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Quantum Units Education

Dissociative Identity Disorder (DID)

Epidemiology, Clinical Diagnosis, and Diagnostic Procedures

1. Which of the following is an accurate statement about studies related to the prevalence of Dissociative Identity Disorder (DID)?

A. In studies of the general population, a prevalence rate of DID of two to six percent of the population has been described

B. Clinical studies in North America, Europe, and Turkey have found that between five to fifteen percent of patients on general inpatient psychiatric units, adolescent inpatient units, and in substance abuse, eating disorders, and obsessive compulsive disorder treatment may meet DSM-IV-TR diagnostic criteria for DID

C. Accurate clinical diagnosis affords early and appropriate treatment for the dissociative disorders, and seven studies of 719 DID patients have shown that they spent three to eight years in the mental health system before they were diagnosed as having DID

D. While progress has been made in educating the professional community about the prevalence and clinical presentation of dissociative disorders, these seven studies suggest that many cases of DID and related disorders are still being missed, misdiagnosed, and inappropriately treated

2. According to the Diagnostic and Statistical Manual, 4th Edition, Text Revision, each of the following is one of the diagnostic criteria for Dissociative Identity Disorder EXCEPT:

A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self)

B. At least one of these identities or personality states recurrently take control of the person’s behavior

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness

D. The disturbance is not due to the direct physiological effects of a substance or a general medical condition

3. Dissociation is defined as “A disruption in the usually integrated functions of consciousness, memory, identity, or perception” and is an ongoing process in which certain information (such as feelings, memories, and physical sensations) is kept apart from other information with which it would normally be logically associated.

A. True

B. False

4. Patients commonly refer to themselves as having, among others, “parts,” “parts inside,” “aspects,” “facets,” “ways of being,” “voices,” “multiples,” “persons,” “individuals,” “spirits,” “demons,” “lines,” and “others.”

A. True

B. False

5. Alterative identities in DID patients have a sense of self, an emotional repertoire, and:

A. Can process information

B. Have limited structure

C. Have the capacity to interact

D. Both A and B above

6. Developmental models propose that DID arises from a previously mature, unified mind or “core personality” that becomes “shattered” or fractured, and from a failure of normal developmental integration caused by overwhelming experiences and disturbed caretaker-child interactions during critical early developmental periods.

A. True

B. False

7. Each of the following accurately describes the interview process and instruments used to assess disassociation EXCEPT:

A. An office mental status examination should inquire about many of the symptoms of DID, including evidence of alternate identities, amnesia, autohypnotic phenomena, PTSD, somatoform symptoms, and affective symptoms

B. The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised assesses amnesia, depersonalization, derealization, identity confusion, and identity alteration

C. The Clinician Administered Dissociative States Scale measures dissociative states and has three factors that assess symptoms of identity confusion, regression, and identity alterations

D. The Dissociative Experiences Scale is the first and most successful of the self-report measures of dissociation and primarily taps absorption, imaginative involvement, depersonalization, derealization, and amnesia

8. According to the authors, dissociative systems are central in other dissociative disorders and in:

A. PTSD somatization disorder

B. Personality disorders and bipolar disorder

C. Major depression and dysthymia

D. Both A and B above

Goals of Treatment

9. Within the DID patient’s subjective experience, he or she experiences a collection of separate people sharing the same body.

A. True

B. False

10. In working with Dissociative Identity Disorder patients, it is the consensus of expert opinion that wherever possible, treatment should move the patient toward:

A. Better integrated functioning

B. Achievement of full fusion

C. Understanding the role of each identity

D. None of the above

11. Systematic outcome studies have shown a positive outcome for DID when using a model including direct work with alternate identities and:

A. Therapies that tend to be less comprehensive

B. Trauma material to help achieve greater integration for the DID patient

C. Focus on resolving extremely painful life issues

D. Using adaptive ways to solve problems

Phase Oriented Treatment Approach

12. Over the past two decades, the consensus of experts is that complex trauma-related disorders including DID are most appropriately treated with a phase or stage oriented approach. The most common structure for this is a treatment consisting of three phases or stages including all of the following EXCEPT:

A. Reducing the suffering that exists in day to day life

B. Safety, stabilization and symptom reduction

C. Working directly and in depth with traumatic memories

D. Identity integration and rehabilitation

13. Which of the following is a true statement about suicide with DID clients?

A. The National Comorbidity Study (Kessler, 2000) found that a diagnosis of PTSD which is related to DID, is associated with a four-fold increase in the likelihood of an initial suicide attempt

B. Individuals with PTSD are two times more likely to make a suicide plan or impulsive suicide attempt compared with those with Major Depression

C. The high rates of severe, repetitive childhood sexual abuse and other forms of maltreatments in the histories of DID patients, strongly indicate that self-injurious behavior including suicidal and parasuicidal behaviors will be common with these patients

D. All of the above

14. Safety issues should be addressed in a comprehensive and direct manner while other treatment issues may need to be put on hold until safety is established. Interventions should include each of the following EXCEPT:

A. Education about the necessity for safety and identifying alternate identities who act unsafely and/or control unsafe behaviors

B. Insight-oriented therapy to help the client understand the negative thought processes that commonly underlie unsafe behaviors

C. Use of symptom management strategies such as grounding mechanisms, crisis planning, self-hypnosis and/or medications to provide alternatives to unsafe behaviors

D. Involvement of appropriate agencies if the clinician has a reasonable suspicion that the patient is abusive to children or to vulnerable adults or is in danger of acting violently towards another person

15. Most models of phase oriented treatment begin with an initial period of symptom stabilization, and the focus in this phase of treatment is the management and control of symptoms rather than exploration of traumatic memories.

A. True

B. False

16. Chronically traumatized individuals, including DID patients, may benefit from periodic interventions such as skill building, soothing images, reaffirming statements, and calming imagery that help them delay, contain or control the level of intrusiveness of the traumatic material into their daily functioning. These strategies are known as:

A. Alternative coping skills

B. Self empowerment exercises

C. Internal enhancement approaches

D. Ego-strengthening interventions

17. Clinicians must accept that successful treatment of DID almost always requires interacting and communicating with the alternate identities in some way.

A. True

B. False

18. Some alternate identities may insist that they do not inhabit “the body” of the host identity, and they may insist that suicide or self injury has no effect on themselves, only on other identities. As a result, severe safety problems can result from this issue, which is known as:

A. Neurotic disjointedness

B. Distorted isolation

C. Misconceived divergence

D. Delusional separateness

19. Which of the following is a true statement about trust and the therapeutic alliance?

A. Treatment may begin to erode dissociative barriers and defenses, leading to greater intrusion of traumatic memories, and patients may feel vulnerable and have difficulty with trust

B. “Traumatic transference” reactivity may be intense among various alternate identities, and while the host appears to trust the therapist, other identities may feel vulnerable and sabotage the therapy

C. The clinician should be actively aware of the potential difficulties of building a therapeutic relationship, and structure sessions to include education about the nature of DID and trauma treatment, and the intense discomfort that can be engendered during treatment

D. All of the above

20. The therapist must carefully plan which memories will be the focus, at what level of intensity, which alters will participate, how to maintain safety during the work, and procedures to contain material if the work becomes too intense.

A. True

B. False

21. Active work on traumatic memories ultimately aims to bring together most dissociated aspects of traumatic experience, including the sequence of events that occurred, and:

A. The understanding of the role of self and others in the events

B. The need to gain control over the experiences

C. The re-experiencing of events while finding alternative meanings to them

D. None of the above

22. As patients become less fragmented, they usually develop a greater sense of calm, resilience, and internal peace and they no longer feel the need to revisit their trauma history, and are able to disconnect from traumatic memories.

A. True

B. False

23. Which of the following is an accurate statement about the frequency of treatment sessions for DID patients?

A. In working with a therapist of average skill and experience, the minimum frequency of sessions for most DID patients is two to three times a week

B. Long-term supportive Phase 3 treatments usually occur once or twice per week depending on the patient’s ability to manage symptoms and maintain themselves at an outpatient level of care

C. For intensive Phase 2 therapy work, many patients will need to be seen two times per week or more in order to provide sufficient intensity for the trauma work and to keep a focus on everyday events in the patient’s life

D. All of the above

24. While some DID patients have  benefited from two 75-90 minute sessions or one extended session and one 45-50 minute session per week, it is generally agreed that sessions longer than 90 minutes are counterproductive and not necessary.

A. True

B. False

25. The most commonly cited treatment orientation for Dissociative Identity Disorder is standard cognitive behavioral therapy, often eclectically incorporating other techniques.

A. True

B. False

26. Which of the following is NOT a correct statement about inpatient treatment for DID?

A. Inpatient treatment should occur in the context of a goal-oriented strategy designed to restore patients to a stable level of function so that they may resume outpatient treatment expeditiously

B. Efforts should be made to identify the factors that have destabilized or threaten to destabilize the DID patient, and emphasis should be placed on building strengths and skills to cope with the destabilizing factors

C. Specialized inpatient units dedicated to the treatment of trauma and/or dissociative disorders may be particularly effective in helping patients develop the skills they need to become more safe and stabilized as outpatients

D. If a DID patient gets to the point of needing hospitalization, it is likely that the hospital stay will be extensive enough to cover intensive individual psychotherapy, psychopharmacological interventions, and symptom management and skill-building

27. Although group psychotherapy is not a viable primary treatment modality for DID, certain types of time-limited groups for selected patients with DID or complex PTSD can be valuable adjuncts to individual psychotherapy.

A. True

B. False

28. Which of the following most accurately describes the use of psychotropic medications for the treatment of DID?

A. Nearly all classes of psychotropic medications have been used empirically with DID patients, and anxiolytics are generally used to treat anxiety symptoms associated with PTSD

B. Neuroleptic or antipsychotic medications have been used to successfully treat the overactivation, thought disorganization, intrusive PTSD symptoms as well as the chronic anxiety, insomnia and irritability experienced by many DID patients

C. Major Depressive Disorder is a common outcome of trauma experienced by DID patients and the monoamine oxidase inhibitors (MAOIs) and the tricyclic antidepressants (TCAs) are the most commonly used medications for these disorders

D. In general, barbiturates, are prescribed to help DID patients who suffer from complex sleep disorders including PTSD nightmares and flashbacks

29. There is a long history of reports of psychophysiological differences between the alternate identities in DID. According to the authors, case reports indicate differences in each of the following areas EXCEPT:

A. Intellectual functioning

B. Medication responses

C. Plasma glucose levels in diabetic patients

D. Differential EEG patterns

30. Hypnosis has been used to assist the treatment of DID since the early 19th century and can be used as a facilitator of treatment, or as a treatment in and of itself.

A. True

B. False

31. While controversy exists concerning the application of Eye Movement Desensitization and Reprocessing (EMDR) to the treatment of DID, there is empirical support for EMDR as an efficacious treatment for complex PTSD and dissociative disorders.

A. True

B. False

32. Each of the following is an accurate statement about alternative interventions for the treatment of EXCEPT:

A. Expressive and rehabilitation therapies such as art therapy, movement therapy, psychodrama, occupational therapy, and recreational therapy may be very helpful to DID patients as they are often uniquely responsive to nonverbal approaches

B. ECT has been shown to be effective in treating dissociative disorders, and may be important in relieving an associated refractory depression

C. Pharmacologically facilitated interviews have been used to assist DID patients in accessing alternate identities or in allowing the emergence of traumatic material that otherwise cannot be recalled

D. There is no evidence to support the use of psychosurgery in the treatment of DID

Special Treatment Issues

33. Which of the following are NOT included as issues that should be covered during the discussion of therapeutic boundaries?

A. Length and time of sessions, fees and payment arrangements

B. Confidentiality and its limits, and therapist availability between sessions

C. The number of sessions offered and how termination of treatment will be addressed

D. Involvement of the patient’s family or significant others in the treatment

34. Because many DID patients are prone to crises at certain points in treatment, patients need a clear statement about the therapists’ or other clinicians’ availability in emergencies, but providing limited availability to the patient on a predefined basis at times may be essential.

A. True

B. False

35. Physical contact for DID patients is generally not recommended as a treatment technique. However, some patients may seek out massage therapy or other types of body work, and these techniques have generally proven to be beneficial to clients in helping them overcome intrusive PTSD symptoms.

A. True

B. False

36. While it is not beneficial for the clinician to tell patients that their memories must be false or that they are accurate and must be believed, it is critical for the therapist to maintain a _________________ stance in dealing with these memories.

A. Compassionate and empathic

B. Patient and sensitive

C. Respectful and neutral

D. All of the above

37. In general, DID patients are often conflicted and unsure about their memories, with different alternate identities taking different points of view. Accordingly, it is most helpful for the therapist to help the alternate identities explore these conflicts and differing viewpoints rather than side with any one of them.

A. True

B. False

38. Which of the following accurately describes various clinical views of ritual abuse?

A. Some clinicians believe that patients’ reports of such occurrences can be rooted in extremely sadistic events of organized abuse experienced by these patients in childhood and/or later in life

B. Although clinicians accept the possibility that these reports can be accurate, they also acknowledge that some accounts may contain inaccuracies, and that other accounts may be entirely rooted in fantasy

C. Some professionals believe that the actual events are distorted or amplified by the patient’s age and traumatized state at the time of the abuse, and sometimes by deliberate attempts by perpetrators of abuse to deceive, intimidate or overwhelm their victims

D. All of the above

39. When patients bring spiritual and philosophical issues into treatment, ethical standards for the various professional disciplines specify the need for the therapist to conduct treatment without imposing one’s own values on patients.

A. True

B. False

40. Each of the following is an accurate statement about helping clients with parenting issues EXCEPT:

A. Because DID may involve a heritable biological predisposition to dissociate, some experts have recommended that the children of all DID patients be assessed by a therapist familiar with dissociative disorders and indicators of child abuse

B. The therapist should actively assess parenting issues and assist the DID patient with appropriate parenting behavior and provide needed education and assistance

C. Many DID patients may have difficulty in parenting and a greater than average number admit to being abusive toward their children

D. Patients should be strongly encouraged to behave as adults with their children, to not switch identities openly in front of children, and to not regress into child identity states with the children in the belief that this is a better way to behave with children

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