CLINICAL CHALLENGE From the Neuropsychiatric to the Analytic: Three Perspectives on Dissociative Identity Disorder Jhilam Biswas, MD, James A. Chu, MD, David L. Perez, MD, and Thomas G. Gutheil, MD Keywords: dialectical behavior therapy, dissociation, dissociative identity disorder CASE HISTORY History of Present Illness Rosalie is a 21-year-old Dominican woman with current diagnoses of dissociative identity disorder (DID) and post- traumatic stress disorder (PTSD), and past incorrect diag- noses of schizoaffective disorder, bipolar I disorder, and borderline personality disorder. For over a year she has been at a public sector, long-term, partial hospital program with a residential component focused on dialectical behavior therapy (DBT) skills. Rosalie had been admitted to the DBT program due to her refractory pattern of suicidality, variably described hallucinations and dissociative episodes, and eight- year struggle with a near deadly eating disorder. Since admission to the partial program, Rosalie has been consistently attending skill groups, is on no medication, and has not been hospitalized in the past one-and-a-half years. She has developed her first long-term relationship, which is also her first with a woman. The outpatient world has brought its challenges, but Rosalie has shown tremen- dous progress. For the first six months of her partial pro- gram, Rosalie was ambivalent about getting better. She would binge, purge, and cut, and she was hospitalized once overnight. After six months, however, she began to wean herself off all her medications and refused to reinitiate them. Through the year Rosalie has had regular outpatient therapy with a therapist who specializes in dissociation. She also attends DBT skills group therapy, where she learns to regulate her emotions, to understand the triggers that lead to her self-destructive impulsive acts, and to stay grounded despite apparent switching between alternate identities. Often, in groups, we will see Rosalie become distant and quiet, and she may stay this way for hours at a time. In our DBT sessions, Rosalie will work hard to talk about events in her day and to stay present, but occasion- ally she will speak in a different voice, with a different posture, for 15Y20 seconds. When asked to come back, she will have experienced no lapse in time and continues on with a sentence without realizing the transition. This partic- ular type of event is frightening for Rosalie. She recognizes the journey to Breintegrate[ her identity through outpatient therapy will be arduous. Sometimes she wonders, with a shudder, whether she herself is only one of the alternate identities that come out for a period of time before she is Bsucked away.[ She says, BI cannot be who I want to be, and I feel my free will is stolen daily by these parts. I would not wish dissociative identity disorder on anyone.[ During her time at the partial program, Rosalie has been more vocal about problems that she recognized earlier dur- ing her hospitalizations but could never fully express. She reports trouble with Blosing time[ during the day and finds evidence of behaviors she does not remember doing. She has problems with controlling Bthe noise of the other alters, the voices[ in her head and with focusing on the external world, and has Bfuzzy[ vision. She describes an elaborate Bsystem of alters,[ 13 at last count, which maintain various emotional states and personalities that Bcome out when they need to say something.[ Rosalie knows some alternate identities better than others. She remembers one, BJo,[ from the age of eight years, and considers her to be Bthe boss[ of all the other alters. Rosalie reports that Jo was the one who helped her navigate through the multiple, recurrent sexual abuses by men in her family and community throughout her 17 years of childhood. There are several other Bparts,[ as Rosalie calls them, who are different ages and have dif- ferent stories and personalities. They emerge frequently, and she discovered each by name during her several hospi- talizations (see Table 1). When these personalities emerge, Rosalie reports to be Bgone.[ Rosalie highlights her vary- ing state of awareness by saying that sometimes she is From Harvard Medical School; Harvard Longwood Psychiatry Resi- dency Training Program, Boston, MA (Drs. Biswas and Perez); McLean Hospital, Belmont, MA (Dr. Chu); Department of Neurology, Brigham and Women_s Hospital, Boston, MA (Dr. Perez); Massachusetts Mental Health Center, Boston, MA (Dr. Gutheil); Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA (Dr. Gutheil). Correspondence: Jhilam Biswas, MD, Department of Psychiatry, Beth Israel Deaconess Medical Center, Rabb-2, 330 Brookline Ave., Boston, MA 02215. Email: jbiswas@partners.org *2013 President and Fellows of Harvard College DOI: 10.1097/HRP.0b013e31827fd7c8 Editor: Robert M. Goisman, MD Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 41 Copyright @ 2013 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.