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group_1_presentation_1_-_dissociative_identity_disorder [2018/09/28 22:07] praveenn [Anatomic Abnormalities] |
group_1_presentation_1_-_dissociative_identity_disorder [2018/09/29 00:22] (current) sabraniw [Environmental Causes] |
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| Dissociative Identity Disorder (DID), is also commonly referred to as multiple personality disorder. It is a very complex disorder characterized by the coexistence of multiple separate identities (Kluft, 1996). DID commonly develops after the occurrence of some form of trauma in childhood. However, as a person with DID grows older, the multiple personalities may grow more complex, as the individual affected may combine posttraumatic events with fantasy to create more intricate personalities (Kluft, 1996). | Dissociative Identity Disorder (DID), is also commonly referred to as multiple personality disorder. It is a very complex disorder characterized by the coexistence of multiple separate identities (Kluft, 1996). DID commonly develops after the occurrence of some form of trauma in childhood. However, as a person with DID grows older, the multiple personalities may grow more complex, as the individual affected may combine posttraumatic events with fantasy to create more intricate personalities (Kluft, 1996). | ||
| - | {{ :dissociative_identity_disorder_by_x_sinister_chaos_x-d5uegwj.jpg?direct&300 |}} | + | {{ :dissociative_identity_disorder_by_x_sinister_chaos_x-d5uegwj.jpg?direct&600 |}} |
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| Generally, people with DID can function normally. However, an experience of extreme emotion especially associated with childhood trauma can trigger a switch. When there is a perceived threat, patients tend to switch to an alter who is more competent to handle the situation. DID patients tend to avoid situations, people and environments that may remind them of a childhood trauma linked to their disorder. Coping with comorbid mental health disorders and symptoms of DID is important to maintaining the individual’s quality of life. Long-term supportive treatment helps individuals manage their symptoms and minimize strain on relational, marital, family, parenting, occupational and professional life (American Psychiatric Association, 2013). | Generally, people with DID can function normally. However, an experience of extreme emotion especially associated with childhood trauma can trigger a switch. When there is a perceived threat, patients tend to switch to an alter who is more competent to handle the situation. DID patients tend to avoid situations, people and environments that may remind them of a childhood trauma linked to their disorder. Coping with comorbid mental health disorders and symptoms of DID is important to maintaining the individual’s quality of life. Long-term supportive treatment helps individuals manage their symptoms and minimize strain on relational, marital, family, parenting, occupational and professional life (American Psychiatric Association, 2013). | ||
| - | ===== Pathophysiology ===== | ||
| - | === Macronutrients Vs Micronutrients === | + | ===== Genetic Causes ===== |
| + | There are many complex factors that contribute to DID. However, different kinds of animal and psychophysiological studies conclude that many types of personality disorders are influenced genetically, in particular the schizotypal and antisocial personal disorder (Kluft, 1987). Furthermore, DID patients who experience early stress during childhood show association with changes in the structure of the hippocampus and the amygdalar volumes. This suggests that one’s genetic predisposition to smaller hippocampus and amygdalar volumes may lead to the development of DID (Vermetten et al, 2007). | ||
| + | One of the predisposing factors of DID is a natural, inborn capacity to dissociate. This is the biological determinant of DID. Although no twin studies have yet been undertaken due to the difficulties in sampling, there is evidence that DID may be trangenerational. It has been reported and/or observed that there is evidence of dissociative phenomenon in the family histories of 18 multiple case (Kluft, 1987). | ||
| - | Macronutrients Vs Micronutrients | + | ===== Environmental Causes ===== |
| - | Macronutrients are the energy providing nutrients and are thus needed in larger amounts. These include carbohydrates, proteins and fats.<sup>[18]</sup> Carbohydrates are they body’s main energy source, whereas proteins provide the amino acids important for the cell structure and the cell membrane.<sup>[18]</sup> On the other hand, fats are used for making steroid and hormones in the body.<sup>[18]</sup> Furthermore, fats have the highest caloric content with approximately 9 calories per gram of fat, and when burned, they provide the largest amount of energy compared to carbohydrates and proteins.<sup>[18]</sup> It has been reported that a high-fat diet induces the development of obesity.<sup>[19]</sup> There is a direct correlation between the amount of dietary fat and overconsumption, thus leading to weight gain.<sup>[19]</sup> It is speculated that this may be due to dietary fat’s weak satiety properties, leading to the feeling of not being satisfied or full after a meal.<sup>[19]</sup> | + | |
| - | Micronutrients on the other hand are needed in smaller quantities and are essential for various chemical reactions in the body.<sup>[18]</sup> These include vitamins and minerals.<sup>[18]</sup> Vitamins allow for normal growth and metabolism as well as cellular functions.<sup>[18]</sup> These may be fat-soluble vitamins which are stored in the fatty tissues such as Vitamins A, D, E and K.<sup>[18]</sup> They may also be water-soluble which are excreted in the urine and must be taken daily such as Vitamins B and C.<sup>[18]</sup> Minerals are ionized in the body, for instance iron, sodium and potassium.<sup>[18]</sup> | ||
| - | === Types of Adipocytes === | ||
| - | <box 28% round right | > {{ :fattissue.png?300|}} </box| Figure 5:Yellow adipose tissue in paraffin. | ||
| - | https://en.wikipedia.org/wiki/Adipocyte#/media/File:Yellow_adipose_tissue_in_paraffin_section_-_lipids_washed_out.jpg > | ||
| - | Body fat or adipose tissue is composed of loose connective tissue which mostly consists of adipocytes or fat cells.<sup>[20]</sup> White adipose tissue (WAT) and brown adipose tissue (BAT) are the two types of adipocytes which make up the majority of adipose tissue.<sup>[20]</sup> Beige adipocytes are a third type of adipocyte, which have recently been identified, however their function and origin is not well understood.<sup>[21]</sup> | + | It has been studied that there is a relationship between detachment in infancy and increased vulnerability to dissociative disorder. The mothers of dissociative patients have been reported to have suffered the loss of a significant other in the first two years of their lives. In addition, childhood trauma, physical and sexual abuse in early childhood, latency and adolescence were shown to be significant predictors of self-mutilation and suicidality. In a study by Collin A. Ross and colleagues, 102 individuals with clinical diagnoses of DID were interviewed with Dissociative Disorders Interview Schedule (DDIS) (Ross et al, 1991). |
| + | The result was that the rates of childhood sexual abuse varied across five large series of cases, but always within the same range. This indicates that there are consistent findings of high rates of childhood trauma such as physical or sexual abuse or both. For the majority of the subjects in the study, the abuse started before the age of 5. | ||
| + | In a larger pool of 388 cases of DID, 91.2% of the patients had been physically or sexual abused (Ross et al, 1991). | ||
| + | |||
| + | <box square centre| > {{:did_enviro_graph.png?nolink&500|}} | ||
| + | </box| Figure 1: Graph showing the number of DID patients and the age at which they were physically or sexually abused.> | ||
| + | |||
| - | White adipocytes are the main cell type found in human adipose tissue.<sup>[20]</sup> Their main function is to store energy and they provide most of the total body fat. WAT cells have receptors for insulin, sex hormones, norepinephrine and glucocorticoids.<sup>[20]</sup> They secrete proteins such as leptin, adiponectin as well as other adipokines.<sup>[21]</sup> Furthermore, WAT is involved in controlling metabolism by acting as a thermal insulator to help maintain energy homeostasis.<sup>[20]</sup> | ||
| - | Brown adipocytes are found in almost in all mammals and they function to dissipate energy through thermogenesis.<sup>[22]</sup> Their characteristic brown appearance is due to a high number of iron-containing mitochondria.<sup>[22]</sup> BAT develop from the middle embryonic layer, the mesoderm, which is also the source of muscle cells and adipocytes.<sup>[20]</sup> It is abundant in newborns as well as metabolically active adult humans, however, its prevalence decreases in humans as they age.<sup>[20]</sup> Furthermore, brown adipocytes also contain more capillaries than white fat, which allows for tissue to be supplied with more oxygen and nutrients.<sup>[22]</sup> In this way, produced heat can easily be distributed throughout the body.<sup>[22]</sup> | ||
| - | === Normal Function of Adipose Tissue & Adipose Tissue Development === | ||
| - | Adipose tissue is an endocrine organ which is mainly responsible for energy storage as well as the synthesis and secretion of several hormones.<sup>[23]</sup> Adipose tissue is a major source of free fatty acids. Free fatty acids (FFA) are liberated from lipoproteins by lipoprotein lipase, allowing it to enter the adipocyte where it is reassembled into triglycerides by esterifying it onto glycerol. Adipocytes have an important physiological role in maintaining triglyceride and FFA levels.<sup>[23]</sup> | ||
| - | In conditions of obesity, hyperplasia and hypertrophy lead to the expansion of adipose tissue, which results in the development of adipocytes that are metabolically unhealthy.<sup>[24]</sup> The activation of biological pathways that favour the differentiation of adipocytes as well as the formation of adipocytes from precursor cells produces an increase in the number of adipocytes.<sup>[24]</sup> There are certain proteins and transcriptional factors involved in inhibiting or promoting the development of adipocytes.<sup>[23]</sup> Adipogenesis, the development of adipose tissue, involves the differentiation of preadipocytes into mature fat cells. Changes in transcription factor expression and activity is what results in the differentiation of these pre-adipocytes into mature fat cells.Transcription factors involved in promoting adipogenesis include the AP-1 family, PPARy, STATs, members of the KLF family, SREBP-1 and members C/EBP family. Conversely, Pref-1, GATA and Wnt family transcription factors are involved in inhibiting adipogenesis.<sup>[23]</sup> | ||
| - | Pre-adipocytes within adipose tissue can differentiate into mature adipocytes throughout their lifetime.<sup>[24]</sup> This allows for the expansion of adipose tissue when increased storage requirements are needed. Furthermore, mature adipocytes have the ability to accommodate increased storage needs, and in cases of overnutrition, these cells can become hypertrophic.<sup>[24]</sup> | ||
| - | Adipose tissue undergoes a continuous process of remodelling.<sup>[25]</sup> This normally maintains tissue health, however, this process is accelerated in obesity which can lead to the death of adipocytes along with the recruitment and activation of immune cells. Increased activation of the immune system leads to inflammation, which is the hallmark of obesity. Overall, an increase in the death of adipocytes, coupled with an increase in immune cell activation leads to many of the pathophysiological consequences of obesity.<sup>[25]</sup> | ||
| - | ===== Genetic Causes ===== | ||
| - | There are many complex factors that contribute to DID. However, many animal and psychophysiological studies conclude that many types of personality disorders are influenced genetically, in particular the schizotypal and antisocial personal disorder. Furthermore, DID patients who experience early stress during childhood show association with changes in the structure of the hippocampus and the amygdalar volumes. This suggests that one’s genetic predisposition to smaller hippocampus and amygdalar volumes may lead to the development of DID. | ||
| - | One of the predisposing factors of DID is a natural, inborn capacity to dissociate. This is the biological determinant of DID. Although no twin studies have yet been undertaken due to the difficulties in sampling, there is evidence that DID may be trangenerational. It has been reported and/or observed that there is evidence of dissociative phenomenon in the family histories of 18 multiple case (reference) | ||
| - | ===== Environmental Causes ===== | ||
| - | There is a relationship between detachment in infancy and increased vulnerability to dissociative disorder. The mothers of dissociative patients reported to have suffered the loss of a significant other in the first two years of their lives. In addition, childhood trauma, physical and sexual abuse in early childhood, latency and adolescence were shown to be significant predictors of self-mutilation and suicidality. In a study by Collin A. Ross and colleagues, 102 individuals with clinical diagnoses of DID were interviewed with Dissociative Disorders Interview Schedule (DDIS). The result was that the rates of childhood sexual abuse varied across five large series of cases, but always within the same range. This indicates that there are consistent findings of high rates of childhood trauma such as physical or sexual abuse or both. For the majority of the subjects in the study, the abuse started before the age of 5. | ||
| - | In a larger pool of 388 cases of DID, 91.2% of the patients had been physically or sexual abused. | ||
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| ===== Anatomic Abnormalities ===== | ===== Anatomic Abnormalities ===== | ||
| - | There are 3 distinct hypotheses that have been supported by research data obtained through various means of data collection. These hypotheses each attribute the symptoms of dissociative identity disorder to a structure of the brain. Respectively, these are the orbitofrontal hypothesis, cortico-limbic hypothesis, and finally the temporal hypothesis (Dorahy et al, 2014). Furthermore, each specific method of data collection tends to support a single hypothesis. <box 16% square right | > {{:orbitofrontal_cortex.png?200|}} </box| Figure 1: SPECT image of the orbitofrontal cortex . On the right are normal control patients and on the left are patients with DID. Patients on the left have reduced perfusion to orbitofrontal region> | + | There are 3 distinct hypotheses that have been supported by research data obtained through various means of data collection. These hypotheses each attribute the symptoms of dissociative identity disorder to a structure of the brain. Respectively, these are the orbitofrontal hypothesis, cortico-limbic hypothesis, and finally the temporal hypothesis (Dorahy et al, 2014). Furthermore, each specific method of data collection tends to support a single hypothesis. <box 16% square right | > {{:orbitofrontal_cortex.png?200|}} </box| Figure 3: SPECT image of the orbitofrontal cortex . On the right are normal control patients and on the left are patients with DID. Patients on the left have reduced perfusion to orbitofrontal region> |
| - | <box 16% square right | > {{:reduced_hippocampal_amygdalar_volumes.png?200|}} </box| Figure 2: Comparison of hippocampal and amygdalar volumes. In blue are healthy patients and in red are patients with DID. Patients with DID show reduced hippocampal and amygdalar volumes> | + | <box 20% square right | > {{:reduced_hippocampal_amygdalar_volumes.png?250|}} </box| Figure 2: Comparison of hippocampal and amygdalar volumes. In blue are healthy patients and in red are patients with DID. Patients with DID show reduced hippocampal and amygdalar volumes> |
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| Although DID is believed to be uncommon, there have been some cases of DID brought up in court rooms. It has been used as a defence in cases ranging from drunk driving, kidnapping, theft and even murder, in extreme cases. | Although DID is believed to be uncommon, there have been some cases of DID brought up in court rooms. It has been used as a defence in cases ranging from drunk driving, kidnapping, theft and even murder, in extreme cases. | ||
| + | {{ :court3_web--2-thumb-large.jpg?300 |}} | ||
| ==== Juanita Maxwell ==== | ==== Juanita Maxwell ==== | ||
