Could this be ADHD, trauma, or both?
(please bear in mind that some children with ADHD do not have behavioural problems)
[Photo credit: woodleywonderworks, Flickr]
Dr. Nicole Brown’s quest to understand her misbehaving pediatric patients began with a hunch.
Brown was completing her residency at Johns Hopkins Hospital in Baltimore, when she realized that many of her low-income patients had been diagnosed with attention deficit/hyperactivity disorder (ADHD).
These children lived in households and neighborhoods where violence and relentless stress prevailed. Their parents found them hard to manage and teachers described them as disruptive or inattentive. Brown knew these behaviors as classic symptoms of ADHD, a brain disorder characterized by impulsivity, hyperactivity, and an inability to focus.
When Brown looked closely, though, she saw something else: trauma. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by a stress response in overdrive.
“Despite our best efforts in referring them to behavioral therapy and starting them on stimulants, it was hard to get the symptoms under control,”…
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Thing you don’t find out from an Abnormal Psychology courses
Violence & Dissociative Identity Disorder – any link, or just stigma?
There’s no link between having DID or any other mental disorder and being violent or committing violent crimes. The only exception is Anti-Social Personality Disorder (and even this is an optional criteria), this disorder only rarely occurs in people with DID. Sources: Mental Illness and Violent Behavior: The Role of Dissociation (2017) in Statement on Split by ISST-D, Peterson, Skeem et al. (2014) in Mental illness not normally linked to crime, DSM-5 p659 ASPD criterion A.
Being a victim of violent crime – especially physical abuse/assault and sexual abuse or rape is extremely common in people with DID. Self-inflicted violence e.g., self-harm and suicide attempts occur in 40-60% of people with DID (source: DSM-5).
Stigma? Extremely common – e.g., this scientific article in a newspaper has a picture with a caption “psychopaths” – a term irrelevant to DID but suggesting violence and crime.
Now, to the “Split” movie Dissociative Identity Disorder quiz…
Click as many answers as you like for each question – correct answers go green, wrong answers go red. There’s no total score to worry about.
Traumatic experiences can cause the mind to “shut down” a part of the body by refusing to transmit sensory or other information to or from it – it can be seen as the mind’s way to protect itself from the unbearable. Similar conditions involve paralysis, deafness, tremors, unexplained non-epileptic seizures (PNES), and some of the person’s body being numb to pain. People with DID often have physiological differences between alter personalities – this is called “physiological variability” – greater difference than would be found in a person without DID – but these differences aren’t as great as between different people. Examples include alters with different glucose levels in diabetics with DID, significant blood pressure changes and vision changes, right or left-handedness depending on the alter currently in control, different medication responses and allergies – but not changing hair color, height, etc. Dissociative Identity Disorder also does not involve superhuman self-healing powers. Souce: Dissociative Identity Disorder Treatment Guidelines for Adults (2011), p121. Does this transient blindness/psychological cause of blindness have anything to do with Dissociative Identity Disorder?
Well, physical symptoms or conditions – particularly those which are medically unexplained are unusually common in people with Dissociative Identity Disorder – and Functional Neurological Disorder an example of one such condition. They are so common that DID expert Dr Ellert Nijenhuis & colleagues found you could screen for DID just by asking about certain physical symptoms. They used historical and current medical records to devise and check for these symptoms, and produced a DID screening tool called the Somatoform Dissociation Questionnaire. It’s one of two self-assessment screening tools mentioned in the Dissociative Identity Disorder treatment guidelines for Adults, and can be used to check whether it’s worthwhile for a full structured interview to be done for Dissociative Disorders. It can reliability tell people with DID apart from those with Schizophrenia, Bipolar Disorder or Posttraumatic Stress Disorder – three of the most common misdiagnosis for people with DID.
To sum it up: people with or without DID can suddenly go blind, or be able to see again, including as a direct result of exposure to or resolving extreme stress or trauma – and certain physical health problems are far more common in people with DID. Trauma can affect both the body and the mind. See links to case studies at the end of the question.
There used to be a lot of emphasis on how many alter personalities there were in people with DID but research no longer focuses much on this; it was not found to be a major factor in assessing the functioning of someone with Dissociative Identity Disorder or to require major differences in treatment.
– Dissociative Amnesia – previously called psychogenic amnesia and well documented among combat troops
– Posttraumatic Stress Disorder – an optional criteria of PTSD is forgetting a significant part of the trauma
– People without a specific mental disorder who were abused or traumatized as children, particularly physically or sexually, are known to spontaneous recall such a memory
“Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures.” Smith (1989) describes a 70 year-old Native American with many alter personalities which see themselves as animals or spirits – unsurprisingly they aren’t evil serial killers either. The logic behind Dissociative Identity Disorder is that alter personalities form as a mental escape or separation from the unbearable – and they begin to form at a very early age (normally before 8 or 9 years old). So alter personalities are limited by a young child’s imagination or needs (and later on in life, by a teenager or an adult’s). So it is possible for an alter personality to regard themselves as an animal – even being unaware they exist in a physically human body. What they cannot do is physically change a human body to an animal one – or physically change gender – so that part of the movie “Split” is fiction/artistic license/metaphorical etc. Abused children have sometimes being treated “like an animal” – literally – for example being fed pet food or chained up outside with dogs, or being called “It” (like Dave Pelzer, in A Child Called It) – so an alter personality may simply assume they are (or prefer to be) in the form of an animal, spirit or some other non-human form. Depersonalization within DID can involve feeling disconnected from your body – as if it (or part of it) isn’t actually yours even when logically you can see it is. All types of alter personality exist as part of the same human mind, and a human body (even though some may “deny” or “disavow” this).
Further links and research for questions
Question 4 – blindness with alters that can see and blindness caused by psychological trauma – videos & cases
Real cases of transient blindness, with and without DID: Blind woman who switched personalities could suddenly see (2013), / Sight and blindness in the same person: original research, 2015 (PMID: 26468893 DOI: 10.1002/pchj.109) / 2007 summary. Diana, with her blind alter personality Margo, and her sighted alter personality Corey.
Somatoform Dissociation Questionnaire (scroll down for the SDQ-20)
Question 8- Example cases of amnesia for a major trauma include:
- Witnessing a murder, recalled years later, allowing police to identify the previously unidentified victim
- Cases of child sexual abuse witnessed by other adults or victims who they never forgot
- a significant percentage of cases of sexual abuse or rape which involved hospital treatment at the time but couldn’t be recalled later (LM Williams, 1995)
See also: The Recovered Memory Project
Dissociative Amnesia – Soldiers witnessing another soldier’s trauma: which the soldier denies all memory of – previously called psychogenic amnesia – is well documented among combat troops (see DSM-5 p300, and Trauma-induced dissociative amnesia in World War I combat soldiers (van der Hart, Brown, & Graafland, 1999)
- Holocaust survivors who were held in concentration camps having not a single memory of it (link above)
- Dissociative Amnesia – a case of losing all memory of finding the body of a loved one after their sudden death (video, may be distressing to watch)
- Posttraumatic Stress Disorder – an optional criteria of PTSD is forgetting a “significant part of the trauma” typically due to “dissociative amnesia”(source: DSM-5, PTSD criteria D.1)
- People without a specific mental disorder who were abused or traumatized as children, particularly physically or sexually, are known to spontaneous recall such a memory
- Historical examples from literature also exist, including the Parisian opera Nina (1786) by Dalayrac and Marsollier, in which the heroine forgets seeing her lover apparantley killed in a duel and still waits for him daily – then won’t accept it is him when he does later appear.
- Somatoform Dissociation Questionnaire (scroll down for the SDQ-20) – physical problems common in people with DID
Question 9 – Animal alters
Smith (1989) describes a 70 year-old Native American with many alter personalities which see themselves as animals or spirits – unsurprisingly they aren’t evil serial killers either.
See also: Alters in DID
Question 10 – Why it’s very difficult to pretend to have Dissociative Identity Disorder to clinicians – besides biological/physical testing
- As it mentions in “Split”, people with Dissociative Identity Disorder spend an average of 7 years in the mental health system before being diagnosed with DID – typically have have a series of misdiagnosis. If many clinicians have neither training or experience diagnosing any dissociative disorders, they aren’t likely to give the diagnosis to someone realistically acting out the symptoms either. But the actors may be diagnosed with schizophrenia, psychotic disorders, borderline personality disorder, or bipolar disorder by mistake – and possibly medicated for them. Even if the actor told a clinician they believed they had Dissociative Identity Disorder/multiple personalities that often won’t lead them to asking relevant questions for diagnosis – they may assume you just want to be a “special” or “interesting” case, or maybe you should be assessed for histronic personality disorder (which involves dramatic, exaggerated behavior). Not until the 2013 publishing of the DSM-5 could people’s self-reporting of DID symptoms count (self-reporting Depresson, Bipolar symtpoms etc, was fine though) – the person had to switch to an alter personality in front of clinical staff (reports and descriptions from partners were ignored). Having an alter personality turn up for the assessment didn’t usually because it wasn’t a “switch” being observed.People professional diagnosed and be told by friends or family that “you don’t have that” or “nobody has that” because they don’t present symptoms that fit the stereotype, or because they don’t “match” movies about real people with DID like Sybil. Check out Truddi Chase’s interviews on Oprah, and see if you can spot her DID symptoms… of course, she might not actually “switch” to an alter personality when on camera.
- Dissociative Identity Disorder (like other mental health conditions) shouldn’t be diagnosed just be observing someone – which is what happens in the movie Primal Fear – the character of Aaron Stampler was acted so brilliantly that Dissociative Disorders specialist Dr Bethany Brand commented on how realistic it was to watch… but clinical assessment has a set of well-validated screening tools and diagnostic interviews available for clinicians which can be used to check for faking DID.
- Dissociative Identity Disorder is a hidden disorder – like all the other dissociative disorders, unless symptoms are continually obvious (which only applies to about 4% of people with it), or the person has a short period of more obvious symptoms (as shown in the movie “Split”) – there won’t be much to act: it’s behavior-based symptoms are subtle, and most clinicians don’t ask about dissociative symptoms or amnesia
- It’s not difficult to memorize answers to standard questionnaires – but the clinician might never give you a questionnaire, and if they do then questionnaires aren’t diagnostic tools. Questionnaires (e.g., the Dissociative Experiences Scale) are screening tools – they simply signal to the clinician that a clinical interview for dissociative disorders would be appropriate/helpful – they give a range of scores in which DID is highly unlikely, or fairly likely to be present in many people with those scores.
- Supposing you get to a clinical interview, and the clinician is knowledgeable about Dissociative Disorders. There’s only two well established clinical interviews, but one has over 100 questions – without a “total score” to aim for, and the other takes around 90 minutes and the scoring information (i.e., the range of ‘correct’ answers isn’t publically available). Supposing the actor did manage to get a set of appropriate answers (there are many different combinations, since DID isn’t the same for everyone), those answers would need to be memorized and repeated at the same time as making subtle movements which indicate some dissociation is taking place – at the same time as not actually looking like you are trying to remember anything. To practice the interview questions you’d need get a copy first, which you have to buy for and they are only given to people who can prove their clinical qualifications in the first place, academic qualifications alone aren’t enough!
- Part of assessing for any mental disorder – including Dissociative Identity Disorder – involves taking into account current and recent life circumstances. If this acting is being done to fake a disorder in order to avoid a criminal conviction, this will mean a “forensic” assessment gets added – and DID is hardly ever counted as a legal defense anyway (in contrast to psychotic disorders, which are accepted as a legal defense if several enough) – not exactly like the movie Primal Fear then. Motivated faking of Dissociative Identity Disorder or truly believing you have it when you don’t (“simulated DID”) both have many indicators, e.g., (e.g., Thomas, 2008) that would be difficult to fake.
- Note: Some poor “teaching” about Dissociative Identity Disorder involves role playing alters, which is mistaking DID for a primarily behavior-based disorder, students may find their memory poor as they act different roles – which is called “state-dependent memory” and exists in non-DID people: it’s easier to remember events when you are in the same emotional state as when the event happened. After, they write up their “experiment” using their memory of it (none will have amnesia for everyday events like many people with DID do, so this won’t be a problem), and they will never have these “symptoms” again… because of course, the symptoms were acted rather than genuine. Faking DID behaviors won’t lead to the students going home and not recognizing their room mates, not remembering the year they were born, or find themselves covered in blood because an alter personality self-harmed without their knowledge. They won’t “come round” several hours later and not know whether they remembered to eat dinner – or whether an alter personality remembered and ate it for them. This “role playing” is actually an example of stigma: it would be totally insulting to “act out” a more familiar disorder like depression by “looking sad and lethargic” for a while, but DID is often treated without compassion and as a “fun” or “entertaining” practical exercise. Even worse, this leads to the assumption that if only someone with DID could “snap out of it” and “behave normally” the whole condition would go away – which doesn’t work for any mental disorder – because it’s not a choice.
Further Information about Dissociative Identity Disorder
Statement on Split by the International Society for the Study of Trauma and Dissociation (ISST-D, 2017)
Dissociative Disorders: An Overview of Assessment, Phenomonology and Treatment A 10 page Dissociative Identity Disorder and Dissociative Disorders summary from the Psychiatric Times, comparing DID with Borderline Personality Disorder, Schizophrenia and Bipolar
Dissociative Identity Disorder Treatment Guidelines for Adults (ISST-D, 2011) – search this 80 page document for everything you ever wanted to know about DID
Dissociative Identity Disorder in the DSM-5 – 10 pages including the diagnostic criteria (APA, 2013, from p580 via google books preview)
Know someone you think is faking having Dissociative Identity Disorder? Read Holly Gray’s excellent blog
Since Thanksgiving is very soon, & many of you feel forced to deal with your narcissistic families on the day, I thought I would write a post for you in that position, Dear Readers …
Read more about this research from The Leadership Council’s post
“Society gives the image of sexual violators as weird, ugly, anti-social, alcoholics. Society gives the impression that violators kidnap children are out of their homes and take them to some wooded area and abandon them after the violation. Society gives the impression that everyone hates people who violate children. If all of these myths were true, healing would not be as challenging as it is.
Half of our healing is about the actual abuse. The other half is about how survivors fit into society in the face of the myths that people hold in order to make themselves feel safe. The truth is that 80% of childhood sexual abuse is perpetrated by family members. Yet we rarely hear the word “incest”. The word is too ugly and the truth is too scary. Think about what would happen if we ran a campaign to end incest instead of childhood sexual abuse. The number one place that children should know they are safe is in their homes. As it stands, as long as violators keep sexual abuse within the family, the chances of repercussion by anyone is pretty low. Wives won’t leave violating husbands, mothers won’t kick their violating children out of the home, and violating grandparents still get invited to holiday dinners. It is time to start cleaning house. If we stop incest first, then we will strengthen our cause against all sexual abuse.”
― Rosenna Bakari, Talking Trees facebook page
- 3 Types of Rape Culture that interfere with Trauma Recovery (traumadissociation.wordpress.com)
- Sexual Abuse and Child Sexual Abuse – is it planned or spontaneous?
- What Would Make You Believe a Survivor of Childhood Sexual Abuse? By Andrea Grimes
- Ten reasons I didn’t tell I was being abused
- Pedophiles groom both the child and the family