About Me
I am Natalie Intrieri, a Counseling and Human Services major at the University of Scranton, where I will be graduating in May of 2022. I have a particular interest in pursuing school counseling and I plan on attending graduate school for a Masters degree upon graduation. I also have a passion for social justice, equity, inclusion, and advocacy work, and I hope to dedicate my time and efforts to helping marginalized populations. The importance and awareness of mental health has been very prevalent throughout my life, as there is a history of mental illness that runs in my family. Additionally, I have had quite the amount of experience in volunteering and partaking in service projects that have helped several minority groups.
I was interested in researching dissociative identity disorder (DID) because this is a disorder that I have not received much education or awareness on, and I was intrigued by the many layers that seem to be involved. I was first introduced to DID from the movie, Split, and I thought that it was fascinating yet could understand the detrimental effects that the disorder may impose on one's life. I wanted to gain a better understanding of the disorder for my own learning because this disorder might be another reason that someone might go to seek therapy. Lastly, there is a possibility that I will have the opportunity to help someone who has been diagnosed with this illness, and I wish to know of the ways and resources that I can utilize in order to better support and provide for them.
What is Dissociative Identity Disorder?
Dissociative identity disorder (DID) is associated with overwhelming experiences, traumatic events, and/or abuse that occurred in childhood. A person might have two or more entities, each with its own way of thinking and remembering about themselves and their life. Other names to describe these alternate states include, "alternate personalities", "alters", "states of consciousness", and "identities" (American Psychiatric Association, 2021).
Case Study
(Rehan, Kuppa, Ahuja, Khalid, Patel, Cardi, Joshi, Khalid, & Tohid, 2018).
Who? Caroline*, a 55-year old Caucasian woman with a history of substance abuse disorder with seven personalities.
What? Caroline has a substance abuse disorder and comorbid bipolar disorder. She also has a history of the fragmentation of a single personality into different personalities under emotional stress and under the influence of a drug.
Stressful situations and substance abuse could aggravate the fragmentation of her personality. This was an involuntary phenomenon with seldom memory of the event. She has reported having anxiety during a personality state transition, as it could occur at any time, and involuntarily, but it mostly occurs in stressful situations and during substance abuse.
Her 55-year aged female self is the default personality that makes her feel the most comfortable.
Caroline also reported that she had been constantly dominated by her alternate personalities and became aware of their existences when people around her informed her after a situation or episode had ended.
Alternate personalities: aspects of her multiple personalities include...
Seven-year-old child: that shares similar interests and choices to her default personality, but is also moody and self-arrogant. This has caused her to hurt herself or have weeping spells.
Teenager: this has caused an increase in substance abuse, alcohol use, and smoking. It has also led to fights, homicidal attacks, and self-harming events.
Male figure: one of Caroline's alters experienced a temporary transition to the opposite sex (male) and had a change in voice and behavior. This included male dressing, language, perception of male body parts, choices of friends, attraction towards females, including sexual behaviors.
Treatment Plan? Caroline has undergone psychotherapy with cognitive-behavioral therapy (CBT) that helped to address the stress and substance abuse disorder.
Her treatment also included dual-treatment of drug therapy, where she was prescribed escitalopram (Lexapro) to reduce anxieties. Caroline also reported that she believed that the anxiety pills were helpful. After six months, her condition had not drastically changed, but she believed that her stress was more manageable.
Influence? Caroline's diagnosis of DID has significantly influenced her life and the lives of those around her.
- While transitioning between her personalities, she was found to be violent to those who were close to her.
- She experienced suicidal and homicidal tendencies which caused her to be arrested twice in the past.
- She had to be isolated and restrained by being locked in a room and calling the police.
- Being under the influence of stress or substances (e.g. marijuana or cocaine) would cause her personality to split into her various alters.
- More violent and harmful events were reported when someone tried to meet her alone rather than in a group.
Neurological background
Neurological connection
What causes the condition? There is a controversial diagnosis surrounding DID.
- Believed to have developed due to severe physical and sexual abuse, particularly during childhood.
- Stress, anxiety, and substance abuse
- Combination of disorganized attachment with later childhood trauma.
- Infant disorganized attachment
- A fear that criminals will get off without being punished by a justice system. This belief holds that an illegal behavior is attributed to another personality/alter and does not hold the perpetrator responsible --> controversial (provide more adequate and affordable mental health resources)
Dispute over the meaning of observed symptoms: is DID a disorder with a unique or subtle set of core symptoms and behaviors that some clinicians do not see when it is before their eyes? OR is it willful malingering or iatrogenically caused symptoms created by other clinicians who think that something is there that is not?
What is the neurological basis of the condition? Neuroimaging studies have identified areas of the brain and the orbitofrontal cortex that function differently in individuals with DID. These studies have also provided structural and functional information about the brain.
- The hippocampus and amygdala of persons with DID were significantly smaller --> implies that these two structures are key in understanding DID.
- Hippocampus: plays a role in forming long-term memories and learning (Anand & Dhikav. 2012).
- Amygdala: the integrative center for emotions, emotional behavior, and motivation (Wright, 2020).
- Irregularities in these brain areas would help account for the variance of memory and emotions among the different alters present in DID.
Studies: measuring the regional cerebral blood (rCBF) of persons with DID.
One study compared rCBF of DID patients while they were in their host personality with normal controls and observed lower rCBF in the orbitofrontal cortex (OFC). The OFC is involved in decision making.
- It was hypothesized that the decreased functioning of the OFC results in impulsivity and that the switch to an altered personality may represent a drastic expression of impulsive behavior caused by cognitive and emotional conflicts.
A second study measured rCBF of DID patients in a neutral personalty state (NPS) compared to a traumatic personality state (TPS) while they listened to a memory script.
- It was found that alters in DID do have different autobiographical selves.
- The medial prefrontal cortex was deactivated in the NPS versus the TPS --> this was a significant finding, as the prefrontal cortex is involved in personality expression and also contains the OFC.
Figure 1 (L)
Figure 1 displays the differences for measures of cortical thickness (CT) and surface area (SA). This was conducted by the utilization of neuroimaging, which is the use of various techniques to either directly or indirectly image the structure, function, or pharmacology of the nervous system (Brammer, 2009).
- A) Clusters with significantly reduced CT in DID compared to controls while controlling for the effects of site and age.
- B) Clusters with significantly reduced SA in DID compared to controls.
- C) Percentage overlap between differences in CT and SA, where orange denotes significant differences in both CT and SA, green denotes differences in CT only, and cyan denotes differences in SA only.
- Individuals with DID had significantly reduced SA in the left superior temporal sulcus, extending into the medial superior frontal lobe and in the orbitoprefrontal cortex.
(Reinders, Chalavi, Schlumpf, Vissia, Nijenhuis, Jäncke, Veltman, Ecker, 2017).
Typical Symptoms
Symptoms that characterize the condition? There are a number of symptoms, but the most prevalent one is the existence of two or more distinct identities (or personality states). These identities are accompanied by changes in behavior, memory, and thinking.
- The disruption in identity involves a change in sense of self, loss of personal agency, and alterations in effect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor function.
- On-going gaps in memory about everyday events, personal information, and/or past traumatic events.
- Symptoms cause significant distress or problems in social, occupational, or other areas of functioning.
- Identities happen involuntarily or are unwanted.
- People with DID may feel that they have suddenly become observers of their own speech and actions, or their bodies may feel different.
Treatment and Prognosis
How is DID treated and what is the treatment prognosis? Various forms of therapy and avoidance of triggers.
DID can be treated by the avoidance of triggers (e.g. stress and substance abuse) may help in unpredicted personality fragmentations into multiple personality states. It can also be treated by weekly or biweekly therapy, with the goal of fusing the personality states while retaining the entire range of experiences contained in all of the alters.
Cognitive-behavioral therapy (CBT) can incorporate effective communication with the alters and helping the patient find more adaptive coping strategies than "switching" during times of distress.
CBT can be a very useful and effective therapy because it can help to challenge irrational thoughts, behaviors, and fears. It also may call for the utilization of relaxation exercises, which can help the patient gain control over cognitive distortions of the self and world. Another important aspect of CBT is that it can help to address the fear on the part of an acting-out or antisocial personality state that is hoped to be obliterated by therapy.
Case Study + Normal Brain Function
What does the case study suggest about normal brain function?
Caroline's condition was reported to be associated with any emotional stress and substance abuse disorder.
- When switching alters, she was not aware of the transition or had any memory of the event.
- At a risk of experiencing post-event confusion and guilt.
This case study gives the idea that stress and drug use can lead to DID symptoms, however, it is not yet known if the change in personality is solely due to marijuana, cocaine, or any drug use.
DID has severe effects on the parts of the brain that regulate emotion and impulsivity, as more than 70% of people with DID have attempted suicide and self-injurious behavior.
Myths and Facts of DID (Brianna Fae, 2021).
Relation to Religion + Christianity
The Role of Religious Coping and Resilience in Individuals with DID: religious coping is a topic of exploration in DID populations, as it can bring issues and concerns to surface, and/or provide strength and positive coping (Bell, Jacobson, Zeligman, Fox, Hundley, 2015).
In the 1980s, religion and dissociative identity disorder became linked through speculation that ritual abuse could contribute to the splitting of personality and formation of alters.
Religious coping has been a topic of exploration (both a negative and positive one). It could be used to determine how religious backgrounds and affiliation has caused an individual to develop DID, and how trauma could have caused the formation of other alters. On the contrary, this coping might provide an individual with strength and support, two important factors that they might need during the healing process.
Concerns that might arise due to religious affiliation for clients with DID:
There are numerous reasons, issues, and concerns that may occur due to religious affiliation and religious coping for clients with DID. Some of these reasons include the fear of being possessed, concern over losing one's faith, experiencing hatred for God, increased feelings of guilt, premature forgiveness of abusers, valuing of traditional female submissiveness, and the creation of negative and unhealthy religious coping due to a history of abuse.
For instance, an individual with DID might have suffered clerical abuse at a young age, and they could have increased feelings of guilt or hatred for God. This could arise because it might cause them to internalize the abuse and wonder what they did to deserve such trauma. Additionally, the use of religious coping can insinuate feelings of anger and resentment towards God for abandoning them during their abuse and/or they were unworthy of being protected. In this case, it might be more beneficial to use another form of coping or therapy with the individual, as the discussion or involvement of religion might cause more harm and distress because it could have been the root of the problem in the first place (Bell et al., 2015).
Moreover, religious coping might enable the premature forgiveness of abusers, which in my opinion, is detrimental and ineffective in the recovery and healing process. There is a very well-known value that is prominent in the Christian faith, and that is the focus on forgiveness. I can understand the encouragement and necessity for forgiveness, as it can be mostly beneficial for the individual as well as the perpetrator. However, I believe that this is a gradual process and I can understand how people might react poorly towards religious coping. It might feel as though that their issues are being swept under the rug or that they should quickly forgive, forget, and move forward. If only it were this easy, we would have little to no problems in the world. In essence, religious coping might cause more harm than good for an individual with DID. Healing and coming to terms with the abuse can be an arduous and lengthy journey, and this method of coping does not sound one hundred percent effective or the most useful in certain cases.
Religion potentially provides strength and positive coping:
In contrast, religion could potentially provide strength, support, and positivity to an individual with DID. This has been exemplified because membership to a religious organization can bring access to support which can help to reduce symptoms of distress. This type of support might be more necessary to those clients with DID who may experience alienation from family, friends, or loved ones. It can provide them with a sense of community and being surrounded by like-minded individuals, which in turn, can help them process, heal, and have the strength for recovery.
Additionally, religion can bring a potential source of healing for those who have been sexually abused. It can provide them with answers, explanations, or reasons to better understand the situation, and/or even some closure. Religion can also be a new way of thinking and an activity or membership that they can dedicate their time and energy to, in order to better themselves. There are several great aspects of religion, such as the community and service aspect, which can immensely benefit the individual. Service can allow the individual to feel more involved, give them a sense of purpose, and an inspiration to help others. It can also teach them things about themselves that they might not have already known. For an individual with DID, they could become involved in activities or service that might aid or support other persons with DID, and this can help to create a shared understanding and connection for both parties.
Lastly, the presence of faith may serve as a deterrent to suicide or self-harm. The risk of suicide and self-harm is extremely high in individuals with DID, and the presence of God or others within the religious community can remind the individual that they are not alone. For instance, if it had felt that they were alone and had no one, religious affiliation to a certain religion could reassure them that they had God or another higher power who was always with them. This could bring them a peace of mind or remembrance that someone or something is always there for them.
Theological perspectives of what makes up a person:
Dissociative Identity Disorder + Religion, Bodies, & Brain
How does DID relate to religion, more specifically, our class? Through spiritual exercises and our memory being fallible.
Spiritual Exercises: a compilation of meditations, prayers, and contemplative practices developed by St. Ignatius Loyola to help people deepen their relationship with God. The most common way of going through the Exercises now is a "retreat in daily life", which involves a monthlong program of daily prayer and meetings with a spiritual director. The Exercises have also been adapted in many other ways to meet the needs of modern people (Ignatian Spirituality, 2021).
How could the Spiritual Exercises be used?
The Spiritual Exercises can be used when working with a client who has been diagnosed with DID. This can be achieved by helping the client find their purpose and the conquest of the self, and the process consists of four weeks of prayer. This could be beneficial and effective because it might provide the individual with a routine and a sense of structure. Additionally, the Exercises allow the client to disengage with the world (and in this case, with their different alters) so that God has free range to communicate with them. In turn, this can provide them with a sense of support, knowing that God is with and there for them.
The fallibility of our memory.
In class, we listened to a podcast that discussed how fallible our memory is and that what we could be remembering, might not be accurate or true after all. I related this to my case study and individuals with DID because those with the disorder might suffer from an increase of inaccurate or inconsistent memories due to their multiple alters. One of the major points that were discussed in the podcast was our memory versus the actual truth when it comes to traumatic events. It was noted that in significant events such as 9/11 and the death of Princess Diana, many people had very different accounts of what had happened. This also included individuals who thought they had remembered what exactly had happened, but years later, they recalled a different story or memory. As for those with DID, these individuals could recall or perceive traumatic events very differently due to their alters that have been created as a result of the trauma that they have endured.
Personhood
Persons with DID could become the topic of conversation when it comes to the dsicussion of personhood. It could pose the question of what is personhood, and is it disordered to have multiple selves or alters? Other questions that should be considered are what is a person? What makes up personhood? What does it mean for someone who has DID, are they one singular person and entity, or individual persons? This is surely a subjective matter and questions that pose neither right or wrong answers. I think that one can challenge the true definition of personhood, as there are an immense amount of situational factors and circumstances that might not enable someone to fully grasp the concept of personhood. Rather than having one concrete definition, personhood could be a variety of things, as each individual is different in their own way, and it would useless and demeaning to fit each person into a specific label or category.
DID Portrayed in the Media
Split (2017): Though Kevin has evidenced 23 personalities to his trusted psychiatrist, there remains one still submerged who is set to materialize and dominate all of the others. Kevin reaches a war for survival among all of those contained with him -- as well as everyone around him -- as the walls between his compartments shatter (IMDb, 2021).
The movie has been criticized by medical and mental health professionals, saying that it could be extremely damaging to those who live with DID and for those who do not have an adequate understanding of the disorder.
Negative Impacts of the Film
Some of the negative impacts of the film is that it stigmatizes the disorder by raising the potential for dangerous attitudes to emerge and for people with the illness to be damaged, and it may imply that someone with DID could be violent, but experts say those people are more likely to hurt themselves than others (Healthline, 2017). As quoted by Dr. Sheldon Itzkowitz, "the film may inadvertently demonize people who are truly suffering. DID is a disorder that has its etiology in the worst form of human suffering -- the abuse of innocent children" (Healthline, 2017). Dr. Itzkowitz views DID as a form of resilience, as it is the mind's effort at trying to cope with overwhelming and terrifying trauma, often at the hands of people who were supposed to care for and protect the child.
In the film, one of Kevin's alters, the Beast, is portrayed as an angry and violent creature who seeks out "impure" humans and consumes them. This has been debunked by licensed professionals and medical experts because DID develops as a coping mechanism, not a weapon (Malley, 2017). Furthermore, it is possible for individuals with DID to be violent, but in most cases, these individuals use their personalities to better cope with the traumas that they endured in early life (Malley, 2017).
Positive Aspects of the Film
On the contrary, Split did portray the textbook definition of DID. According to the DSM-5, "the defining feature of DID is the presence of two or more distinct personality states or an experience of possession" (American Psychiatric Association, 2013). The main character, Kevin Crumb easily fits this description with his twenty-three defined personalities.
Another accuracy of the film is that the DSM criteria also states that DID involves recurrent gaps in recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting (APA, 2013). In the film, when Kevin switches back from the Beast to himself, he immediately asks what he did, and had no recollection of the events that conspired while he was dominated by the Beast (Malley, 2017).
Additionally, DID is typically caused by childhood trauma. As a result, individuals are subjected to a sort physical or emotional torture that they cannot cope with at their current developmental period. One way to protect themselves is to create splits in personalities, instead of a weak host dealing with the trauma, a new identity is created to protect the original. The film accurately portrays this by giving the audience a glimpse during a flashback of Kevin's mother screaming and threatening him. This is followed by several identities stating that those who are "impure" deserve to be consumed by the Beast. "Impure" is used to describe those who have not suffered in their lives. Lastly, this shows more proof that Kevin underwent extreme suffering as a child (Malley, 2017).
Clip from Split -- When Kevin switches to one of his alters, Dennis, during therapy.
Closing Thoughts
In essence, dissociative identity disorder is a complex mental illness that is continuously being researched and commonly misunderstood. This can be due to a lack of awareness regarding DID, in addition to misrepresentation and stigmas caused by the media. It has been found that cognitive-behavioral therapy is one of the most prevalent approaches used with individuals with DID, and it would be interesting to see how effective that a religious coping approach would be. Religious affiliation has demonstrated how it has posed concerns and issues for people with DID, however, it has exemplified a number of benefits as well. It would be intriguing to see how much of an effect that religion has on an individual with DID, and how that it can potentially help, even after possibly harming them.
I will leave you with one question, how do you perceive personhood? What makes each of us human? For someone who has been diagnosed with dissociative identity disorder, could you argue that their multiple alters are individual persons, or simply just part of the host personality?
References
Anand, K. S., & Dhikav, V. (2012, October). Hippocampus in health and disease: an overview. Annals of Indian Academy of Neurology, 15(4), 239-246.
Bell, H., Jacobson, L., Zeligman, M., Fox, J., & Hundley, G. (2015, October 1). The role of religious coping and resilience in individuals with dissociative identity disorder. Counseling and values, 60(2), 151-163. https://onlinelibrary.wiley.com/doi/10.1002/cvj.12011
Brammer, M. (2009, December). The role of neuroimaging in diagnosis and personalized medicine-current position and likely future decisions. Dialogues in Clinical Neuroscience, 11(4), 389-396. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181933/
DiStefano, I. (2021, May 27). Identification and acceptance of dissociative identity disorder. The Fordham Undergraduate Research Journal. https://tfurj.com/2021/05/27/identification-and-acceptance-of-dissociative-identity-disorder/
Gillig, P. M. (2009, March). Dissociative identity disorder: a controversial diagnosis. Psychiatry MMC, 6(3), 24-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719457/
Healthline. (2017, February 14). Movie 'Split' does harm to people with dissociative identity disorder, experts say. Healthline. https://www.healthline.com/health-news/movie-split-harms-people-with-dissociative-identity-disorder
Ignatian Spirituality. (2021). The spiritual exercises. Ignatian Spirituality. https://www.ignatianspirituality.com/ignatian-prayer/the-spiritual-exercises/
Malley, K. (2017, June 12). Dissociative identity disorder in M. Night Shyamalan's Split: fact vs. fiction. Psi Chi. https://www.psichi.org/blogpost/987366/277421/Dissociative-Identity-Disorder-in-M-Night-Shyamalan-s-Split-Fact-vs-Fiction-Contains-Spoilers#.YalebfFKi3J
Manton, S. (2021). Disorganized attachment and the orbitofrontal cortex as the basis for the development of dissociative identity disorder. BU Arts & Sciences Writing Program. https://www.bu.edu/writingprogram/journal/past-issues/issue-3/manton/
National Alliance on Mental Illness. (2021). Dissociative disorders. NAMI. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Dissociative-Disorders
Ozturk, E. (2021, April 21). Trauma based alliance model therapy. Medicine Science International Medical Journal. http://www.medicinescience.org/wp-content/uploads/2021/05/631-650-53-1616697339-MS-2021-03-100.pdf
Rehan, M. A., Kuppa, A., Ahuja, A., Khalid, S., Patel, N., Cardi, F. S. B., Joshi, V. V., Khalid, A., & Tohid, H. (2018, July 10). A strange case of dissociative identity disorder: are there any triggers? Cureus, 10(7). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132594/
Reinders, A.A.T.S., Chalavi, S., Schlumpf, Y.R., Vissia, E.M., Nijenhuis, E.R.S., Jäncke, L., Veltman, D.J., & Ecker, C. (2017, December 27). Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder. Acta Psychiatrica Scandinavica, 137(2), 157-170. https://onlinelibrary.wiley.com/doi/full/10.1111/acps.12839
Rose, S. (2017, January 12). From Split to Psycho: why cinema fails dissociative identity disorder. The Guardian. https://www.theguardian.com/film/2017/jan/12/cinema-dissociative-personality-disorder-split-james-mcavoy
Saad, M., & de Medeiros, R. (2011, December 14). Spiritual-religious coping -- health services empowering patients' resources. IntechOpen. https://www.intechopen.com/chapters/40016
van Minnen, A., & Tibben, M. (2021, September). A brief cognitive-behavioral treatment approach for PTSD and dissociative identity disorder. Journal for Behavior Therapy and Experimental Psychiatry, 72. https://www.sciencedirect.com/science/article/pii/S0005791621000203
Wang, P. (2018, August). What are dissociative disorders? American Psychiatric Association. https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociative-disorders
Wright, A. (2020, October 10). Amygdala. Neuroscience Online. https://nba.uth.tmc.edu/neuroscience/m/s4/chapter06.html