects of Xanax XR include: depression, diarrhea, drowsiness, dysarthria, headache, insomnia, memory impairment, nervousness, sedation, and tremor.
• Beta-blockers, clonidine stabilize mood and reduce intrusive symptoms, hyperarousal, and anxiety.
• Atypical (second generation) antipsychotics stabilize mood and reduce overwhelming anxiety and intrusive symptoms.
• Prazosin is effective in reduction of nightmares.
• Carbamazepine and other mood stabilizers can be helpful to reduce aggression, intrusive symptoms, hyperarousal.
• Naltrexone used to reduce self-injurious behavior

References

Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (5th Ed). Washington DC: American Psychiatric Association.

Dissociation, I. S. (2011). Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, 115-187.

Gentile, J. D. (2013). Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Clinical Neuroscience, (10) 22-29.

Harper, S. (2011). An examination of structural dissociation of the personality and the implications for cognitive behavioural therapy. The Cognitive Behaviour Therapist, 4:53-67.

Jongsma, A. E. (2006). The complete adult psychotherapy treatment planner. New Jersy: John Wiley and Sons, Inc.

Jongsma, A. E. (2014). The adult psychotherapy progress notes planner. New Jersy: Wiley.

Pais, S. (2009). A systemic approach to the treatment of dissociative identity disorder. Journal of Family Psychotherapy, 20:72-88.

Publications, H. H. (2016). Drugs.com. Retrieved from Drugs.com: www.drugs.com