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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 4 of 4. This is the beginning of the thread.
Posted by alexandra_k on March 28, 2005, at 1:03:51
While the distinctive and defining feature of dissociative identity disorder is the presence of alters it is acknowledged by sceptics and supporters both that only 20% of DID patients exhibit clear-cut indications of this condition at the beginning of treatment. The remaining 80% exhibit only specific ‘windows of diagnosability’, namely transient periods during which the classic features of DID are evident (Kluft, 1991). Although there is disagreement concerning the exact percentages, ‘virtually all authors in this literature have concurred that a large proportion – perhaps a majority – of DID patients in their samples exhibit few or no unambiguous signs of this condition prior to therapy’ (Kluft, 1991).
When we consider the typical presentation of potential DID subjects we are left with a more general picture of overall muddle. Often subjects with ‘transient windows of diagnosability’ may be considered to present as something of an unintegrated, fairly incoherent intentional system. Over time the intentional system varies radically in its beliefs and desires. It may profess one thing and act in accordance with it, but at other times it may disavow actions, memories, or past utterances. The behaviour of such a system would be lacking in integration and coherence, they would exhibit, contradictory beliefs and conflicting goals. The natural interpretation would seem to be that a system such as this is impulsive or unpredictable, contradictory, and perhaps with diminished rational capacity.
The amnesia requirement that was dropped from the DSM III was restored, partly as an attempt to curb the dramatic increase in prevalence rates. Subjects often meet this requirement by claiming that they find new possessions that they do not know how they acquired. They find their belongings moved around to a degree that cannot be explained by ordinary forgetfulness. They may claim that they are approached by people who claim to know them well but they cannot recall meeting them. They also claim that they have amnesiatic episodes where they cannot recall their behaviour. This seems to further illustrate that these subjects present as fairly disorganised intentional systems.
Some theorists have considered DID to be a variant of Borderline Personality Disorder (BPD) and as many as 70-80% of subjects with DID also meet the criteria for a diagnosis of BPD (Ross, 1996). If we ignore the issue of alters and consider the behavioural presentation of subjects with DID there is a large overlap of symptoms . While supporters consider that BPD symptoms are best explained by the presence of alters; sceptics maintain that the presence of alters is best explained in terms of BPD symptoms with the addition of alters as a treatment induced artifact. The emotional ‘instability’ and impulsivity that could be interpreted as variability between alters is covered by criteria (2), (4), (5), and (8).
[here is a link to the criteria if anyone wants to get the reference of the numbers] http://www.borderlinepersonalitytoday.com/main/dsmiv.htm
(3), (7), and (9) relate to identity disturbance, dissociative symptoms, and subjects that report being afraid of the actions or voices of persecutory alters may be considered delusional or paranoid.Alters also may be considered ‘responsible’ for the self damaging behaviours reported by criteria (4), (5), and (8). Subjects with DID are typically considered to have at least one hostile or persecutory alter who engages in damaging behaviours to the subjects body and / or other people. While it is considered that not all DID subjects meet the criteria for BPD, some clinicians consider that DID takes precedence and so would not list BPD as an additional diagnosis (Ross,1989 p. 143). Not all BPD subjects present with alters, and so some theorists consider that DID is a form of, or severe variation of BPD. Ross (1996, p. 149) states that
Looking at MPD patients from a borderline vantage point, they hold that MPD is an epiphenomenon of borderline personality. Basically, the argument is that MPD specialists create an MPD artefact in borderlines. Such clinicians rarely diagnose MPD because they deal with the “real” disorder, borderline personality.Because the Diagnostic and Statistical Manual of Mental Disorders aspires to establish psychiatry with the same empirical grounding and treatment success as enjoyed by the rest of medicine, disorders are considered disease entities that are to be differentiated by unique aetiology (including age of onset), behavioural presentation (offered as a set of symptoms or syndrome), and effective course of treatment (course of illness and predicted treatment outcomes). Psychiatric disorders are thus conceptualised and presented as discrete, distinct, and all or none in that one either meets the criteria for the disorder or one does not. While this discrete disease entity conceptualisation works well for some illnesses (e.g., Alzheimer’s), there is controversy as to whether the disease conceptualisation is appropriate for all of the listed pathologies (Davidson & Neale, 2001 pp. 69-71).
Dissociative disorders, post-traumatic stress, somatoform disorders, histrionic and borderline personality disorder, substance abuse, eating disorders, anxiety, and depression (that does not respond as effectively as clinical depression when treated) seem to co-occur in a number of subjects. The DSM is structured in such a way that there seems to be little natural relation between these disorders, whereas some clinicians recognise that they frequently occur together and they maintain that future structuring of the DSM should reflect this. These disorders also may be better conceptualised as lying along a continuum where symptoms are ranked for severity from normal to abnormal to severe. This would reflect the notion that many of the symptoms do appear in the normal population and it is the degree to which the behaviour is present that is of concern. This is currently debated and may result in a restructuring of the DSM in subsequent editions (Davidson & Neale, 2001 pp. 69-71).
Because there is overlap in content (with respect to symptoms) for diagnosing this cluster of disorders many individuals meet the criteria for more than one of these and some meet the criteria for different disorders at different times. While some individuals present fairly clearly with one or two (or three) of the above, others seem to be diagnosed with a variety of these over a 7-10 year period before a diagnosis of DID is made (Ross, 1993; Gleaves, 1996). Medication assists with symptoms in a limited way but does not seem to control the disorder the way it does with the model diseases such as schizophrenia, bi-polar, and true clinical depression. These subjects are the ones that seem to show that diagnosis can often be a somewhat arbitrary matter that is indeed, to a very large degree, a matter of interpretation.
Posted by Dinah on March 28, 2005, at 2:58:52
In reply to (v) The phenomenon of DID, posted by alexandra_k on March 28, 2005, at 1:03:51
Good job in dissecting the DSM. :)
And I do understand the intentional system idea.
Posted by alexandra_k on March 28, 2005, at 3:18:08
In reply to Re: (v) The phenomenon of DID, posted by Dinah on March 28, 2005, at 2:58:52
> Good job in dissecting the DSM. :)
Thats nothing, you should see me get stuck in to their definition of delusion. I have 10 substantial issues with a single definition, would you believe...
And their definition of hallucination doesn't fare much better...
(Though they are the best we have got to be sure)
> And I do understand the intentional system idea.:-)
It is one of my favourite bits from Dennett. Intentional Systems Theory and the idea of different level stances (Physical Stance, Design Stance, Intentional Stance) are what made him famous. Well... In philosophical circles anyway.
It should be ok from here on in...
You are doing well :-)
Posted by Dinah on March 29, 2005, at 21:05:04
In reply to (v) The phenomenon of DID, posted by alexandra_k on March 28, 2005, at 1:03:51
My therapist liked your conceptualization.
At least the idiot's version that this idiot was able to relay to him. :)
This is the end of the thread.
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