Vol.

IX (LXXI)
102 - 108
No. 2/2019

Dissociative Identity Disorder. Psychotic functioning and

impairment of growing-up processes
Simona Trifu*
University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

Abstract

American psychiatric literature shows the presence of 5% dissociative identity disorder (DID) in the
psychiatric population; in Romanian psychiatry the cases with DID are difficult to diagnose because
they are confused with schizophrenia considering the DID effect on social functioning. We present in
detail the functioning of the DID patient's thinking, to highlight the illogical constructions, how he
reverse the cause with the effect, how he’s discourse slips to the secondary meanings of the words, how
he easily move from general to particular and from abstract to concrete. We notice the impersonal
speech, the use of several pronouns with reference to the Ego, together with the denial of reality. We
identified four personalities with symbolic meanings related to his personal life history.

Keywords: dissociative identity disorder; psychotic functioning; paranoid obsessive area; arguments;
abuse; dissociation of memories of affections

1. Introduction

In dissociative identity disorder (DID), dissociation is the main mechanism using

which patients cope with stress. In Kluft’s opinion (Kluft, 1985), we are talking about
ʺa pathology of hidingʺ, having issues of confidence as it is seen by these patients;
considering the traumatic pathology of these patients the stages of personality
development are highly affected.
Ideally, therapists refer to multiplicity not as a bizarre aberration, but as an
adaptation of a person to a specific history, to cope with chronic post-traumatic stress
syndrome originating in childhood (Spiegel, 1984). Recently, the interest in
dissociation has increased; this interest is closely associated with an interest in post-
traumatic stress disorder. Thus, psychodynamic psychiatrists shifted their focus on
trauma, after largely neglecting it for a long period in favor of intrapsychic phantasms
(Ross, 1997).
The dissociated Ego is fractured into many partial Selves, each performing certain
functions, such as infantile components, internal persecutors, victims, protectors, and
other identities for special purposes (Putnam, 1986). The world of a dissociative
person is flooded with unexamined transfers. As a person who is often abused, the
patient is ready to see an abuser in whoever he/she gets to depend on. Affected
individuals can become ʺpetrifiedʺ by any violation of boundaries between the
therapist and themselves. (Ludwig, 1972). The therapist should not seek to restore the
truth (patients always remember a mixture of reality and fantasy), but they must be
curious and uncritical. He/she does not have to seem fascinated, surprised,
incredulous, or express opinions, because he/she could prevent the patient from trying
to prove his authenticity (Brende, 1981).
DID involves the inability to evoke important personal information that is too
extensive to be explained in common oblivion. Those concerned may experience

* Corresponding author. Tel.: +4-0731-58110

E-mail address: simona.trifu@umfcd.ro
 Simona Trifu /Journal of Educational Sciences and Psychology 103

periods of time in which the patient acts psychotically, attributing the phenomena to
external forces that have taken control of them. DID can often be misdiagnosed as
Borderline Personality Disorder, Hysteria, and Psychopathy. In the case of
schizophrenia, however, patients have a gradual, insidious flattening, accompanied by
withdrawal, which does not lead the therapist to the suspicion of strong
countertransference.
Bennet Braun (Braun,1989) proposed a DID conceptualization system called
BASK. In his conception, dissociation becomes an overclass and refers to a series of
processes that appear together but are not always seen as being related. In this
construction, rejection is auxiliary (secondary):
B—behavior—involves the behavior of paralysis or self-induction of a state of
trance;
A—affect—suggests “belle indifference” (beautiful indifference) with respect to
what is happening to him/her or the possibility of remembering the trauma without
feelings;
S—sensation—suggests ʺbody memoryʺ, using its function and the extreme variant
of conversion anesthesia;
K—knowledge—getaway states and dissociative amnesia.
The novelty of the case is represented by the identification of such a pathology on
the Romanian population, by the detailed presentation of the patient's speech for a
better delimitation of this pathology from schizophrenia. It is possible that in Romania
to be a higher percentage of patients diagnosed with DID. Probably due to an
insufficient listening of their speech to enable a correct diagnosis, the number of
patients diagnosticated with DID is so low. In this present case, it is even more
difficult to diagnose, as the patient associates psychotic functioning. The "migration"
of the symptomatology over the last years, from the ruminant obsessional are to the
dissociative one is interesting, the culminating point being the non-appurtenance of
certain feelings to his Ego.
2. Methodology
2.1. Objective

We aim to diagnose a patient with DID by interviewing both the psychiatric and the
psychodynamic point of view. Brain organicity was excluded through neuroimaging
investigations. Subsequently the presentation highlights the intra-psychic dynamics
and the therapy attempts. After diagnosis the patient was pharmacologically
approached with Ziprazidone. We associated the psychoanalytic psychotherapy in
order to reintegrate the fragments of his Ego. Looking in its dynamic evolution, it was
revealed that the patient acted psychotically, starting from the obsessive area of
manifestations that involved arguments, reaching in the final the paranoid area. As a
result we want to present in detail the functioning of the DID patient's thinking, to
highlight the illogical constructions, how he reverse the cause with the effect, how
he’s discourse slips to the secondary meanings of the words, how he easily move from
general to particular and from abstract to concrete. We notice the impersonal speech,
the use of several pronouns with reference to the Ego, together with the denial of
reality as a way to cope with the trauma (from the area of abuses). The patient was
concerned about accounting for his own resources having a severe Super-Ego. We
have identified four personalities with symbolic meanings related to his personal life
history, deficiency of mentalization, emphatic laugh and attitude of superiority.
2.2. Participants
A 42-year-old male patient was under psychiatric monitoring for about four months
after having the first contact with a clinical psychologist who referred him to a
psychiatrist. Treatment with an initial dose of 40 mg/day Ziprasidone was initiated;
this was subsequently increased, and the patient complied with it. Contact with
specialists was always carried out at the sister’s request and in the sisters’ presence,
 Simona Trifu /Journal of Educational Sciences and Psychology 104

because the current request was for long-lasting psychoanalytic psychotherapy,

secondary to the DID.
In preliminary meetings, the patient behaved playfully in a playground among
psychiatrist-psychoanalyst-sister, describing himself as ʺan object that is subject to
what he has to doʺ, in an empirical infantile manner, as a repetition of an abuse.
With regard to social background, he comes from a two-parent family; both the
parents are engineers and the sister, who is 2 years older than him and an art institute
graduate, paints icons in gold and silver using an old technique. She has a home
workshop and still lives with her parents at the age of 44; according to her, she is
having a hard time because ʺpainters do not earn much money nowadaysʺ.
The patient graduated from a high-school with art study profile; subsequently, he
refused to attend a faculty in the profile and worked as a web-designer for a period of
about 10 years. After a financial crisis, he could not find a job and remained without
any source of income for 11 years. His parents paid the house utility and daily
expenses. In the past year, he worked as a cashier in a restaurant where previously, he
says, he was a client, but the management ʺtook pityʺ on him. He lives with a
colleague to facilitate the payment of utility bills; however, because the colleague
could not honor his financial obligations, the patient perceives him as a stranger,
dissociates from him, and forgets his name, belongings, and the way he met him and
received him in the house. He says, ʺI do not know who he is. I know that I have
chased him off so many times and yet he is back! ʺ
The patient’s speech highlights his psychotic functioning, his feelings thoughts and
actions that do not belong to his Ego and the obsessional starting point (ruminative);
in time, the dissolution of thought, the patination of the speech and the highlighting of
his four personalities overlapped. These have symbolic representations in the patient's
life history
2.3. Instrument
It was used a psychiatric and psychological examination of his current condition, a
monitoring for four months of the patient evolution under treatment; we associated the
psychoanalytic psychotherapy and we tried to make psychodynamic interpretations of
this case. Also, standard medical analysis were performed in order to exclude a
somatic pathology of the brain.
2.4. Procedure
Observations: The patient dressed neatly and showed mannerism and emphatic
attitude, rich mimic and gesture, tense insight with speculative and flat voice—
modulations of which suggest the change of characters—and an attitude that betrays
the contradictions of the inner world and extensive rumination. He is temporo-
spatially self- and allo-psychically orientated; however, he often dissociates from the
memories of his own past using the noun ʺrefusalʺ. At the interviewer’s insistence, the
second or third response reaches reality.
Perceptions: He denies the presence of auditory hallucinations, both in the present
and past. The discourse almost borders the possible auditory pseudo-hallucinations,
which—at present, under the influence of Ziprasidone—both the patient and the sister
deny, describing them as his own inner voices, alter-egos, or various parts of
personality communicating between themselves. When the questions were repeated,
the patient denied xenopathy, assuming the identity of these voices and recognizing
his dissociation. The patient’s sister acts as an auxiliary mind or a Super-Ego who
always takes care that the dissociated parts do not move away from the Ego and
become external: ʺHe has never had hallucinations; it is like a three-seat scene, in
which he alone moves from one seat to another and speaks with the other parts of
himʺ.
Attention: Tachypsychia suggests a decrease in the attention filter functioning, with
difficulties in concentration, stability, and prosex selectivity; there is a spontaneous
 Simona Trifu /Journal of Educational Sciences and Psychology 105

hyperprosexia for insignificant details that are later ruminatively-obsessionally

integrated with voluntary hypoprosexia.
Memory: The predominant use of the dissociation mechanism creates elective
memory amnesic gaps of the type of partial amnesia in relation to memories that the
patient fails to keep away from consciousness through the rejection process. The
affections of representations are dissociated, with the patient seeming disemotional
and ʺcrowdedʺ with thoughts and his discourse somehow suggesting a Chaslin
hypermnesic mentism (characterized by the tumultuous, incoercible development of
ideas and memories). He becomes a spectator of the ideological tumult that he cannot
stop (though feeling embarrassed and parasitic) and takes his sister to be faithful in an
admirable position.
Thinking: Tachyphemia (the global growth of all functions and mental processes) is
doubled by the weakening of logical associations, slipping of discourse that goes to
multiple meanings, and repeated use of the proximal genre and the secondary
derivative meanings of the words. He is using illogical constructions sustained by
stubbornness and presented with safe attitude. He switches the effect with the cause
and show hyper analyzability within 10 seconds, where he reanalyzes everything that
happens to him in Auerbach’s continual space and acts simultaneously along with
issuing evaluative judgments about them. He demonstrates immature thinking,
mentalization deficit, and obsessive digressive speech, with phrases repeated several
times to emphasize the meaning and argue concerns. The multitude of thoughts
overwhelms his personality, with the patient failing to stop his/her kaleidoscopic
development. The strangeness is felt; however, the patient negates the existence of
xenopathy. Thinking takes place in the area where the obsessional register is bordered
by the paranoid register; we found the ʺobsessionsʺ that reach the delirious intensity,
centered on several main themes: poverty versus avarice, asceticism, assuming
masculinity, controlling, counting for energy expenses, and counting for time.
Affectivity: The patient provokes interest and curiosity, but he presents himself as
an emotionally flattened person who is proud of the success of the dissociation
between affections and representations. He easily refers to attachments to objects,
suggesting indifference in building relationships with the dear being—a sofa type.
Love is replaced by need; with the patient experiencing poor management of
traumatic events and insufficient resources for working-through, his emotions remain
as islands that fail to connect. We are talking about dissolution of affections,
secondary to their denial. The patient feels above the trauma, while he cannot
mentalize them.
Activity: Significant decrease in useful efficiency occurs via quasi-continuous
energy spent in ruminative thoughts, arguments, and ʺobsessionsʺ. He finds a socially
useful activity difficult to performs, and the endeavor with which the patient tries to
maintain contact with the rhythm of life is admirable. He tells that he lives in a
disarray with a bizarre motivation, counting the amount of effort versus the obtained
benefits.
Day/night rhythm: Insomnia due to intrusive thoughts and the phenomenon of
hypermnesic mentism was observed.
Instinct of life: Diminished appetite supported by food preferences that fuel his
asceticism and concerns for greed, effort, and money spent. He recognizes that
consumption of marijuana facilitates his need to relax and to diminish the burden with
which he sustains his thoughts and obsessive representations.
Motivational system: Pulled by a rigid Super-Ego, the patient experiences increased
impulsive requirements, inability to rise to the level of his expectations, and inability
to sustain actions in a concrete manner due to a hyperbole inconsistent with the sense
of activities and selective orientation towards a basal stubbornness.
2.5. Data analysis
Personality: dissociated.
Diagnosis: Dissociative Identity Disorder.
 Simona Trifu /Journal of Educational Sciences and Psychology 106

Arguments Inability of the patient to integrate memories, perceptions, identity, or

for Dissociative consciousness.
Identity The meaning of the Self is disturbed, as well as the memory of life events,
Disorder diagnosis which is poorly integrated and sometimes suggestive of dissociative amnesia.
Considering that the patient’s self-experience and self-perception are
disturbed, DID is associated with depersonalization disorders.
In his life history, we assume that there was an overwhelming stress or
unbearable inner conflict that has forced the mind to separate unacceptable
information and feelings.
The four personalities inside the patient interact with each other within an
elaborate inner world.
The DID is serious and chronic, and it has led to disability and incapacity;
the risk of an attempted suicide in the future is not excluded.
The marijuana abuse is complicated; on one hand, it is for purposes of
relaxing the rigid and punitive Supra-Self and on the other hand, for purposes
of maintaining dissociation.
The patient can release his own memories, perceptions, or identity from
everything he consciously knows.
In his past life, we assume that there were defensive organizations that have
opposed the normal development process. In Kohut’s perspective, we note
both obsessions in the area of analytics and obsessions in the way of
overcoming the genital stage in solving the Oedipus and fraternal complex,
with the inability to assume gender identity and maintain his perception of
being neutral.
The family system to which the patient reported did not provide enough
education on the extent of compassion in response to painful experiences,
leaving him deprived of protection from subsequent painful experiences (the
patient took his father’s assertion (ʺIt is not me who created you, it is God!ʺ)
seriously, on the basis of which he built a pathology of attachment, that is, it
does not seem significant to him if he develops a relation with a being or an
object).
Abuse during childhood is frequently incriminated in DID; (this abuse is
not necessarily real, possible, or fantastic)
The patient has a remarkable variety of symptoms, which may suggest a
variety of neurological or psychiatric disorders.
Role changes between personalities, as well as the amnestic barriers
resulted in a chaotic life.
The patient complains of internal conversations, as well as voices of the
other personalities who comment on him or address him.
He shows temporal disorientation, lapses and amnesia, depersonalization
experienced as an unreal sensation, self-estrangement, and detachment to his
own physical and mental processes to an extreme extent where he sees himself
as an observer of his life, as if he is watching a movie. Adjacent derealization
occurs when he unfamiliarly, bizarrely, and unrealistically experiences the
perception of some known people or places.
The last years represented a period of crisis, revealing a serious
psychopathology under which the patient is caught in the trap of his own
possessions.

3. Results
Symptoms accentuated and recovered spontaneously; however, DID has no
spontaneous solution. In this case, 120 mg/day Ziprasidone addresses psychotic
functioning in the patient, but integration involves psychotherapy. At this stage, it is
not clear whether the concerned person wishes to achieve integration. The first
 Simona Trifu /Journal of Educational Sciences and Psychology 107

objective would be to facilitate cooperation and collaboration between personalities

and to alleviate the symptoms. This seems difficult and painful, with the risk of many
seizures as a result of the action of the personalities and the despair of the patient
when confronted with traumatic memories.
Hypnosis is often useful to contact different personalities, facilitate communication
between them, and stabilize and interpret them. It is also used to comment on
traumatic memories and to diminish their effects (Coryell, 1983). The integration of
multiple personalities is the most advantageous result.
Psychotherapy has three main phases. In the first phase, the priorities are safety,
stabilization, and strengthening of the patient and preparing him for the difficult
process of processing the traumatic material and confronting the problematic
personalities. The personality system is explored and mapped to apply the rest of the
treatment. In the second phase, the patient is helped to process the painful episodes of
his past and to regret the losses suffered as well as the negative consequences of
trauma. When assessing motivations for the remaining dissociations, therapy can be
directed to the final stage in which the patient’s multiple selves, as well as his
relationships and social activity can be restored, integrated, and rehabilitated. Some
integrations appear spontaneously; however, many integrations must be encouraged
through discussions and by setting up an agreement to unify the personalities.
Otherwise, it should be facilitated by directed reverie or hypnotic suggestion. After
integration, the patient continues treatment to cope with unsolved issues. After the
post-integration treatment seems complete, visits to the therapist are interrupted, but
they are rarely finished. The patient gets to consider the therapist as a person who can
help him cope with his psychological problems.
4. Discussions
We noted disorganization of phrases and multiple dissociative symptoms that
support an identity disorder marked by issues of separation—individuality, instability
of self-image, and instability of Ego continuity—and by dissociative efforts to avoid
abandonment and affectional flattening hidden in tachyphemia and masked by
stubbornness. An emphatic laughter is identified to dissimulate the phenomena of
depersonalization and derealization, as well as pseudo-hallucinations and relationship
sensitivity. We identify an obsession from the paranoid area alongside a fragmented
Ego.
There is a cognitive rigidity, in which (to the limit) people are synonymous with
animals; in schizoid thinking, the concerned person refers to their proximal genre
most of the time (Men with moustaches are monkeys). Separation involves too much
emotional load, with the patient’s only way of coping with it being the denial of
reality. The newly created reality becomes a strong image suggesting xenopathy,
although it is dissimulated in speech (ʺI was under the control of a stateʺ). The
dissociation of the Ego makes it difficult for an observer to understand when the
concerned person speaks from the inside of his/her being and when from the outside
of it.
The multiple personality is sustained through inner voices, by the fact that he is
speaking about himself to the third person, and through the sister’s metaphor of
moving from one chair to another and trying to play several roles. He talks to the
personalities created by his mind. Regarding the character of his sweet lover (Alina),
her recall is in opposition to the borderline manner, in which devaluation wound have
come after the idealization. ʺI will use your presence as I want! ʺ is a paranoia-like
statement, which suggests “My desire creates the reality”!
The inner dialogues result in the great contradiction experienced by the patient:
although he repeatedly states that life is the most beautiful thing, he states that he
cannot afford to live it. The de-emotionalization achieved by means of an initial
obsessional mechanism strikes the dehumanization; his relationship with Alina is
similar to that seen in the movie ʺHerʺ, in which one’s mind creates a hallucinating
reality with the aim of self-satisfaction—a reality that later defeats that person. The
 Simona Trifu /Journal of Educational Sciences and Psychology 108

obsessive speech hides masturbation in the form of this ʺmadnessʺ in which the
patient cast away the reality.
He preserves a symbiotic relationship with his sister, which corresponds to Green’s
perspective, that is, everything the patient represents is similar to islands that cannot
connect with each other. He seems to be a son unrecognized by his father and a copy
of his sister, who uses him in a strange manner and invests in him to enrich her
wealth—a fact superior to a simple dressage.
The sofa is synonymous with attachment; it is something that had to make him feel
the emotions that burned out but were never reborn. Then he covers it! The only form
of attachment he is capable of is with objects. He had no one to develop emotions
with. Ants represent poverty, as the only realm of attachment. The patient himself
borders the poverty of feelings and enrichment of thoughts.
Chocolate was broken into four pieces to feed the four parts of a whole Ego. In his
metaphor, the patient maintains his stubbornness. It is an illogical panacea, in which
we find hyper-analyzability and accounting. Defects are found in the other characters.
Thoughts are abuses, and the patient follows the mechanism of denial, posturing non-
energetic exchanges with the world: ʺDo not think that I want you to understand
something about me! The aim was to be myself. But the moment I interacted with
people (was) the moment I stopped to be me!
He is an infantile, theatrical, hysteroid, actor of the stage, who is proud of what is
happening to him (counterargument for schizophrenia). Symbolically speaking, he is
the prisoner of his personalities, who is still undecided between severe psychopathy
and schizophrenia. In other words, his psychosis was not yet decided. In the struggle
with thoughts, a multifaceted personality was built. He rejects the Super-Ego,
externalizes it, and designs himself in other identities he personalizes.
He talks about safety and costs, equating the world with the chance he never had.
He was denied the chance to a triumphant life like the speech. The dissociative
personality may be based on an unexplored sexual identity disorder originating from a
fraternal competition. He seems to have read a book about four parts of his split
personality. He feeds from his own reservoir with the motto ʺRepress your desire that
is at the root of sufferingʺ (intellectualization). He reverses the effect with the cause
and assigns a female Super-Ego to be sure he will not want to test homosexuality. The
envy on his sister’s shoes can be considered a fetish. The patient is rather concerned
with his accounting dimension and with what he loses, but not about reality.

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