Mary is a 27-year-old woman seen for a series of three consultation sessions to evaluate self-harming behaviors via cutting. She states she knows she cut herself but that “I only know about it because I can see I have cuts. I don't remember cutting. I know I must have done it because there is nobody else who could or would have done it!”
In addition to this self-destructive behavior, she complains of symptoms of major depression with massive sleep disturbance (she sleeps randomly when exhausted), severe anxiety and panic attacks, and recurrent confusion. She describes seeing blood on the floor frequently but indicates she knows it isn't really there: “Things don't feel real to me, ever.”
When asked to describe her experience of her body, she looks puzzled for a moment, then replies: “Body, I know what you mean, because I know that everybody has a body. As far as I'm concerned, this body is something that is somehow connected to me, but I have never been in my body.” She reports that people have come up to her at her job and said they knew her, but that she did not know them. She also says another odd thing that happened at work was when her co-workers reported to her that they found her curled up in a ball in a corner of the warehouse. She has no recollection of the incident itself, but repeats what she had been told.
She reports she “loses time” frequently and may find that several hours may have elapsed since she was last fully aware of herself. She often is confused and requests that we not discuss the meaning of having lost time experiences. She believes “I am probably better off not knowing.” She says she often finds papers among her most personal effects but has no idea how they got there.
She has a history of substance abuse, having experimented with a number of street drugs. Her drug of choice is marijuana. In regard to her sleep disturbance, marijuana may help her to relax. She is often frightened at night and reports that closing her eyes is “unmanageable.”
She says she had received a number of psychiatric diagnoses in the past, including schizophrenia, schizoaffective disorder, rapid-cycling bipolar disorder, and major depression. She says that she understands the depression “piece” but that the others don't fit her, and she has read about them. She says she knew she was moody — everybody told her so — but that her jumps from being excited about something to being severely depressed often happen several times a day, for no apparent reason, and that she is left “confused and not knowing who or how I am.”
During discussion of her life history and her recollection of childhood experience, Mary suddenly begins to speak in the frightened voice of a small child and cries. The clinician gently inquires, “You sound frightened and you are crying. Do you know what that's about?” She continued to cry, drawing her legs up under her body and seeming to try and disappear into the chair. “I'm scared,” she sayes, “I don't want to be left here.” The clinician is uncertain of the context of the patient's reference regarding “here” and continues the interview in a common sense way, checking on the patient's degree of orientation:
“My name is Dr. Smith. What's your name?”
“Who is Mary?”
“Mary is big, and I'm little. She doesn't like me because I cry and make her upset, but I can't help it, I'm scared and I don't want to be left here!”
To the clinician, it appears as if the subjective sense of the patient as Janey was that “here” indicated being present for the interview. Following that thought, the common sense response was to address the subjective view of Mary, who had been present:
“Mary, it seems that there is a lot of ‘scared’ present right now. Can we talk about that, please, Mary?”
The patient's facial expression changes abruptly as her eyelids blinked closed for a moment, and her body relaxes as Mary begins to speak through a tear-streaked face, of which she seemed oblivious. “I'm sick and tired of her! She pops out whenever she is scared and gets me in trouble! Damn! Why does she do that to me?! I can't stand her and her moaning about being scared!”
The patient is well oriented and without evidence for a thought disorder. She also denies the presence of hallucinations or delusions but notes that she hears comments from inside her head regarding her behavior that are specific, derogatory at times, and express preferences for action and making choices in activities that are typically at odds with her own sense of will. She denies thought broadcasting and ideas of reference.
She acknowledges posttraumatic experiences such as intrusive thoughts and images, affective numbing, heightened startle reflex, and hyperarousal states. She also reports numerous dissociative experiences, including but not limited to flashback-quality revivification, enthrallment, spontaneous trance and age regression, switching phenomena, lost time, passive influence and interference phenomena with made feelings and impulses, disremembered behavior, and references to the presence of alternate states of consciousness with independent experience and narrative histories with executive control of the body.
However, when the clinician queries her regarding these alternate self-states, she expresses intense distress, with images of violent behavior and inner voices proclaiming admonishments to proceed no further with the inquiry. She fears great harm might come to her if she proceeded at these points. She associates this experience with admonishments in childhood not to tell about abuse. This occurrs on three occasions in three separate hours of the evaluation.
Suicidal ideation is chronic and, paradoxically, absent of intent because “then I wouldn't be able to hurt myself to atone for what I did.” The patient reports her imagination is so intense that she routinely is unable to recall whether or not she had just thought or actually done something.
Her speech is normal but varies between interview sessions with regard to the global manner of eye contact (none though openly engaged), energy (passive in one session and hypomanic in the last), and sophistication of language (street smart versus intellectual). Her judgment is poor and limited by a fragmentary memory and her inability to trust her own reliability based on her knowledge of lost time and fugue, during which she would cut or burn herself and have no memory of it. She reports that at other times she could scratch herself and feel no pain. Her ability to provide a cogent history is limited by a tendency toward tangentiality, which she acknowledges in the last session to be a distraction strategy to keep the interviewer at a distance. She was quite apologetic for this, but was unable to alter this behavior even though she said she tried.
Diagnosis and Discussion
Does this patient have psychosis or schizophrenia?
While she denies the presence of hallucinations and delusions, she does report seeing blood on the floor and also knew that it wasn't really there. She heard voices from inside her head, not from outside. Auditory hallucinations are common in both schizophrenia and dissociative disorders. Schneiderian first-rank symptoms are actually more common in the dissociative disorders,1 except for thought broadcasting and ideas of reference (Kluft, see page 633). Hearing voices does not guarantee a diagnosis of schizophrenia, although it does satisfy criterion A when voices provide a running commentary or converse with each other.2
However, a presumptive diagnosis of schizophrenia on the basis of hearing voices, without considering issues related to dissociation, may be misleading. The presence of the hallucination of blood on the floor, in the context of her cutting behaviors and amnesia for those activities, raises the possibility of this being an implicit memory with a flashback-quality experience, rather than a hallucination of a bizarre variety. She spoke in the voice of a child, and made reference to Mary as being another person different from her, followed by Mary doing the same for Janey.
The patient interview provided evidence for profound depersonalization, derealization, amnesia, identity confusion, and identity alteration. She met full criteria for dissociative identity disorder in criteria from both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),2 and the Structured Clinical Interview for the Diagnosis of DSM-IV Dissociative Disorders – Revised (SCIDD-R)11 (Kluft, see page 633).
Clearly, to consider “hearing voices” as presumptive of schizophrenia without a concurrent effort to discern the absence or presence of dissociative symptoms could provoke clinical difficulty. Patients usually will not report experiences of depersonalization, derealization, and identity confusion/alteration voluntarily. Careful and skillful interviewing is essential to diagnosis.3
Axis I diagnoses for this patient include dissociative identity disorder, posttraumatic stress disorder, and major depression. Isn't the patient bipolar? Rapid-cycling is defined as mood change that occurs four times per year or more. The bipolar disorder construct would seem to imply that there is a relatively slow shift in biochemical process that results in a switch of mood from euthymia to depression or mania. Adapting this construct to explain switches that occur in a weekly manner, daily, or multiple times each day does not seem to rely upon a biochemical model.
What the patient described was a shift in subjectivity. This includes cognitive as well as meaning structures in discerning the difference between her experience of herself as Janey versus Mary. This switch occurred back and forth in a couple of minutes. Changes in subjective state that occur this fast seem to hopelessly distort bipolarity as a syndromal concept. There is evidence that proposed mechanisms of biochemically driven bipolar state change can account for the shifts in subjectivity described by this patient. On the other hand, state changes that include identity alteration are the sine qua non of dissociative disorders, and the diagnosis has been validated to an extent that meets or exceeds other psychiatric diagnoses.4 Detailed theoretical explorations of the development of states of mind are available in both the study of neuroscience5 and infant attachment,6 for example. Psychoanalytic models are also of note.7,8 Unfortunately, core training programs in psychiatry and psychology often omit studies in the dissociative disorders.
Another possible diagnostic consideration would be a severe characterologic disorder such as borderline personality disorder (BPD). Dissociative identity disorder is an Axis I diagnosis, not a personality disorder, although this does not exclude concurrent diagnosis of an Axis II disorder. Of equal importance to this question, given that the patient has posttraumatic stress disorder, is the extent to which that, and the alternating states of a dissociative disorder, might account for meeting criteria for BPD. Regardless, while she undoubtedly does meet criteria for BPD on axis II, it is concurrent with her Axis I diagnosis. What will be most interesting is to watch the extent to which her borderline symptoms might remit when her dissociative symptoms are better compensated. In this clinician's experience, that is often, but not always, the case.
In a patient of this complexity, where does one begin? An eclectic, multifaceted approach is in order. Safety from self-injury is a “bottom line” starting point. Some of the approaches possible are outlined elsewhere in this issue (Welzant, see page 678). It may be especially useful to consider that self-injurious behavior is paradoxically self-soothing and affect regulatory. Cutting may induce a dissociative reaction that includes global affective numbness and relief from feelings of terror, intractable shame, humiliation, panic, posttraumatic intrusion, and similar overwhelming experience. Bulimic behavior provides a similar “rebooting” of affective consciousness, usually associated with a numbing dissociative “fog” after purging, followed by sleep. Efforts to remove the symptom without first providing direct relief for overwhelming affects are likely to fail.
Pharmacologic intervention to provide an increment of affective control is useful. Selective serotonin reuptake inhibitors may do this, even in low doses, although some experienced clinicians find, in their patient populations, that higher doses are almost always necessary (Loewenstein, see page 666). Hypnosis, used for affect regulation, may be especially effective and provide a sense of self-efficacy through teaching self-hypnosis.9 Guided imagery techniques fall into this category.
An eclectic, flexible approach to treatment that has a basic respect for psychodynamic issues is a gold standard of treatment for these disorders. Experienced clinicians who are new to the treatment of dissociative disorders may become easily rapt by the phenomenology of the disorder itself, and temporarily misplace their hard won basic psychotherapeutic common sense. It is worth making note of this idea. Guidelines for treatment of dissociative identity disorder are available on the web site of the International Society for the Study of Dissociation12 and have been revised and will be published later this year.10,12
Editor's Note: This monthly presentation describes a case of a psychiatric disorder, discusses past treatment attempts, offers options for continuing treatment, and explains the reasons the solution was selected. Submissions of interesting psychiatric case reports are being accepted for this department. Please e-mail
email@example.com for further information.
This case is presented by Richard A. Chefetz, MD, guest editor.
- Kluft RP. First-rank symptoms as a diagnostic clue to multiple personality disorder. Am J Psychiatry. 1987;144(3):293–298. doi:10.1176/ajp.144.3.293 [CrossRef]3826426
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
- Loewenstein RJ. An office mental status examination for complex chronic dissociative symptoms and multiple Personality disorder. In: Loewenstein RJ, ed. Psychiatric Clinics of North America, vol. 14. Philadelphia, PA: W.B. Saunders Company; 1991:567–604. doi:10.1016/S0193-953X(18)30290-9 [CrossRef]1946025
- Gleaves DH, May MC, Cardena E. An examination of the diagnostic validity of dissociative identity disorder. Clin Psychol Rev. 2001;21(4):577–608. doi:10.1016/S0272-7358(99)00073-2 [CrossRef]11413868
- Siegel DJ. The Developing Mind: Toward A Neurobiology of Interpersonal Experience. New York, NY: The Guilford Press; 1999.
- Main M, Morgan H. Disorganization and disorientation in infant strange situation behavior: phenotypic resemblance to dissociative states. In: Michelson LK, Ray WJ, eds. Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives. New York, NY: Plenum Press; 1996:107–138. doi:10.1007/978-1-4899-0310-5_6 [CrossRef]
- Bromberg PM. Standing in the Spaces. Hillsdale, NJ: The Analytic Press; 1998.
- Stern D. Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press; 1997.
- Kluft RP. Applications of hypnotic interventions. Hypnos. 1994;XXI(4):205–223.
- Chu JA, Loewenstein R, Dell PF, et al. International Society for the Study of Dissociation. Guidelines for treating dissociative identity disorder in adults. J Trauma Dissociation. In press.
- Steinberg M. Structured Clinical Interview for the Diagnosis of DSM-IV Dissociative Disorders – Revised. Washington, DC: American Psychiatric Publishing; 1994.
- Barach P, Bowman E, Fine C, et al. International Society for the Study of Dissociation. Guidelines for treating dissociative identity disorder (multiple personality disorder) in adults. 1997. Available at: http://www.issd.org/indexpage/isdguide.htm. Last accessed on July 20, 2005.
- International Society for the Study of Dissociation. Guidelines for treating dissociative identity disorder (multiple personality disorder) in adults (1997). J Trauma Dissociation. 2000;1(1):117–134. doi:10.1300/J229v01n01_09 [CrossRef]