Question:
I've been diagnosed with DID for some
time now. Every time I have an insurance change, I
have to go through the entire diagnosing process
over again and causes serious disruptions
in therapy. Do all diagnosis have to go
through that? I always get stuck taking a MMPII
and I've never had valid results. I've told
them that's what happens. The psychiatrists and
psychologists ask me why. The last time I wrote
to the manufacturer who stated it doesn't
test for dissociation. But I know some DID's
are able to take 'valid' MMPI's. Do you know
why some can take valid MMPII's and other DID's can't?
Your theories on medications are interesting. I've
had several bad experiences with Prozac.
Paxil did very little. Zoloft, nothing.
Effexor, nothing. And Celexa didn't get a fair trial
because I started Adderall at the same time which
felt like they canceled each other out. My
problem with Prozac occurs in about 6 months.
Eating disorders kicked in and other self
destruction problems that normally aren't an
issue for me without very extreme stress,
including suicidal. Typically I don't display
a lot of BPD symptoms without being under
extreme stress and even then, I don't identify
with the feelings associated. Relationships are
stable, sticking with therapy hasn't been a
problem, haven't had cutting urges or been
hospitalized, no threats, etc. But for now, I'm
assuming that a BPD part could become
dominant--that I haven't had to deal with much
yet. Previously, I went through 4 trials with
Prozac with different providers--7 to 10 years
ago. I was at maximum dosage almost immediately.
I tried the Tegretol for about a year and it
just put me into a 'knock out sleep' which I
wasn't fond of. Towards the end, my
blood pressure and cholesterol raised to dangerous
levels, pointing to additional medication and
normally they are extremely low ("you'll
never have heart disease"). Some of my
discomfort was probably due to the fact that I use
frequent switching to mask changes and
slowing that down was disruptive. I'm not sure if
masking changes was to prevent others from
noticing DID or to keep me from being aware
of DID, since I was fairly newly diagnosed at the
time.
I discovered I was a 'non-absorber'
decades ago, trying to get medication for my asthma
under control. The doctor wondered where
the medication was going. That hasn't changed.
I'm at maximum dosage within a month or two
for pretty much any medication. Tegretol
makes me nervous because it doesn't take a
lot to cause a serious problems. I had one
experience where several parts came out in
succession and took it without me realizing it. I
think I've got that fixed, but it makes me nervous now.
What did work was 400mg of Wellbutrin and 90mg
of Adderall daily. The Adderall was a
godsend, literally. It calmed me down
and I could fall into a nice sleep during the first
20min. I could focus. My friends
notice immediately when 4 hours is up just based on my
spaciness. Several therapists have been
surprised the Adderall worked because they didn't
notice signs of ADD or ADHD. The therapists
seem to be more aware of the differences
between ADD/ADHD vs. PTSD than the psychiatrists
have been.
What was suggested to me was that my 'normal'
anxiety level is routinely high and the
Adderall adds enough to kick my brain
'over the edge' to shut it down, creating the
sedating effect I experience. In other
words, I'm beyond the 'fight or flight' syndrome--
which calms me. At the time I started
taking it, I was 'freezing' and had been out
of therapy for awhile. The medication change
allowed me to function again. Well, now I'm
back in regular therapy and I'm freezing up
with or without the medication. I'm
wondering if that might mean I'm better (less
anxious) when the medication can't put me
'over the edge' as well.
I feel like I'm living in flashbacks of
half present and half past. There's no
difference for me between 5 minutes, 5 years
or 40 years ago, emotionally and I can't keep
up with it daily to keep track of, process, or
contain (whatever I've just remembered) at that rate.
I don't have a psychiatrist familiar with or one
that 'believes in' DID. (You'd think DID was
a religion). That also means I don't
have a psychiatrist that I can be too honest
with. I've gotten used to that and I've
adjusted by doing my own basic research into the
direction I want to take with medication. I
can usually give them the idea of what to prescribe
and let them make the final adjustments. I know
this isn't ideal or standard. It's just the best I can
do under the circumstances. I'm grateful I have
access to that much.
I realize you can't make
specific recommendations because you haven't seen me, but I
would be interested in hearing the general
direction you might take with such a situation
and why.
I think your basic concept that there's a continuum
is interesting (PTSD -> complex PTSD ->
BPD -> DID). I've heard it's impossible to
have DID without PTSD, and in that way, it
would make sense for the same to be true for BPD
as well. The other theory I've heard
developmental age related since DID (and
BPD?) required developing during childhood,
unlike PTSD and DID tended to form at an
earlier developmental age than BPD. As far as I
can tell, my abuse began very young (< 3).
DID formed before a personality did, resulting
in chronic dissociative states and BPD formed
after some sense of identity was formed (the
terrible two's) resulting in transitory
dissociation.
The reason why I bring that up was because
that might alter therapy somewhat. For
example: your website made me aware that
I honestly don't have the vaguest concept of
what 'safety' is or feels like. I used
to teach English as a second language to Hmong people
from Cambodia. They don't have a written
language at all. Just instilling the idea that what
they spoke could be put on paper and read
was 90% of my efforts. When I explained the
challenge to friends, I'd say it was like
explaining what the color looked like to a person
that had been blind from birth. If someone
had a basic identity allowed to form, then they
might also have an instinctive concept like
what safety feels like. I didn't know if you had
additional thoughts about that since that's
also part of the theory behind ISSTD's
guidelines.
I've had a couple of therapists test me for
DBT and I wasn't able to keep consecutive track
of what was happening enough. They
explained it as I was too 'compartmentalized' and
information isn't flowing between the
barriers. I'm not sure how 'retraining' the brain
would help resolve that, but I haven't
finished reading your website yet. My 'self help'
library is frightening and it's like movies,
I never have to worry about reading or seeing
something twice. It always feels like the first time.
Obviously, your website has given me information already.
Dr. Heller's Answer:
I’ve treated approximately 15 patients
with DID, diagnosing another one this week.
Virtually all have done very well compared to
their baseline condition. It’s not uncommon
for me to ask if any particular personality
has needed to come out since our last visit. This
is difficult for the occasional individual
who don’t remember the episode. DID is usually a
disabling condition, although some are able to
maintain employment and families (it is
usually extremely difficult). The right
medications really make a difference, especially the
correct "as-needed" medications.
It’s caused by profound abuse and has lots of
interesting phenomena, such as one
personality having breast cancer and another
one doesn’t. There’s far more that’s not
known about the DID than is known.
Virtually everything is theory based on minimal
good research.
The principles of treating DID are the same
as I use on everyone, with the addition of
Remeron (mirtazapine) and techniques to
help the individual feel safe. Make all the
medically treatable diagnoses and come
up with a comprehensive plan to treat them all.
Every one I’ve treated had the BPD. Remeron
(mirtazapine) is needed for all of them due
to its PTSD effects, particularly sleep and
nightmares. I usually recommend a motion
sensor over the bedroom door that will squeal
if anyone gets into the room. A large dog can
be helpful as well and made a huge difference
for one of my DID patients.
In my experience, the MMPI is useful for following
treatment, not for making diagnoses.
The other personalities are there to protect
you. I don’t try to "integrate"
the personalities or get the individuals to
"fight" the other personalities.
I try to help individuals with DID
understand they are there for protection.
What makes the other personalities stay away is
having the individual doing well emotionally
and feeling safe.
You jump to a lot of conclusions about
medications, why they work, why they have side
effects, etc. Most of them are probably
incorrect. An example, the Adderall could have
triggered a hypomanic episode that made you
feel great. It’s not just the medications, but
the right medications, in the right sequence, and
at the right doses. There is no "mental
health" pill. Prozac doesn’t "stop
working". What likely happened is you
either went into a BPD dysphoria episode or
temporarily needed Wellbutrin (buproprion).
Being a poor absorber of medication (such as
after gastric bypass surgery) complicates the treatment,
but liquid medication can usually be used,
and blood levels can be monitored for Tegretol.
50% of those with the BPD have ADHD. The
cognitive generalized anxiety disorder
(genetic worry - the "caveguarder gene") is also
very common and if it is not treated
properly will cause most medications to have
adverse effects.
Not everyone has the same symptoms. 20%
of individuals having a heart attack do not
have chest pain. While symptoms are
important, it’s the diagnoses that are the most
important. From there, adjustments to medications
can be made based on symptoms and side
effects.
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