A 28-Year-Old Man with Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, and Dissociative Identity Disorder Responding to Aripiprazole Augmentation of Clomipramine Combined with Psychoeducation and Exposure and Response Prevention.

BACKGROUND We report the case of a 28-year-old man with comorbidity of OCD, PTSD, and DID responding to aripiprazole augmentation of clomipramine combined with psychoeducation and exposure and response prevention (ERP). CASE REPORT A 28-year-old, well-educated man presented with depression, obsessive thoughts, behavioral impulsivity, and suicidal thoughts/behavior. He was known to be stubborn and sensitive to criticism since childhood. The obsessive thoughts and compulsive behaviors also started at an early age. He had 4 past psychiatric hospitalizations, mostly for dissociative episodes and bizarre behaviors, complicated with significant anxiety and distress from traumatic experiences during doctoral study. He had no-to-minimal responses to various psychotropics and traditional Chinese medicine. A thorough assessment showed he met the diagnostic criteria for OCD, PTSD, and DID. He was then treated with clomipramine in combination with aripiprazole, plus psychoeducation and exposure and response prevention (ERP). His anxiety and irritability significantly improved within 2 months and his obsessive thoughts faded away. At 6-month follow-up, the patient achieved clinical remission. One year later, he remained stable and reported having a normal life. CONCLUSIONS The case illustrates both how impairing the comorbidity of OCD, PTSD, and DID can be and how concurrent use of tricyclic antidepressant (TCA) clomipramine and partial dopamine agonist aripiprazole, together with psychoeducation and ERP, can improve outcomes when other treatment choices fail to be effective.

A comparison between auditory hallucinations, interpretation of voices, and formal thought disorder in dissociative identity disorder and schizophrenia spectrum disorders.

OBJECTIVES: Dissociative identity disorder (DID) and schizophrenia-spectrum disorders (SSD) share some overlapping phenomenological features making accurate diagnosis more difficult. Childhood abuse and depersonalization have been associated with psychotic symptoms across psychological disorders but their relationship to psychotic phenomenology remains understudied. METHOD: The present study used quantitative measures to examine (1) similarities and differences in phenomenological voice hearing experiences, interpretations of voices, and thought disorder symptoms in individuals with DID (n = 44) or SSD (n = 45), and (2) whether depersonalization and childhood maltreatment influenced the initial pattern of findings. RESULTS: DID participants perceived their voices as being more internally located and generated, louder, and uncontrollable than SSD participants. Furthermore, the DID participants endorsed a greater frequency of thought disorder symptoms. Adding the covariates (sex, depersonalization, and child maltreatment) did not change the findings associated with location and origin of voices, and derailment, but there were now no differences in loudness or controllability. However, the schizophrenia sample reported more distress and metaphysical beliefs associated with voices, as well as more thought disorder incoherence and word substitution with the covariates controlled. CONCLUSION: While tentative, metaphysical interpretations of voices, incoherent thoughts and word substitution may reflect more psychotic processes.

Inter-identity amnesia for neutral episodic self-referential and autobiographical memory in Dissociative Identity Disorder: An assessment of recall and recognition.

Amnesia is a core diagnostic criterion for Dissociative Identity Disorder (DID), however previous research has indicated memory transfer. As DID has been conceptualised as being a disorder of distinct identities, in this experiment, behavioral tasks were used to assess the nature of amnesia for episodic 1) self-referential and 2) autobiographical memories across identities. Nineteen DID participants, 16 DID simulators, 21 partial information, and 20 full information comparison participants from the general population were recruited. In the first study, participants were presented with two vignettes (DID and simulator participants received one in each of two identities) and asked to imagine themselves in the situations outlined. The second study used a similar methodology but with tasks assessing autobiographical experience. Subjectively, all DID participants reported amnesia for events that occurred in the other identity. On free recall and recognition tasks they presented a memory profile of amnesia similar to simulators instructed to feign amnesia and partial information comparisons. Yet, on tests of recognition, DID participants recognized significantly more of the event that occurred in another identity than simulator and partial information comparisons. As such, results indicate that the DID performance profile was not accounted for by true or feigned amnesia, lending support to the idea that reported amnesia may be more of a perceived than actual memory impairment.

Transfer of episodic self-referential memory across amnesic identities in dissociative identity disorder using the Autobiographical Implicit Association Test.

Individuals with dissociative identity disorder (DID) often report having no access to autobiographical experiences encoded by other identities. This research used the autobiographical Implicit Association Test (aIAT) to determine whether there was transfer of episodic self-referential memory events across amnesic identities. Nineteen DID individuals, 16 DID simulators, and 41 comparison participants (divided into amnesic and nonamnesic groups) engaged with an audio vignette of embarrassing scenarios to produce the experience of episodic self-referential events. Results showed transfer of episodic self-referential memory using the aIAT across identities that reported no conscious awareness of encoded content in DID. These aIAT results in DID patients were similar to the nonamnesic comparison group and the simulator group, and differed from the amnestic comparison group. These results are in line with previous literature showing transfer of memories, but extends this work to episodic self-referential memory. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Dissociative Identity Disorder CPAP Adherence: An Uncommon Factor in Obstructive Sleep Apnea.

ABSTRACT: We present a case of a patient with dissociative identity disorder and symptomatic sleep apnea who was treated with continuous positive airway pressure (CPAP). CPAP use depended upon which personality the patient exhibited but apnea reduction did not. This case illustrates in one individual how personality can positively or negatively affect CPAP adherence.

Estudio de caso: ¿simulación o trastorno de personalidad múltiple? / Case study: malingering or multiple personality disorder?

El trastorno de identidad disociativo (TID) puede considerarse un trastorno raro, dada su aparentemente baja prevalencia, pero en los últimos años se apunta a su posible infradiagnóstico a causa de su complejidad y de la confusión que puede haber a la hora de establecer el diagnóstico diferencial. Por otro lado, la simulación de psicopatología mental puede tener un gran impacto socioeconómico y jurídico, de especial relevancia en este tipo de trastorno, dada la gran incapacidad que genera y su complejidad diagnóstica. En este trabajo referiremos el caso de un paciente que ingresa en la unidad de hospitalización breve del Hospital Dr. Rodríguez Lafora (Madrid) con sintomatología depresiva, que posteriormente pareció evolucionar hacia un caso de TID. La evaluación consistió en una anamnesis psicológica y la aplicación del Inventario Semiestructurado de Simulación de Síntomas (SIMS) y del Inventario Clínico Multiaxial de Millon (MCMI-II). Los resultados mostraron un perfil claramente alterado de personalidad, así como una posible simulación de síntomas que impidieron concretar la existencia o inexistencia del TID. A la luz de los resultados se discuten las posibles implicaciones de este caso

The dissociative identity disorder (DID) can be considered a rare disorder because of its seemingly low prevalence. However, in recent years it points to the possible underdiagnosis because its complexity and confusion at the time of differential diagnosis. On the other hand, the malingering of mental psychopathology can have a major socio-economic and legal impact, particularly important in this type of disorder, given the inability it generates and its complex diagnostic. This paper refers the case of a patient admitted to the short-term hospitalization unit of Dr. Rodríguez Lafora Hospital (Madrid) with depressive symptoms. Then the patient seemed to become a TID case. The evaluation consisted of a psychological history and the application of the Structured Inventory of Malingered Symptoms (SIMS) and the Millon Clinical Multiaxial Inventory (MCMI-II). The results showed an altered personality profile as well as likely malingered symptoms, what prevented us from a DID diagnosis. In view of the results, possible implications of this case for the clinical setting are discussed

Trauma-related pathological dissociation in a case with cerebral palsy.

This article provides a case report of a Chinese-Cantonese female with both cerebral palsy and dissociative identity disorder. To my knowledge, this is the first report of a case with dissociative identity disorder from Hong Kong, as well as the first report of a case with both dissociative identity disorder and cerebral palsy in the literature. Large-sample studies should be undertaken in the future to investigate the prevalence of dissociative disorders in a variety of populations in Hong Kong, including individuals with diagnosed brain diseases.

Sight and blindness in the same person: Gating in the visual system.

We present the case of a patient having dissociative identity disorder (DID) who-after 15 years of misdiagnosed cortical blindness--step-by-step regained sight during psychotherapeutic treatment. At first only a few personality states regained vision whereas others remained blind. This could be confirmed by electrophysiological measurement, in which visual evoked potentials (VEPs) were absent in the blind personality states but were normal and stable in the seeing states. A switch between these states could happen within seconds. We assume a top-down modulation of activity in the primary visual pathway as a neural basis of such psychogenic blindness, possibly at the level of the thalamus. VEPs therefore do not allow separating psychogenic blindness from organic disruption of the visual pathway. In summary, psychogenic blindness seems to suppress visual information at an early neural stage.

La encefalopatía espongiforme: ¿un trastorno conversivo? / Spongiform encephalopathy: a conversive disorder?

Las prionpatías, constituyen un grupo de enfermedades neurodegenerativas con presentación familiar, esporádica o adquirida, con clínica heterogenea y resultado fatal. Los síntomas psiquiátricos pueden estar presentes al inicio y/o durante la evolución del cuadro, con la presencia o no de focalidad neurológica. Esta condición conlleva a que estos pacientes sean derivados a unidades de Psiquiatría tanto a nivel hospitalario como ambulatorio, para estudio de trastornos psiquiátricos. El caso clínico que nos ocupa el paciente fue atendido en varias ocasiones en las Urgencias Hospitalarias, evaluado por neurólogos y psiquiatras con diversos diagnósticos psiquiátricos. Sin embargo, la encefalopatía espongiforme sólo fue diagnosticada en el último mes de enfermedad (AU)

Prionpathies represent a group of neurodegenerative diseases of familiar, sporadic or acquired origin, heterogeneous symptoms and fatal outcome. The psychiatric symptoms can be present at the beginning and/or during the clinical evolution, with the presence or not of neurological disorders. Patients with these sympthoms are referred to psychiatric units, both at hospital level and as outpatients, to study a psychiatric disorder. In the described clinical case, the patient was admitted several times at emergency units, rated by neurologists and psychiatrists leading to different psychiatric disorders diagnoses. However spongiform encephalopathy was diagnosed only during the last month of the disease (AU)

Dissociative identity disorder: An empirical overview.

OBJECTIVE: Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation. METHODS: The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment. RESULTS: DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID. CONCLUSIONS: The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.

De la respuesta a la locura, a la locura como respuesta / From the answer to madness and madness as an answer

Se presenta el caso clínico de una mujer de cuarenta años de edad que es atendida en el Servicio de Urgencias (por recomendación de su hija) al contactar con su difunto cuñado, y sentirlo “como si estuviera dentro de ella”. La paciente comentó que el fallecido le había trasmitido que deseaba que su viuda rehiciera su vida de pareja y familiar. Durante la observación psicopatológica se aprecia, entre otros datos, verbalizaciones de ideas de perjuicio. La hija de la paciente especifica reiteradamente que existía una asociación entre la toma de tratamiento anticonceptivo con dispositivo intrauterino hormonal (levonorgestrel) y síntomas premórbidos (caracterizados por apatía, abulia y abandono parcial de sus tareas cotidianas). Se planteó el diagnóstico diferencial entre un trastorno psicótico de debut o un trastorno disociativo, a descartar una posible inducción del tratamiento hormonal. La evolución clínica y el conocimiento de la situación vital de la paciente permitirá discernir el cuadro (AU)

A case involving a 40-years old woman attended by the Emergency Service (at the request of her daughter). The woman claimed she had had contact with her late brother-in-law and felt “as if he had been inside her”. The patient also said that the deceased had expressed his desire to see his widow recover her intimate personal and family life. During the psychopathological observation, vocalizations of prejudicial ideas, among other data, were noted. The patient’s daughter repeatedly specified an association between the intake of contraceptive treatment with hormonal intrauterine device (levonorgestrel) and premorbid symptoms (characterized by apathy, abulia and partial abandonment of her routine activities). A differential diagnosis was proposed among which, a psychotic disorder, a dissociative disorder, or a possible induction by the hormonal treatment, was presented. The clinical progress and the knowledge of the patient’s vital situation will help determine the linical picture (AU)

La construcción de la identidad personal y el desarrollo de la auto-autoría / The construction of the personal identity and the development of the self-authorship

El presente artículo se propone justificar la relevancia de analizar el vínculo entre la identidad y la auto-autoría. Entendiendo la identidad, con base en las propuestas de Giddens (1997) y Ricoeur (1996), como una construcción narrativa realizada a partir de una reflexión del individuo sobre su propia biografía. En concordancia con el abordaje de Baxter Magolda (2004), entendemos la auto-autoría como la capacidad del individuo de dar sentido a sus experiencias basándose en sus propios valores y creencias. Así, argumentamos sobre las ventajas de esta integración para entender a los jóvenes, y tratamos de mostrar que el análisis de las creencias epistemológicas del individuo es fundamental para comprender la construcción de su identidad entendida como un proceso reflexivo.

This article intends to justify the importance of analyzing the link between identity and selfauthorship. Understanding identity, based on Giddens' (1997) and Ricoeur's (1996) proposal,as a narrative construction starting from a reflection of the individual on his own biography. In accordance with Baxter Magolda's approach (2004), self-authorship is understood as the ability the individual has to make sense of his experiences based on his own values and beliefs. Thus, we argue about the advantages of this integration to understand the young people, and we attempt to show that the analysis of epistemological beliefs of the individual is fundamental to understanding the construction of his identity as a reflective process.

Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy.

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

Inter-identity autobiographical amnesia in patients with dissociative identity disorder.

BACKGROUND: A major symptom of Dissociative Identity Disorder (DID; formerly Multiple Personality Disorder) is dissociative amnesia, the inability to recall important personal information. Only two case studies have directly addressed autobiographical memory in DID. Both provided evidence suggestive of dissociative amnesia. The aim of the current study was to objectively assess transfer of autobiographical information between identities in a larger sample of DID patients. METHODS: Using a concealed information task, we assessed recognition of autobiographical details in an amnesic identity. Eleven DID patients, 27 normal controls, and 23 controls simulating DID participated. Controls and simulators were matched to patients on age, education level, and type of autobiographical memory tested. FINDINGS: Although patients subjectively reported amnesia for the autobiographical details included in the task, the results indicated transfer of information between identities. CONCLUSION: The results call for a revision of the DID definition. The amnesia criterion should be modified to emphasize its subjective nature.

Memory fragmentation in dissociative identity disorder.

This study examined the quality of self-reported memories of traumatic experiences in participants with dissociative identity disorder (DID) and compared them with their memories of non-traumatic, but emotionally significant life experiences. Systematic interview data were gathered from 30 DID patients in The Netherlands. All participants reported a history of severe childhood abuse; 93.3% reported some period of amnesia for the index traumatic event, and 33.3% reported periods of amnesia for significant non-traumatic childhood experiences. All participants who had been amnestic for their trauma reported that their memories were initially retrieved in the form of somatosensory flashbacks. This suggests that, like PTSD patients, DID patients at least initially recall their trauma not as a narrative, but as somatosensory re-experiencing. Surprisingly, however, DID participants also recalled emotionally charged non-traumatic life events with significant somatosensory components, a phenomenon that has not been previously reported. This finding raises important issues regarding basic memory processing abnormalities in DID patients.

Transfer of newly acquired stimulus valence between identities in dissociative identity disorder (DID).

Patients with Dissociative Identity Disorder (DID) frequently report episodes of interidentity amnesia, that is amnesia for events experienced by other identities. The goal of the present experiment was to test the implicit transfer of trauma-related information between identities in DID. We hypothesized that whereas declarative information may transfer from one identity to another, the emotional connotation of the memory may be dissociated, especially in the case of negative, trauma-related emotional valence. An evaluative conditioning procedure was combined with an affective priming procedure, both performed by different identities. In the evaluative conditioning procedure, previously neutral stimuli come to refer to a negative or positive connotation. The affective priming procedure was used to test the transfer of this acquired valence to an identity reporting interidentity amnesia. Results indicated activation of stimulus valence in the affective priming task, that is transfer of emotional material between identities.

Dissociative identity disorder associated with mania and change in handedness.

OBJECTIVE: To investigate the overlap between dissociative and bipolar disorders with reference to their neurophysiological foundations. BACKGROUND: Case reports of anomalous lateralization and shifts in handedness associated with both affective and dissociative conditions have intermittently surfaced in the literature. The two disorders are, however, usually considered to be distinct psychopathological entities. METHOD: A case of co-occurring bipolar disorder and dissociative identity disorder (DID) is presented. RESULTS: The "switch" in personality coincided with manic or hypomanic symptoms and was associated with a change in handedness. CONCLUSIONS: A parallel between the "personality" shifts that characterize DID and the mood fluctuations that underlie bipolar disorder is drawn, suggesting some nosological overlap between the two disorders. The possibility that these two psychiatric conditions share a similar neurophysiological architecture is also raised.

Dissociative identity disorder and memory dysfunction: the current state of experimental research and its future directions.

Memory dysfunction is a central feature of dissociative identity disorder (DID). Following the memorial anomalies outlined by Putnam [Putnam, F. W. (1994). Dissociation and disturbances of self. In: D. Cicchetti & S. L. Toth (Eds.), Disorders and dysfunctions of the self, vol. 5 (pp. 251-265). Rochester, NY: University of Rochester Press; Putnam, F. W. (1995). Development of dissociative disorders. In: D. Chicchetti & D. J. Cohen (Eds.), Developmental psychopathology, vol. 2 (pp. 581-608). New York: Wiley], the experimental research using DID case studies and samples is reviewed. As a whole, research suggests that amnesic barriers between alter personalities are typically impervious to explicit stimuli, as well as conceptually driven implicit stimuli. Autobiographical memory deficits are also experimentally evident in DID. Although no experimental studies have addressed the issue of source amnesia or pseudomemories, there is some evidence that pseudomemories are an infrequent but real phenomenon in DID patients. Finally, potential deficits in working memory are outlined, including those relating to cognitive inhibition. Research directions are discussed throughout to further elucidate the nature of memory dysfunction in DID.

Transitional interpersonality thunderclap headache.

OBJECTIVE: To report a patient with multiple personality disorder who experienced severe acute headaches without warnings, solely during the transition between her host personality and her pain-prone personality. BACKGROUND: The initial detailed description of headache in multiple personality disorder was made by Packard and Brown and published in this journal 15 years ago. METHODS: Clinical history, neurologic examination, electroencephalogram, and brain magnetic resonance imaging. RESULTS: A 54-year-old Holocaust survivor with an established diagnosis of multiple personality disorder had recurrent, excruciating, acute ("thunderclap") headaches only when switching between her domineering personality and her pain-prone personality, who suffered from chronic back pain. None of her personalities otherwise suffer from headaches. Electroencephalogram and brain magnetic resonance imaging were normal. CONCLUSION: This is an independent and current confirmation of the existence of transitional headaches in a patient with multiple personality disorder. They may occur as an isolated event during the switch process and have features of benign thunderclap headache.