Underwriting considerations for dissociative disorders.

OBJECTIVE: Dissociative identity disorder (DID) has been diagnosed more frequently and is under greater scrutiny. Because of the number of comorbid conditions, the underwriting risks must be evaluated to determine morbidity and mortality implications. BACKGROUND: The number of diagnosed cases of DID has increased in recent years. The diagnosis often coexists with other diagnoses such as bipolar disorder, major depression, post-traumatic stress disorder, anxiety disorder, somatization, personality disorders, and psychotic disorder. A high incidence of substance abuse and eating disorders is found in the population diagnosed with DID. METHODS AND RESULTS: A query of disability claim experience with DID indicated that these claims tended to reach the maximum duration for mental/nervous benefits despite case management and return to work activities. CONCLUSIONS: The DID psychiatric population is a complex group with mental disorders that place them in a group likely to use maximum disability benefits and who would pose increased life underwriting risk. In addition, the literature indicates a high excess risk for early mortality and excess health care expenses compared to the normal population.

Multiple personality disorder in an intellectually disabled man: a case report.

The case of a young man with the dual diagnoses of severe intellectual handicap (IQ 30 and mental age 4 years) and Multiple Personality Disorder is presented. The intellectual handicap is probably due to hypoxia in infancy and the Multiple Personality Disorder follows prolonged physical and sexual abuse. The patient frequently switches between any of nine discrete but incompletely formed identities. Although some personalities seem more capable than others, all have similar levels of disability on testing. The diagnosis of psychiatric disorders coexistent with the intellectual handicap is hindered by the difficulty in separating psychiatric phenomena from the behavioural disturbances associated with the disability. Differential diagnosis and management are discussed.

The criminal responsibility of people with multiple personality disorder.

Because multiple personality disorder (MPD) is more frequently diagnosed today than in the past, it is likely that more multiples will plead insanity. The courts are in a state of disarray as to how best to respond to these pleas. This article considers multiples' responsibility on three interpretations of the status of their alters: that they are different people; that they are different personalities; or that they are parts of one complex, deeply divided personality. On all three theories multiples are nonresponsible. Nevertheless, three rare circumstances exist under which multiples should be found guilty. The article concludes by indicating the kinds of issues psychiatry might explore to further assist the law in its analysis of the criminal responsibility of multiples.

Living and working with MPD.

1. Multiple Personality Disorder (MPD) is more common than one may think. There are many people with undiagnosed MPD. 2. As a caring, effective nurse for MPDs, set boundaries. Clients with MPD need to feel safe with the nurses with whom they talk. It is essential to establish a trusting bond. Respect each patient's alters--and believe in them. They will come out when they feel safe. Be direct and honest. 3. Do not play games. Although it is fascinating to watch the switch take place, it can be extremely frightening for an MPD patient when a nurse tries to call alters out and send others back.

An occupational therapy perspective in the treatment of multiple personality disorder.

Adult persons with multiple personality disorder have survived a traumatic past. After diagnosis and the initiation of psychotherapy, they frequently face a long and arduous treatment process. During this time, intense emotions and memories are retrieved that can disrupt functional life skills in an already disjointed life. The stresses of life combine with therapeutic issues to perpetuate the dissociation that interrupts functional performance. The original traumas occurred when the child was functioning primarily at a sensorimotor level. Occupational therapy can identify sensorimotor activities that provide a focal point of control to reduce stress during the therapeutic process and to develop new life skills.

Four cases of supposed multiple personality disorder: evidence of unjustified diagnoses.

Four cases are presented in which an unjustified diagnosis of multiple personality disorder was made. These cases are used to illustrate the concern that some cases of multiple personality disorder may be the result of misdiagnosis by both patients and clinicians.

Multiple personality disorders: treatment coordination in a partial hospital setting.

Many patients with multiple personality disorder (MPD) can be effectively treated in a partial hospital setting. Partial hospital treatment teams and their patients develop and manage a safe transitional environment that contains the therapy and begins the process of independent functioning in the community. Not all patients with MPD can be treated in partial hospital settings. The author provides guidelines for appropriate placement of these patients.

Treatment choices: rehabilitation services used by patients with multiple personality disorder.

This article identifies mental health rehabilitation services for patients with multiple personality disorder. Through the use of a literature review and a retrospective examination of 20 patients' records, the frequency of discipline-specific services is noted in occupational therapy, art therapy, movement therapy, vocational counseling, and recreational therapy. Recommendations for practice and program development include ongoing education about multiple personality disorder and continual assessment of the patient's functional level to identify subsequent treatment needs and services.

Use of the Role Checklist with the patient with multiple personality disorder.

A paucity of occupational therapy evaluation tools exists for use with patients with multiple personality disorder. The Model of Human Occupation (Kielhofner & Burke, 1980), particularly the volition and habituation subsystems within this model, proved useful for the identification of the many facets of patients with multiple personality disorder on a short-term treatment unit. The Role Checklist (Oakley, Kielhofner, Barris, & Richler, 1986), a tool derived from the Model of Human Occupation, was adapted for use with this population and was found to be beneficial in the identification of common goals held by most of the personalities of each patient with multiple personality disorder. The use of the Role Checklist is illustrated with a case example.

Art and multiple personality disorder: an expressive framework for occupational therapy.

Patients with multiple personality and dissociative disorders have learned to create an alternate identity system, originally designed to protect them from experiencing the pain of inescapable, unrelieved trauma and abuse. The resulting amnesia and identity confusion cause significant dysfunction in daily living. Issues of trust and control are paramount, and occupational therapists are challenged with the task of engaging these patients in meaningful activity. Although these patients often avoid structured groups, they have generally been responsive to expressive art opportunities as an initial activity. This paper outlines an expressive framework by which occupational therapists can therapeutically manage the artwork behaviors of the patient with dissociative or multiple personality disorder. The material presented is based on clinical observation of more than a dozen patients with multiple personality disorder in various stages of recovery and of many persons with dissociative trauma who may have multiple personality disorder. These observations took place within an acute care, inpatient occupational therapy setting. Guidelines for the creation of a positive working alliance and therapeutic climate for self-expression are outlined, and a progressive model for the viewing of patients' art products is described.

Occupational therapy with patients with multiple personality disorder: personal reflections.

Patients with multiple personality disorder are being admitted to acute care psychiatric units with increasing frequency. Occupational therapists have been confronted with setting treatment goals and designing interventions for this population with little information available in the occupational therapy literature. This paper describes how one therapist, the author, reviewed psychiatric and psychological literature on multiple personality disorder to delineate a role for occupational therapists who are working with this special population on an acute care psychiatric unit within the context of existing programs.

Toward becoming one self.

I communicated often with the patient's psychologist during her last hospitalization. As the patient moves slowly toward integration, she and I remain in contact through correspondence and occasional lunch meetings. This friendly relationship provides a much-needed ongoing support system for the patient, which is provided by one who is familiar with her diagnostic picture. This paper has described early occupational therapy interventions with a patient whose condition has been newly diagnosed as multiple personality disorder. Skinner (1987) suggested that additional occupational therapy interventions be implemented as the patient improves.

Understanding and cooperation among alter and host personalities.

There is little occupational therapy literature that addresses the profession's efficacy in the treatment of persons with multiple personality disorder, yet the characteristics and complexity of this disorder render it one that can gain much from occupational therapy intervention. This paper examines the ways in which the occupational therapist can help in the treatment of patients with multiple personality disorder by introducing the alter personalities to each other, encouraging rapport among the personalities, and providing tasks that allow the alter personalities and the host to work together for mutual benefit.