Diagnosis and Differential Diagnosis of Dissociative Identity Disorder: A Case Report

Sahin N; Balkan D

Case Study

Diagnosis and Differential Diagnosis of Dissociative Identity Disorder: A Case Report

Sahin N^* and Balkan D
Department of Child and Adolescent Psychiatry, Mugla Sıtkı Koçman University, Turkey

^*Corresponding author: Nilfer Sahin, Department of Child and Adolescent Psychiatry, Mugla Sıtkı Koçman University, Turkey

Published: 24 Oct, 2018
Cite this article as: Sahin N, Balkan D. Diagnosis and Differential Diagnosis of Dissociative Identity Disorder: A Case Report. Ann Clin Case Rep. 2018; 3: 1550.

Abstract

Dissociation is defined as the impairment or alteration in the complementary functions of consciousness, memory and identity. Contrary to the common belief, the frequency of Dissociative Identity Disorder is not uncommon, however, symptoms are difficult to diagnose unless specifically questioned, and these patients may be misdiagnosed. It can be a long time between psychiatric admission and diagnosis. Until diagnosis, patients can have different diagnoses such as affective disorder, personality disorder, anxiety disorder and schizophrenia. In this case report, a 15-year-old male with dissociative identity disorder who admitted to our polyclinic with psychotic findings, will be discussed.
Keywords: Differential diagnosis; Dissociative identity disorder; Diagnosis

Introduction

Dissociation is defined as the impairment or alteration in the complementary functions of consciousness, memory and identity. Dissociative Symptoms can disrupt all areas of psychological functions [1]. The frequency of Dissociative Identity Disorder (DID) is not uncommon, contrary to what is thought. According to community-based studies the prevalence of Dissociative Identity Disorder (DID) is estimated to be about one percent. The prevalence of DID is higher among patients receiving mental health care, but rates vary widely [2,3]. The prevalence rate of DBP in psychiatric inpatients in Turkey is 5.4%. The rate is 2.8% among substance addict patients and 2.0% to 2.5% in general psychiatric patients who applied to the outpatient clinic [4-6]. Dissociative Disorders usually begins in childhood. Despite the early onset, adolescents (12-18 years of age) with DID are less than 8% [7]. Although it is common, it is difficult to diagnose unless its symptoms are specifically questioned. Since patients think that they can be misunderstood, they often do not tell the symptoms without being asked. It has been shown in studies that there is an average of 7 years between the patients admitted to the psychiatry clinic and their diagnosis and meanwhile the patients have been got 4 different diagnoses such as affective disorder, personality disorder, anxiety disorder and schizophrenia [8]. Especially adolescents with dissociative disorder are often misdiagnosed because they show the behavior and symptoms of other psychiatric disorders specific to this age group. Other psychopathological features may mask dissociative disorder [9,10]. In our case, due to the presence of schneiderian symptoms and depressive symptoms in dissociative disorders, there were many features that could be confused with these diseases. Our aim in preparing the case report is to emphasize that dissociative disorder should be kept in mind and questioned in patients with similar complaints that we have frequently encountered in the clinic.

Case

15-year-old male patient, student at open high school, he lives with his parents, and his sisters, aged 13 and 2. Dad is a 43 years old tradesman. Mother is a 38 years old housewife. Six years ago, they migrated from Kahramanmaraş to Muğla due to his father's job. 3 months ago, he applied to clinic for several hours of hallucinations in the form of seeing blood on the ground and seeing dead bodies in the kitchen after watching a horror film, and depersonalization in the way of monitoring his body from the outside. Routine hemogram and biochemistry analysis results evaluated by pediatric neurology, tox drug results, MRI and EEG results were normal. No organic pathology was detected in the case. Then, he was evaluated by the pediatric psychiatry and treatment with sertraline 25 mg/day and risperidone 2 mg/day was started.
According to the information received from the patient who received this treatment for about 3 months; he had been living in Muğla for about 6 years, he felt very lonely here, he was unhappy for this reason, he wanted to return to his country and he would be happier with his cousins there. About 4 years ago, after moving to Muğla, he said that he received the death knell of his grandfather who was the most supportive of him and whom he loved the most, and went to the country for the funeral. He said that when they returned and were sitting with his brother at father's workplace, a man from the same neighborhood came and said "If I see you here again, I will kill your father". He said he was very scared of this but never saw that man again. He couldn't remember another traumatic event. When he was asked about the hallucinogenic experience he had three months ago, he was able to recall parts of the incident. He said that it did not recur, and he did not describe any other visual hallucinations. He said that he had heard voices coming from inside of his head for about 4-5 years, that there was too much sound, that he could not understand many of them, and that what he understood was voices giving orders like "get out of here". Apart from these sounds, he was able to distinguish two different voices, the first of them belonged to İsmail, who was 20 years old, physically very strong, medical school student and who started to live with him 4 years ago after the death of his grandfather; The second one belonged to Necati who was 24 years old, working in industry as a worker, with the ability to control the light and who started to live with him when he escaped from home to his country. By connecting with the two alter identities via the host, it has been learned that Ali who was 32 years old and wasn't recognized by host before but started to live with the host after preventing him from suicide by taking drugs, was present. He said that these alter as do not take control completely; they can sometimes affect him as passive influences. Several times, he described amnesic periods, which lasted maximum two hours. He said that he and his friends were out in these periods and they had not used alcohol or drugs, that the next day when he talked to his friends, he couldn't remember what he was doing in those few hours, and he had learned those from his friends. He didn't have any somatic complaints. Especially for 6 months, he had depressive feelings, anhedonia, initial insomnia, lack of energy, thoughts of death in passive nature, thoughts of worthlessness and loneliness. It was learned that he had smoked too much recently. There was no history of substance use.
In the mental state examination; he was the adolescent patient who showed his age and had good self-care. Consciousness was open and orientation was complete. His psychomotor activity was slightly decreased. He was respectful to the interviewer. His mood and affectivity were mildly depressive and his speech was spontaneous, and speed was reduced. He described visual, auditory hallucinations and depersonalization. His thought content was dominated by depressive themes and themes related to going home, he had suicidal thoughts in passive nature, thought process was natural. The level of intelligence was normal.
As a result of the patient's history and examination, according to DSM-5, due to the presence of 3 different alter personality other than the host person, simple amnesic periods that cannot be explained with a simple forgetfulness, presence of schneiderian symptoms, depersonalization experiences, depressed mood, anhedonia, low energy, initial insomnia, worthlessness and occasionally passive death thoughts, pre-diagnosis was considered as Dissociative Identity Disorder and Major Depressive Disorder. The result of the Dissociative Experiences Scale (DES) was 32 and the Depression Scale for Children was found to be 23. Weekly meetings were planned with Alters. Because of depressive disorder, the risky behaviors such as escape from home, death thoughts in passive nature and suicide attempt by taking drugs once in the past, pharmacological treatment was continued in the same way.
In the second meeting; he said that the sounds he heard had decreased after the previous meeting and that after Ali's appearance two other alters did not come. Through the host, we had an interview with Ali. The deal with alters was rebuilt.
In the 3 interview; he said that all the noises had disappeared and Ali had gone after the last meeting. He was reminded of the agreement with alters again. Except of mild level of depressive symptoms and intense thoughts about going to his country, occasionally forgetfulness, amnesias lasting 1-2 hours which is not very often, the patient had no symptoms related to alter and the sounds he heard. This situation made us think that the system of alter had ceased to communicate in order to hide themselves, that the fusion had not yet taken place and should continue with the attempts to gain the trust of the alter. Interviews with the patient continue.

Discussion

In the etiology of dissociation, childhood traumas, abuse and neglect have a very important place. Initially, dissociation acts as a defense against childhood trauma and allows the child to move away from a situation that he/she cannot control. However, it becomes pathological when it continues to be used when it has physical control over time [11]. In our case, there were traumatic experiences such as migration, loss of a loved one, and threatening death of another loved one.
In addition to childhood traumas, family environment, attachment disorders, social and cultural factors are thought to play a role in the etiology of dissociation. Genetic etiology has not been elucidated yet, and in brain imaging studies, the hypoperfusion of the orbitofrontal lobe, degrowth in the hippocampus, amygdala and parahippocampal gyrus are mentioned [12].
The main symptoms of dissociative disorders are amnesia, depersonalization, derealization, identity confusion and identity change [13]. In addition to these, there are schneiderian symptoms that frequently accompany dissociative disorders and can lead to diagnostic complexity, symptoms of post-traumatic stress disorder, symptoms of mood disorder, suicide attempts, self-destructive behaviour, somatoform disorder, eating disorder and personality disorder [14]. In a controlled study conducted by Sar et al. [15], it was found that 93.9% of the adolescents had an additional psychiatric disorder and the most common concomitant diagnoses were separation anxiety disorder, major depressive disorder, Attention Deficit Hyperactivity Disorder (ADHD) and oppositional defiant disorder. In our case, there were symptoms of depressive mood disorder, schneiderian symptoms and suicide attempt. These symptoms facilitate the concealment of the basic symptoms of dissociative disorder such as amnesia, depersonalization and alter identities.
Among this symptom confusion, differential diagnoses of the patients' imaginary friends, ADHD, psychotic disorders, mood disorders, epilepsy, and behavioral disorders should be made carefully.
Because of the presence of auditory hallucinations, thinking that the connotations are disorganized as a result of rapid personality changes, thinking that there are thought blocks because of alters that orders him to not to speak, and inconsistent and unreasonable behaviors due to alter changes should be carefully evaluated in the differential diagnosis with psychotic disorders. However, features such as the functionality of the child, the interest in the environment, the absence of response from auditory hallucinations to antipsychotic drugs suggest dissociation rather than a psychotic disorder.
This disease, which is more common than it is thought, and which is especially affected by childhood experiences, is an issue that should be known to all health workers who are interested in children and adolescents. It is difficult and retarding to diagnose because of complex symptom clusters, unless especially unquestioned. However, early recognition is important both in terms of protecting the child from traumatic experiences and early diagnosis, so that the treatment is easier and shorter.

Case Study