Comparison of Dissociative Identity Disorder With Other
Diagnostic Groups Using a Structured Interview in Turkey
L. ilhan Yargl£:, Vedat ~;ar, Hamdi Tutkun, and Behiye Alyanak
Twenty patients with dissociative identity disorder
(DID), 20 with schizophrenic disorder, 20 with panic
disorder, and 20 with complex partial epilepsy were
evaluated with the Dissociative Disorders Interview
Schedule (DDIS) and the Dissociative Experiences
Scale (DES). Subjects with dissociative identity disorder were more frequently diagnosed as having somatization disorder, past or concurrent major depressive
episode, borderline personality disorder, depersonalization disorder, and dissociative amnesia than other
groups. They reported Schneiderian symptoms and
extrasensory perceptions more frequently. In their
anamnesis suicide attempts, trance states, sleepwalking, and childhood traumas were more frequent than
those in comparison groups. The secondary features
of dissociative identity disorder and the DES score
differentiated these patients from comparison groups
significantly. DID has a set of clinical features different
from that of schizophrenic disorder, panic disorder
and complex partial epilepsy. The differences are
similar to those yielded previously in studies from
North America.
ISSOCIATIVE IDENTITY DISORDER
(DID), also known as multiple personality
disorder, ] was thought to be rare until the late
1980s. After its inclusion in DSM-III, 2 it has been
diagnosed in North America in increasing frequency. The development of self-report instruments 3,4 and structured clinical interviews, 5,6 which
were designed for the assessment of various dissociative disorders, enhanced further evaluation of
this diagnostic category. Although there is growing
interest in this category among clinicians and
researchers of several countries, 7-]3 structured interview data from different cultures are still sparse.
First studies conducted with structured interviews
in Western Europe 14and Turkey 15yielded symptom
profiles similar to those previously 16 reported in
North America.
DID patients, who had been in the mental health
system before the diagnosis of DID was given,
usually had several other diagnoses. 17 It seems to
be due to the polisymptomatic nature of the disorder that extends beyond its diagnostic criteria
defined in the DSM-IV. TM Indeed, it is not uncommon that patients with DID meet DSM-IV diagnostic criteria for several other disorders at the same
time, e.g., somatization disorder or borderline personality disorder. 19 However, problems in differential diagnosis are not limited to excessive descriptive comorbidity. Some symptoms such as voices
heard inside of the head, black-out spells, and
excessive anxiety against covert clues of past
trauma can simply lead the clinician to misdiagnose
DID patients as schizophrenic disorder, epilepsy, or
panic disorder.
The purpose of this study was to determine the
clinical differences between DID and comparison
groups that have been reported as common rnisdiagnoses for DID. A survey among psychiatrists in
Turkey showed that most professionals questioned
how DID could be reliably differentiated from
schizophrenic disorder and complex partial epilepsy. 2°,21 Indeed, schizophrenic disorder and anxiety disorder are among the most common misdiagnoses given to DID cases before correct diagnosis
is made. 22We considered these reports in determining the diagnostic categories selected as comparison groups in this study.
D
Copyright© 1998by W.B. Saunders Company
METHODS
Subjects
The subjects consisted of 20 patients with DID, 20 with panic
disorder, 20 with schizophrenic disorder, and 20 with complex
partial seizures.
The DID cases were patients in the psychiatry clinic of the
Istanbul Medical Faculty Hospital, a general medical center
with 2,500 beds. All DID patients over 18 years of age who were
under evaluation and treatment in the Dissociative Disorders
Program during the 3-month study period between May and July
of 1994 were considered for participation in the study. Only one
case among them was excluded because she had an abnormal
EEG. The remaining 20 patients composed the study group.
Except for two probands, all DID cases were outpatients.
The clinical diagnosis of each DID case was made by the first
and third authors initially, and was confirmed by the second
author. The first and third authors were senior psychiatry
residents and had 2 years of clinical and research experience on
dissociative disorders during the study period. The second
From the Clinical Psychotherapy Unit and Dissociative
Disorders Program, Department of Psychiatry, Istanbul University, Istanbul Medical Faculty Hospital, lstanbul, Turkey.
Address reprint requests to L. llhan Yargl6 M.D., Istanbul Ttp
Fakiiltesi Psikiyatri Klinigi 34390, ~apa lstanbul, Turkey.
Copyright © 1998 by W.B. Saunders Company
0010-440X/98/3906-0010503. 00/0
ComprehensivePsychiatry,Vol. 39, No. 6 (November/December), 1998: pp 345-351
345
346
author, who is a psychiatrist, faculty member, and director of the
Dissociative Disorders Program of the clinic, met all the patients
separately and confirmed the diagnosis clinically. He also
supervised the long-term outpatient and inpatient treatment of
the same cohort.
To increase the reliability of the diagnosis, intrainterview
switching from one personality to another was required for the
final decision. Moreover, all of the DID patients met the more
strict National Institute of Mental Health (NIMH) research
criteria, which required observation of at least two different alter
personalities with full-control during at least three different
interviews and presence of amnesia between at least two of them
in addition to DSM-III-R criteria. 23 Thus, all of the patients also
met DSM-IV criteria for DID because they had dissociative
amnesia.
Subjects with complex partial seizure disorder were recruited
from the Epilepsy Unit of either the Department of Neurology,
Istanbul University Istanbul Medical Faculty Hospital (n = 8)
or the Neurology Clinic, Bakarki3y State Hospital for Nervous
and Mental Diseases (n = 12). These subjects had been diagnosed independently by a neurologist, All subjects had EEG
findings related to epileptic focus, and they had active seizures
at least twice monthly in the last three months before the
psychiatric interview.
Schizophrenic subjects were recruited from outpatient (n = 9)
and inpatient (n = 11) units of our clinic. All of these subjects
met DSM-IV criteria for schizophrenic disorder, and had a level
of psychological functioning sufficient to cooperate for the
study. Subjects with panic disorder (all met DSM-IV criteria)
were recruited from the outpatient unit of our clinic, and were
interviewed before the treatment.
Informed consent was taken from all subjects. To avoid
selection bias, the first 20 patients available in each group, who
consented to interview, were included in the study. No efforts to
match subjects were made. Only one patient with schizophrenic
disorder and one with epilepsy refused to participate in the
study.
Assessment Measures
The Dissociative Disorders Interview Schedule. The Dissociative Disorders Interview Schedule (DDIS) is a structured
interview consisting of 131 items. 5 It is used to make DSM-III-R
diagnoses of somatization disorder, major depressive episode,
borderline personality disorder, and all the dissociative disorders. This schedule also inquiries about childhood physical and
sexual abuse and a variety of features associated with DID
including the following: 11 Schneiderian symptoms, 16 secondary features of dissociative identity disorder, and 16 extrasensory experiences. Two items inquiring about childhood emotional abuse and neglect were added to the Turkish version.
The schedule has an overall interrater reliability of 0.68
(kappa), a sensitivity of 90%, and a specificity of 100% for the
diagnosis of DID. 5 The DDIS was translated into Turkish
independently by the first three authors of the study, and the
consensus version was tested on dissociative, nondissociative,
and normal subjects to evaluate if it was sufficiently understood.
The final version, after the corrections, was used in the study.
Interrater reliability and test-retest reliability were evaluated by
having two independent interviewers administer the DDIS to 11
patients with dissociative identity disorder and nine patients
with a nondissociative psychiatric disorder on two occasions,
YARGI(~ ET AL
with a minimum 6-month interval between administrations.
Kappa value for the diagnosis of DID was 0.80.
All of the interviews were administered by the first and third
authors, who were experienced in administration of the DDIS. It
was conducted by an interviewer other than the clinician who
made the initial diagnosis. Because all the authors were working
in the same institution where the patients were recruited, it was
not possible to keep the interviewer blind to the clinical
diagnosis.
Association with any other psychiatric disorder or epilepsy
was not taken into consideration when making the diagnosis of
dissociative amnesia, fugue, and depersonalization disorder,
because one of the aims of this study was to determine the extent
of the phenomenological overlap between DID and other
diagnostic groups, i.e., an epileptic patient reporting amnesia or
a schizophrenic patient reporting depersonalization were scored
as having these symptoms regardless of the etiology, although
DDIS would not allow it so. Otherwise a tautology would occur.
The Dissociative Experiences Scale. The Dissociative Experiences Scale (DES) is a 28-item self-report instrument) It
serves as a screening instrument, but it is not a diagnostic tool.
High scores on the scale suggest, but do not prove, the existence
of a dissociative disorder. 3,24.25The Turkish version of the scale
has a reliability and validity as good as its original form. 26,27
RESULTS
Demographic information for subjects in each
group is provided in Table 1. The DID group was
the youngest on variance analysis (F = 3.44, df = 3;
76, P < .05). Although DID patients had the highest female-to-male ratio (9/1) among all groups, the
difference was not significant (×2 = 7.32, df = 3,
P > .05). The rate of marriage was lowest among
schizophrenic probands (×2 = 17.9, df= 9,
P < .05). They had higher education level than
other probands (F = 5.14, df = 3;76, P < .005).
The clinical diagnosis of DID was confirmed
with the DDIS for 19 patients with the exception of
one patient who had dissociative disorder not
otherwise specified (DDNOS) on structured interview. One subject with schizophrenic disorder
among the controls was diagnosed as having DID
on the DDIS. Thus, sensitivity and specificity of the
structured interview were 95.0% and 98.3%, respectively. Positive predictive power was 95.0%, and
negative predictive power was 98.3% (Table 2).
Table 1. Demographic Characteristics of the Subjects
Group (n = 20 for
each group)
DID
Female
(%)
Age
(mean -+ SD)
Married
(%)
Education (yr)
(mean -+ SD)
90
24.9 -+ 7.0
40
7.5 -+ 3.6
Schizophrenic
disorder
Panic disorder
C o m p l e x partial
epilepsy
55
31.7 -4- 8.0
20
11.7 +_ 3.0
55
31.9 -+ 7.6
70
8.1 -+ 4.3
65
31.4 -+ 9.8
55
7.7 +- 4.6
STRUCTURED EVALUATION OF DID
347
Table 2. Relation of Clinical Diagnosis of DID to the DDIS
Diagnosis
DDIS
Clinical Diagnosis
Diagnosis
Present (n = 20)
Present
19
1
20
1
59
60
Absent
Absent (n ~ 60)
Total (N = 80)
NOTE. Yates corrected ×2 = 69.80, d f = 1, P < .00001.
The patient diagnosed as having DDNOS on the
structured interview reported that he had different
personalities within himself, each of which was
dominant at a particular time. However, he did not
affirm that each personality had distinct features,
i.e., behavior and social relationships that are not
shared by other personalities. This was due to the
amnesia and unawareness of the host personality
about the alter personalities. Nevertheless, alter
personalities of this patient met during previous
sessions had presented different and enduring patterns of perceiving, relating to, and thinking about
environment and self.
The schizophrenic patient who gave affirmative
answers to the questions on diagnostic criteria of
DID was a 20-year-old man. He had seven secondary features of DID and met four borderline
personality disorder criteria. He described selfmutilative behavior, possession experiences, trans
states, and childhood imaginary companionship,
which was still going on. He reported physical
abuse by his father that had continued until 19
years of age, and childhood emotional trauma.
Although this patient reported amnesia between
alter personalities, he did not give affirmative
answers to direct questions about dissociative fugue,
amnesia, and depersonalization disorder. He did
not report any somatic complaints either. This is
considered a false-positive DID diagnosis on DDIS,
because the patient already had clinical features
fitting the DSM-IV diagnostic criteria of schizophrenic disorder.
The differences between DID and other groups
on the main symptom clusters of structured interview and DES scores are shown in Table 3. There
were significant differences in all of these items
between the DID group and other diagnostic groups.
All of the DID subjects reported at least seven
secondary features of DID, whereas none of the
other subjects had more than seven, 85.0% of the
DID subjects, whereas only 8.3% of the other
subjects had DES scores above 30.
Table 4 shows the differences between the DID
group and the other diagnostic groups on the
percentages that met DSM-III-R criteria tbr the
following: four dissociative disorders, somatization
disorder, major depressive episode, and borderline
personality disorder. All of these diagnoses were
more common in the DID group than in any other
group. There were no significant differences between the schizophrenic disorder, panic disorder,
and complex partial epilepsy groups on the frequencies of any of these diagnoses.
Evaluation of dissociative amnesia was the most
intriguing part of assessment. When questioned
specifically, 17 probands in the DID group reported
that they were aware of the amnesia between their
alter personalities. However, only 12 of the DID
cases gave an affirmative answer to direct questions
inquiring diagnostic criteria of dissociative amnesia on DDIS, despite the observation of intrainterview amnesia in all DID cases. Nevertheless, DID
patients gave some indications of amnesia on other
items of structured interview, such as being told by
others of unremembered events, strangers knowing
Table 3. Differences Between DID and Other Groups on the Main Clusters of DDIS
DiD
Symptom Clusters
(n = 20)
(mean±SD)
Panic Disorder
(n ~ 20)
Comprex Partial
Epilepsy (n = 20)
Mean±SD
t(df=38)
Mean-~SD
t(df=38)
Mean-SD
t(df=38)
2.1±2.0
12.25
2.3_+1.9
12.15
0.5_+0.5
18.15
Extrasensory experiences
4.0 _+ 2.6
1.8 _+ 2.2
2.9/-
1.0 _+ 1.1
4.8:1:
0.9 _+ 1.4
4.75
No. o f Schneiderian s y m p t o m s
6.3 _+ 1.8
4.3 ± 2.9
2.6*
0.2 -+ 0.7
14.35
0.4 ± 0.8
13.6$
13.2 ± 5.4
2.1 ± 2.1
8.65
3.5 + 5.3
6.835
3.6 ± 3.4
3.9 + 2.0
1.4 ± 1.6
4.3¢
0.6 ± 0.9
6.6$
1.7 ± 1.6
3.71-
15.6 + 2.7
6.25
8.5 _+ 8.0
8.6$
12.8 + 10.4
7.25
Secondary features o f DID
No. o f somatic c o m p l a i n t s
No. of borderline personality disorder criteria m e t
DES score
Abbreviation: NS, not significant.
* P < .05.
tP<
.01.
¢ P < .0001.
11.0+2.5
Schizophrenic Disorder
(n -- 20)
46.1 -+ 17.9
6.735
348
YARGI(~ ET AL
Table 4. Differences Between DID and Other Groups on DDIS Subdiagnoses
Diagnosis
Major depressive episode
(current or past)
Borderline personality
disorder
Sornatization disorder
Psychogenic amnesia
Psychogenic fugue
Depersonalization disorder
Multiple personality disorder
DID
Schizophrenic
Disorder
(n = 20),
(n = 20)
No.
Positive No. Positive
×2(df= 1)
Panic Disorder
(n = 20)
Complex Partial
Epilepsy (n = 20)
No. Positive
×2(df= 1)
No. Positive
×2(df= 1)
17
7
10.42"
6
12.381-
6
12.381-
7
11
12
4
15
19
0
0
1
0
1
1
Fisher's exact*
15.175
13.701Fisher% exact(NS)
25.895
32.45
0
0
0
0
1
0
Fisher's exam*
15.175
17.145
Fisher% exact(NS)
25.895
36.195
g
0
4
0
3
O
Fisher's exam*
15.17t
6.67*
Fisher% exact(NS)
19.80t
36.19t
* P < .01.
t P < .001.
$P < .0001.
the patient, coming out of a blank spell in a strange
place, as inquired among the secondary features of
DID.
The differences between the study groups on a
number of mental health history items are shown in
Table 5. There were significant differences on
childhood sexual abuse, trance states, and sleepwalking between DID patients and comparison
groups. Chronic severe headache and childhood
physical or emotional abuse differentiated the DID
group from the schizophrenic disorder and panic
disorder group, but not from the complex partial
epilepsy group. Self-mutilative behavior differentiated in DID patients from other groups except
patients with schizophrenic disorder.
Frequencies of extrasensorial perception and
supernatural experiences in each group are shown
in Table 6. Only possession experiences differentiated DID patients from all other groups. Contact
with spirits differentiated DID patients from other
groups except for patients with schizophrenic disorder. Reincarnation and cult experience did not
differ any group from others.
DISCUSSION
To our knowledge, this is the first study in
Turkey that compares subjects with DID with other
diagnostic categories using structured interview
data. Our findings suggest that DID patients can be
differentiated from subjects with schizophrenic
Table 5. Differences Between DID and Other Groups on Some Mental Health History Items of the DDIS
Item
Headache
Sleep walking
Trance states
Childhood imaginary
companionship
Substance abuse
Suicide attempts
Self-mutilative behavior
Childhood sexual abuse
Childhood physical abuse
Childhood physical and/or
sexual abuse
Childhood emotional abuse
Childhood neglect
*P<
tP<
SP<
§P<
.05.
.01.
.001.
.0001.
DID
Schizophrenic
Disorder
(n = 20),
(n = 20)
No.
Positive No. Positive
×Z(df= 1)
Panic Disorder
(n = 20)
Complex Partial
Epilepsy (n = 20)
1)
No. Positive
×2(dr= 1)
No. Positive
10
3
4
3.96*
6.09*
26.78§
12
3
12
1.90 (NS)
6.09"
10.581-
x2(df =
16
8
19
7
3
7
6
1
16
11
14
12
2
3
9
5
4
4
4.29 (NS)
Fisher's exact (NS)
5.23*
3.75 (NS)
10.41 t
6.67T
0
1
1
0
g
2
11.61t
Fisher's exact (NS)
23.02§
15.205
21.54§
10.995
1
0
3
1
3
6
5.06 (NS)
Fisher's exact (NS)
16.94§
11.905
12.38$
3.64 (NS)
16
12
13
8
3
8
6.675
9.531"
2.51 (NS)
2
3
4
19.80§
9.53t
8.291"
8
6
8
6.67t
3.64 (NS)
2.51 (NS)
8.29t
6.09*
19.54§
STRUCTURED EVALUATION OF DID
349
Table 6. Differences Between DID and Other Groups on Extrasensory Experiences
DID(n = 20)
Item
Panic Disorder
(n = 20)
Schizophrenic Disorder
(n = 20)
No. Positive
No. Positive
×2 ( d f = 1)
13
5
7.11"
1
Contact with spirits
7
2
Fisher~ exact(NS)
0
Reincarnation
4
1
Fisher's exact(NS)
3
18
1
10
Fisher's exact(NS)
7.62t
Possession
Cult/sect experiences
Any extrasensory perception
No. Positive
×2(df= 1)
Complex Partial
Epilepsy(n = 20)
No. Positive
×z (df = 1)
8.49t
1
O
17.97$
8.491"
0
2.5(NS)
1
Fisher's exact (NS)
4
10
0.2(NS)
7.62t
1
8
Fisher's exact (NS)
10.995
20.5§
Abbreviation: NS, not significant.
* P < .05.
TP < .01.
:I:P< .001.
§ P < .0001.
disorder, panic disorder, and complex partial epilepsy using a structured interview. Moreover, the
differences between DID cases and comparison
groups in the main items of the interview were
similar to the findings reported in North
America.28, 29
In our study, one patient with schizophrenic
disorder among the control subjects was diagnosed
as having DID on the DDIS. Ross et al5 reported
that only four subjects among 500 schizophrenic
patients had been diagnosed as having DID on the
DDIS. Having alter personalities may be considered as a delusion for the patient in our study. On
the other hand, this patient reported childhood
traumas that have been shown as interrelated with
dissociative experiences, independent of the main
diagnosis among general psychiatric patients 3°-32
and nonclinical populations. 33,34 Ross 35 even suggests a dissociative subtype of schizophrenic disorder. This issue needs further investigation.
There was a discrepancy about dissociative amnesia between clinical observation and structured
interview. This discrepancy was apparently caused
by the phenomenon called "amnesia for amnesia. ''36 These findings suggest that direct questioning of dissociative amnesia does not always yield
reliable results, rather indirect cues of amnesia
should be searched. On the other hand, patients
with chronic dissociative disorders with distinct
personality states can show different characteristics
on state measures, whereas they report relatively
consistent features on trait measures. Dissociative
amnesia seems to be a state dependent characteristic, whereas some indirect cues of the disorder, i.e.,
secondary features of the disorder, are relatively
enduring characteristics that do not drastically
change depending on identity alteration.
In our study, a history of depersonalization
disorder, and past or concurrent major depressive
episodes, differentiated the patients with DID from
other groups. In the Ross et al study, 28 these items
did not have any significant differences between
DID, schizophrenic disorder, and panic disorder
groups. In fact, the discrepancy between two studies depends rather on the higher frequency of major
depressive episodes and depersonalization disorder
in the Ross et al. control groups compared with
ours. The rates of these items are similar for DID
patients in both studies. Depending on their results,
Ross et al. questioned the existence of depersonalization disorder as a specific clinical entity, and
suggested that it is only a symptom that may be
seen in various psychiatric populations. Our results
do not support the Ross et al. opinion.
There are several reports 16,17,22,37,38 in North
America that suggest high incidence of alcohol and
substance abuse among DID subjects. However,
there was only one substance abuser in our DID
group, and the frequency of alcohol or substance
abuse did not differentiate the DID group from the
others. The low rate of substance and alcohol abuse
in our DID patients may be due to their relatively
low frequency in the general population in Turkey.
Unfortunately, there is not any reliable epidemiological data for substance and alcohol abuse in our
country.
In our study, the feeling of being reincarnated
and cult experiences did not differ DID group from
the others. Neither belief of reincarnation nor
satanic cults are known to be common in Turkey.
Different results about alcohol or substance abuse,
feeling of being reincarnated, and cult experiences
may show a cultural variation. However, our study
group consists of cases who admitted to a univer-
350
YARGI~: ET AL
sity clinic; the cases in other institutions, or in the
community, may differ in these characteristics.
Frequency of childhood sexual and physical
abuse reported by our DID subjects is within the
same range as the frequencies reported in five large
DID case series reported in North America16,17,22,37,38:
60% to 82% physical abuse, 68% to 90% sexual
abuse. As most of the DID subjects in this study
were at the beginning phase of their treatment, they
might have hidden their trauma history from the
interviewer, or they might still be amnesic about
their childhood traumas. We did not include here
the trauma histories of some DID subjects that were
reported after the study interview, therefore, these
are rather minimum numbers of childhood abuse
histories of the DID subjects. However, we have
the impression that the childhood trauma histories
in most of our DID patients were not as brutal as
those reported from North America.
This study focused on misdiagnosis of DID;
however, excessive descriptive comorbidity is another problem for DID eliciting interesting questions for future research on nosology and classification. In a consecutive screening study, the most
frequently accompanying psychiatric diagnoses
were past or current depressive episode, somatization disorder, and borderline personality disorder. 19
These patients will continue to have several concurrent diagnoses, because the diagnostic criteria for
these categories do not exclude each other. On the
other hand, the excessive descriptive comorbidity
might be reflecting different faces of a single
multifaceted psychiatric condition, the clinical expression of adult psychopathology related to childhood trauma. 39,4° Differentiation of these disorders
from DID should be studied further.
The interviewers o f this study were not blind to
the diagnoses. However, the DDIS is highly structured to minimize and control for demand characteristics of the interviewer. Moreover, the patients
were assessed both by self-report and structured
interview in this study.
In conclusion, diagnostic criteria, clinical phenomenology, and historical properties of DID described in North America can also differentiate this
disorder from schizophrenic disorder, panic disorder, and complex partial epilepsy in Turkey. Although limited to the diagnostic groups selected for
comparison, the present study provides crosscultural support for the validity of the DDIS.
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