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Dissociative Identity Disorder: Ethically Unsplitting the Split Personality
Dissociative Identity Disorder continuing education addiction counselor CEUs

Manual of Articles Sections 15 - 28
Section 15
Understanding Dissociation

CEU Question 15 | CEU Answer Booklet | Table of Contents | DID
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

What exactly is dissociation?
According to the international version of the Diagnostic and Statistical Manual of Mental Disorders, 'the essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of multiple personalities Dissociative Identity Disorder mft CEUconsciousness, memory, identity, or perception of the environment'. Put simply, dissociation is a psychological mechanism that allows the mind or body to split off or compartmentalize traumatic memories or disquieting thoughts from normal consciousness.

DSM lists five dissociative disorders:
Dissociative Amnesia — distinguished by a persistent loss of memory of significant personal information, typically of a traumatic or stressful nature, that is too all-embracing to be explained by normal absent-mindedness.

Dissociative Fugue — defined by an abrupt, non-scheduled journey away from one's home or usual place of work, accompanied by a loss of memory of one's past, confusion over one's identity, or assuming a new identity.

Dissociative Identity Disorder (DID — formerly Multiple Personality Disorder) is the most extreme form of dissociation. It is characterized by two or more separate identities or personality states that recurrently take control of the individual's behavior, accompanied by a loss of memory of significant personal information that is too all-embracing to be explained by normal absent-mindedness.

Depersonalization Disorder — defined by an unrelenting or frequent feeling of disconnection/detachment from oneself (mind-body split), during which reality testing remains intact. Depersonalization is sometimes accompanied by derealisation (a sense that the external world feels strange or unreal).

Dissociative Disorder Not Otherwise Specified (DDNOS). This term is used to classify disorders where dissociative symptoms are a predominant feature but do not meet the criteria for any specific Dissociative Disorder. Paraphrased from APA criteria (pp. 489-503)

Etzel Cardeña gives this concise definition of dissociation: 'In its broadest sense, 'dissociation' (Janel's désagrégation) simply means that two or more menial processes or contents are not associated or integrated.’

Dissociation in relation to self-injury
It is becoming increasingly recognized that dissociative processes — particularly dissociative amnesia, depersonalization, and derealisation can underpin self-injury (for example, self-cutting or burning). People who experience depersonalization 'have disconcerting feelings of being detached from their bodies and mental processes'. (Favazza, 1996, p. 247)[sup4] Indeed, many self-injurers report, feeling 'emotionally numb', 'detached from themselves' or 'dead inside' prior to the act;  feeling little or no physical pain during the act, and feeling more alive, more real, and more grounded following the act. Looking at self-injury in this light, we can see that it serves an important role in terminating dissociative episodes — which by all accounts are very unpleasant and frightening. Judith Herman, in her landmark book Trauma and Recovery (1994)[sup5], whilst discussing dissociation and self-injury within the framework of major childhood trauma, identifies the sequence described: 'Survivors who self-mutilate consistently describe a profound dissociative state preceding the act. Depersonalization, derealisation, and anesthesia are accompanied by a feeling of unbearable agitation and a compulsion to attack the body. The initial injuries often produce no pain at all' (p. 109)

Rachael, a participant in my current research into self-injury, gave this response when invited to explain how she felt prior to her most recent episode of self-injury:  'I am not exactly sure how I felt specifically this time. I do know that during previous times, I have felt spacey, not part of myself, and detached... this feeling is hard for me to explain. It is almost as if it is not "me"... it feels like something else has taken over and I no longer control it... it feels as if "I" am not really present during the time.'

For purposes of clarity, probably one of the best explanations of the relationship between dissociation and self-injury comes from Ruta Mazelis (1998)[sup6] author of The Cutting Edge: A Newsletter People Living with Self-Inflicted

Violence: 'Whereas SIV [self-inflicted violence] is used as a coping mechanism to manage excruciating emotional slates, it can also serve to alter feelings of profound numbness or deadness... SIV seems to be an effective tool for managing dissociation in both directions — to facilitate it when emotions are overwhelming, as well as lo diminish it when one feels too disconnected from oneself and the world.'

In a clinical setting, depersonalization may be described in terms of 'looking down or in on oneself', 'standing beside oneself, 'outside oneself, 'blank spells', or as a 'floaty, foggy, dazed out, phased out, zoned out, or trance-like feeling.' In some cases, the 'I' may be dissociated — for example 'she is not me'.

In derealisation the environment may be experienced as two-dimensional, strange, unreal, or The individual may perceive an uncanny alteration in the size and shape of objects'. (DSM, p. 500) In this context self-injury can serve as an extreme grounding technique to bring oneself back to the here-and-now ('I do exist", 'I am alive/real').

Amnesia, self-injury and DID
Some individuals who engage in self-injury are amnesic during the act, reporting that they feel shocked when they realize they have injured themselves, or describing how they wake up in a pool of blood without knowing they have hurt themselves. In the case of self-injurers with Dissociative Identity Disorder (DID), one hypothesis is that a persecutory 'alter" personality may punish the "host" personality or another 'alter" in the system (for example, if the 'host' or an 'alter' discloses abuse to a therapist during the course of treatment).

Jessica, a research participant diagnosed with dissociative identity disorder, describes the process of amnesia during the act, due to an 'alter' personality taking control: 'I have DID and there is an alter... Sometimes when I consciously self-injure she will come out and take over and finish the job. I will not know what damage has been done until I wake up the next day. I become so detached that it is like I become in a trance-like state and it is like I am watching someone else doing the cutting.'

Interestingly, Ross (1997,p.151)[sup7] argues that, 'the persecutor's underlying motivation is actually positive'. This is a view I share and if we return to the example given above, one positive scenario might be that the persecutory 'alter' believes she/he is acting in the 'host's' best interests. In other words, she/he is trying to prevent the truth coming out about the abuse for fear of 'not being believed' or other possible dire consequences (for example, the 'system' being emotionally overwhelmed or flooded with memories, mental disintegration, or rejection and abandonment by significant others).
Ross goes on to explain that, 'Most often, the persecutor is a misguided protector whose behavior makes sense within her own world view: The first challenge to the therapist is to understand the persecutor's universe, and the laws that govern it.' (p. 151). I agree with this.
- Sutton, Jan; Understanding dissociation and its relationship to self-injury and childhood trauma; Counseling & Psychotherapy Journal; April 2004; Vol. 15 Issue 3
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about understanding dissociation.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 15
What is the DSM description of Dissociative Identity Disorder? Record the letter of the correct answer the CEU Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
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