Dissociative Identity Disorder in an Inpatient Setting

Abstract

Despite recognition in current and past versions of DSM, dissociative identity disorder (DID) remains a controversial psychiatric disorder which hampers its diagnosis and treatment. Factors that lead misdiagnosing of DID are the unfamiliarity with spectrum of dissociative disorders, the existence of feigned DID, the reluctance of individuals with DID to present their dissociative symptoms, and lack of knowledge and appreciation of its epidemiology which is shown to have 1.5% lifetime prevalence. An accurate diagnosis allows the appropriate interventions leading to fewer hospitalizations.

KC is 28 y.o. female with a psychiatric history significant for polysubstance use, PTSD, and GAD, who presented to the ED due concern for DID per mother. Prior to presentation, she had thrashed her mother’s home of which she denies recollection. She has a history of early sexual trauma by her own family. She screened 44 on the Dissociative Experiences Scale (DES). Throughout her hospitalization, she exhibited questionable lapses of disassociation, although there were no noted changes of posture, dress, speech, or acknowledgement of alters. She was discharged on Remeron 15 mg, Risperdal 2 mg, and Prazosin 2 mg with outpatient resources for trauma-based therapy.

DID is characterized by two or more distinct identities or personality that coincide with fluctuating states of consciousness and changing access to autobiographical memory. The neurological similarities between personality states in DID and PTSD subtypes support a trauma-related etiology of DID. Although there are many interviewing tools, the DES has been the most widely used clinically. Although collateral information, detailed history, and DES were concerning for DID, observation did not show distinct dissociative episodes as discussed by collateral (alter described as destructive and cold towards her own infant) although the hospital environment may not have provided enough stress for patient to transition from one personality to another.

The International Society for the Study of Trauma and Dissociation proposes a phase-oriented treatment approach: 1) establishing safety, stabilization, and symptom reduction; 2) confronting, working through and integrating traumatic memories; 3) identity integration and rehabilitation. From inpatient standpoint, phase 1 and 2 may be promptly addressed. Besides initiation of Remeron and Risperdal (consistent with treatment of DID in two prior case reports), implement grounding techniques and coping mechanisms against triggers for dissociative episodes. Inpatient screening can facilitate earlier accurate diagnosis, faster and more targeted interventions, prevent unnecessary direct and indirect societal costs, and, most importantly, improve quality of life for those with the disorder.

Funding

No Funding