Dave is a 19-year old student. His parents recently divorced. Dave was a happy child until when he was seven years old. Family conflicts began unsettling their home when he was five years. He developed feelings of insecurity, and his friends and family think he is rebellious. The yelling from the parents causes him to get paralyzed mentally and shut down. The academic records demonstrate a steady decline in grades and his teachers see him as disrespectful and inattentive. He presents with a reasonable degree of amnesia, not recollecting events. Words spoken by some people do not make sense to him. His reading is affected as well because he could read and write but could not keep in his memory what is read. Feelings of frustration and fear are expressed. His information retention ability is little. Dave is unable to think rationally. His decision-making potential has deteriorated significantly and has developed poor social skills.
Dave's classmates and friends discover that he changes moods often and anger is one form of expressing himself with people. One moment he is alright or normal and the next he becomes angry, sullen, sad, irritable, or tearful. He is seen to be anxious about classes and teachers. Occasionally, he will go out with his friends and neighbors to play but comes home feeling frightened and confused. Especially with his parentsmost of the time he is not happy. In several instances, he has used "we" instead of "I" when asked a personal question in the class by the teachers. He infrequently wakes up at night feeling scared and having difficulty sleeping. Dave feels a sense of rejection that has its origin from his early childhood. Thus, he has trouble trusting people because of fear of rejection.
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Dave does not feel loved and worthy. There is a sense of emptiness in him and blames people for his inconsistent relationships. The manner in which people relate to him allows them to assess his social skills and this cause people to either discontinue or continue associating with him. Thus, his relationships are inconsistent and sometimes volatile. He has not attempted suicide but had felt life is not worth living. Discrepancies exist in adult and gender demographic diagnosis, giving a DSM-IV value estimate at 1.5% of the adult population in the United States. However, there is no apparent discrepancy in gender when it concerns children and adolescents (American Psychiatric Association, 2013). There are differences between outpatient and inpatient data (Foote et al., 2006; Ross, Duffy, & Ellason, 2002); significant to the paper is the relative coherence of findings in children and adolescent.
Dave had physical abuse and rejection as a young child. His father is a casual worker in a factory who recovered from depression. He was abusive and placed high expectations from Dave. His mother is an alcoholic with borderline personality characteristics. Dave suffered abuse from his perfectionist father and his neglectful mother. Thus, he lost the attachment necessary for the development of his teenage and adult life. The nature of attachment and family structure can influence dissociative tendencies positively or negatively (Korol, 2008). Abuse and neglect at an early age have been researched and documented to predispose a child to Dissociative Identity Disorder (DID). The DSM-IV diagnostic criteria for Code 300.14, presents the following:
The disruption of identity. “The disruption of marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.” (American Psychiatric Ass., 2013).
Persistent forgetfulness of important information or events.
Symptoms cause impairment of function in critical areas of life.
Expressed behavior not typical of culture or religion.
Symptoms are not linked to substance ingestion or other medical condition.
Other differential diagnostic symptoms that comorbid with the above suggest a diagnosis of Dissociative Identity Disorder as Dave's presented condition from the case study. However, this needs to be further investigated clinically.
Cognitive Behavior Therapy (CBT) Approach
Personality states or Alters are standard features of DIDs. The goal of treatment is to integrate alters so as the individual becomes a unified self without different identities. Patients with DID switch personalities when exposed to any form of psychological threat. These switching causes some alters to hide or retreat while others are presented to cope with the threat. Working to resolve Alters is the best treatment approach for DID. A therapist who misses on the importance of alters and focuses on other characteristics is likely to leave the patient in an unfinished state which may lead to relapse. CBT is the most common therapeutic approach recommended for DID.
Cognitive-behavioral therapy is a combination of theories of behavior causations. The first is the cognitive theory that maintains that human thoughts are the causes of feelings and behavior. Central to this approach is the influence of external events in a given environment on someone. The manner in which these events in the environment are interpreted is critical to one’s cognitive state. Thus, the identification and transformation of abnormal thinking patterns are the focus of the cognitive theory. It emphasizes the building process of core belief systems that form people’s behaviors. The Behavioral Theory considers that people's behavior defines their personalities according to the environmental variables. The convergence of cognition and behaviors is to transform the individual into a personality that is not dysfunctional.
The CBT theory posits that thoughts are mediators of emotions which precede actions. External factors or stimuli elicit ideas and these thought form beliefs. Assumptions of the therapy are that an individual has the potential of knowing and becoming aware of their thoughts. This knowledge gives them the power to transform the thought pattern. Also, there is a possibility of false reflection of reality by a given process of thinking. The concept holds the position that mental distress is caused by improper processing of information from the external environment. The person's behavior is taken into consideration in treatment. Therapists attempt to get to the root of the mental distress by evaluating the relationship between thoughts, emotions, and behaviors.
The process of treatment is a long-term engagement with a patient so that they can find more adaptive ways of coping rather than switching alters. The therapist is to model the most appropriate relationship and reaction to environmental cues. By applying the patient's cognitive elements, one can gain control over any mental disruptions and core beliefs built over the years. The therapists can create activities that give the individual freedom of expression resulting in confidence building and dislodgement of locked traumatic experiences. This approach has the promise of resolving alters as the treatment proceeds.
According to the case, Dave has a family history that reflects a dysfunction and abusive behavior. The therapy is to identify and highlight the causes of his behavior and the Alters that he had developed over the years. Also, the beliefs that he has created about his family and people over time have to be assessed. These processes will help in the treatment of the condition.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association . ISBN 0890425558. Retrieved from http://traumadissociation.com/dissociativeidentitydisorder
Foote, B., Smolin, Y., Kaplan, M., Legatt, M., & Lipschitz, D. (2006). Prevalence of dissociative disorders in psychiatric outpatients. American Journal of Psychiatry,163(4), 623-629. doi: 10.1176/appi.ajp.163.4.623
Korol S.(2008). Familial and social support as protective factors against the development of dissociative identity disorder. J Trauma Dissociation, 9 (2):249–267. [PubMed]
Ross, C., Duffy, C., & Ellason, J. (2002). Prevalence, reliability and validity of dissociative disorders in an inpatient setting [Abstract]. Journal of Trauma & Dissociation, 3(1). doi: 10.1300/J229v03n01_02
