Prognosis

Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and posttraumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of other serious psychiatric disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration. Sometimes therapy helps a patient with a poorer prognosis make rapid strides toward recovery.

Treatment of Dissociative Identity Disorder (DID)

Symptoms wax and wane spontaneously, but dissociative identity disorder does not resolve spontaneously. Drugs help manage specific symptoms but do not affect the disorder itself. All successful treatments that aim to achieve integration involve psychotherapy that specifically addresses the dissociative identity disorder. Some patients are unable or unwilling to pursue integration. For them, treatment aims to facilitate cooperation and collaboration among the personalities and to reduce symptoms. This treatment is often arduous and painful, and many crises tend to arise as a result of the personalities' actions and the patient's despair when dealing with traumatic memories. One or more periods of psychiatric hospitalization may be necessary to help some patients through difficult times and during the processing of particularly painful memories. Hypnosis is often used to help access the personalities, facilitate communication between them, and stabilize and interpret them. Hypnosis is also used to discuss traumatic memories and diffuse their impact. Eye movement desensitization and reprocessing (EMDR), applied cautiously, is a useful adjunct. EMDR tries to process traumatic memories and to replace negative thoughts about self that are associated with these memories with positive ones.

Generally, two or more psychotherapy sessions per week for 3 to >= 6 years are necessary to integrate the personalities or to achieve harmonious interaction among them that allows normal functioning without symptoms. Integration of the personalities is the most desirable outcome.

Psychotherapy has three main phases. In the first phase, the priority is safety, stabilization, and strengthening of the patient in anticipation of the difficult work of processing traumatic material and dealing with problematic personalities. The personality system is explored and mapped to plan the remainder of the treatment. In the second phase, the patient is helped to process the painful episodes of his past and to mourn the losses and other negative consequences of the trauma. As the reasons for the patient's remaining dissociations are addressed, therapy can move to the final phase, in which the patient's selves and relationships and social functioning can be reconnected, integrated, and rehabilitated. Some integration occurs spontaneously, but much must be encouraged by conversing with and arranging the unification of the personalities or must be facilitated with imagery and hypnotic suggestion. After integration, patients continue treatment to deal with some issues that have not been resolved. After postintegration treatment appears complete, visits to the therapist are tapered but are rarely completely terminated. Patients come to think of the psychiatrist as someone who can help them deal with psychological issues, just as they periodically need assistance from a primary care physician.

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Reviewed: 04/2006