DISSOCIATIVE IDENTITY DISORDER IN CHILDHOOD: FIVE TURKISH CASES Salih Zoroglu, M.D. L. Man Yargic, M.D. Hatndi Tutkun, M.D. Mucahit Ozturk, M.D. Vedat Sar, M.D. Salih . Zoroglu, M.D., is a resident at the Child and Adoles- cent Psychiatry Clinic, Department of Psychiatry, Istanbul University, Istanbul Medical Faculty, Istanbul. L. Ilhan Yargic, M.D., is a psychiatrist and Coordinator of the Disso- ciative Disorders Program, at the Department of Psychiatry, Istanbul University Istanbul Medical Faculty, Istanbul. Hamdi Tutkun, M.D., is a psychiatrist in private practice in Istan- bul. During this project he was a resident at the Department of Psychiatry, Istanbul University Istanbul Medical Faculty, Istanbul. Miichait Oztiirk, M.D. is a resident at the Child and Adolescent Psychiatry Clinic, Department of Psychiatry, Istanbul University. Vedat Sar, M.D., is Professor of Psychi- atry and Director of the Clinical Psychotherapy Unit & Dis- sociative Disorders Program at Department of Psychiatry, Istanbul University Istanbul Medical Faculty, Istanbul. For reprints write Salih Zoroglu, M.D., Istanbul Tip Fakiil- tesi Psikiyatri Klinigi, Capa 34390, Istanbul Turkey. ABSTRACT In this paper, the diagnostic processes, previous diagnoses, clinical symptomatology, life events, traumatic experiences, family histories, and treatment of five children (three girls and two boys between five and eleven years of age) with DID are presented. Clinical findings were headaches, aggressive behavior and outbursts, trance-like expe- riences, amnesias, inconsistent school performance, lying, sleep dis- turbances, and depressive symptoms. One of the patients had been treated previously under different diagnoses. The number of alter personalities ranged from two to eleven. One of the patients, a ten- year-old girl, had two distinct personality systems. A ll of the cases presented at least four Schneiderian first-rank symptoms except an eleven-year-old boy who had only one. A ll of the cases had amnesia between at least two alters during interviews initially, except for a five-year-old case who did not. A ten-year-old girl was treated suc- cessfully and her alter personalities integrated. The others discon- tinued the therapy. INTRODUCTION Dissociation is a psychophysiological process that occurs on a continuum ranging from minor normative dissociations such as daydreaming to psychiatric conditions such as dis- sociative identity disorder (DID), a chronic and polysymp- tomatic condition formerly called multiple personality dis- order (MPD) (Bernstein & Putnam, 1986; Putnam, 1991a). The essential feature of dissociative disorders is a disruption in the usually integrated functions of consciousness, mem- ory, identity, or perception of the environment (American Psychiatric Association, 1994). In adults, increased levels of dissociation and the disso- ciative disorders are closely linked to abuse and trauma dur- ing childhood (Bliss, 1984; Branscomb, 1991; Chu & Dill, 1990; Coons, Bowman, & Milstein, 1988; Demitrack, Putnam, Brewerton, Brandt, & Gold, 1990; Putnam, 1985a; Ross & Miller, 1991; Yargic, Tutkun, & Sar, 1994). The same asso- ciation has been shown also in child and adolescent cases (Bowman, Bliss, & Coons, 1985; Coons, 1994; Dell & Eisen- hower, 1990; Fagan & McMahon, 1984; Hornstein & Putnam, 1992; Hornstein & Tyson, 1991; Kluft, 1985a; Putnam, 1991b; Vincent & Pickering, 1988; Weiss, Sutton, & Utecht, 1985). However, the detection and documentation of dis- sociative disorders in children and adolescents have lagged behind those of adults (Putnam, 1991b) . The first published account of MPD in childhood was Despine's report of his patient "Estelle" 1840 (Ellenberger, 1970; Fine, 1988) . This 11-year-old girl is also the first report- ed case of MPD whose treatment was successfully complet- ed. Fagan and McMahon (1984) described the syndrome of incipient MPD in four children. These authors described the process of diagnosis and treatment in detail and developed a predictor list based on their patients' symptoms and behaviors. Fagan and McMahon also found that family inter- ventions and play therapy proved effective (Fagan & McMa- hon, 1984; McMahon & Fagan, 1989). Kluft (1985a) reported five childhood cases of MPD. Kluft also derived a predictor list with 16 items. He emphasized the similarities and differences between child and adult cases of MPD, and summarized the difficulties of diagnosing MPD in children. Kluft reported that child cases of MPD were dif- ferent from adult cases in the types and number of alter per- sonalities, the alters ' lesser narcissistic investment in sepa- rateness, greater ease and shorter lengths of treatment, and a diminished frequency of relapses. Kluft (1985a) has offered follow-ups on some of his cases, indicating that the poten- 253 DISSOCIATlO\, Vol. IX, No. T, December 1996