I.

PENDAHULUAN
According to the text revision of the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR), the essential feature of the dissociative
disorders is a disruption in the usually integrated functions of consciousness, memory,
identity, or perception of the environment. The disturbance may be sudden or gradual,
transient or chronic. The DSM-IV-TR dissociative disorders are dissociative identity
disorder, depersonalization disorder, dissociative amnesia, dissociative fugue, and
dissociative disorder not otherwise specified (NOS).
Gangguan ini disebut disosiatif karena dahulu dianggap terjadi hilangnya asosiasi ana
(MARAMIS)
Dissociative identity disorder (formerly multiple personality disorder) is described in
DSM-IV and requires the presence of two or more distinct identities, or personality states,
each with its own relatively enduring pattern of perceiving, relating to, and thinking about
the environment and self'. At least two of these identities or personality states must
recurrently take control of the person's behaviour.

According to DSM-IV-TR, dissociative identity disorder, previously called multiple
personality disorder, is characterized by the presence of two or more distinct identities
or personality states that recurrently take control of the individual's behavior accompanied
by an inability to recall important personal information that is too extensive to be explained
by ordinary forgetfulness. The identities or personality states, sometimes called alters,
self-states, alter identities, or parts, among other terms, differ from one another in that each
presents as having its own relatively enduring pattern of perceiving, relating to, and
thinking about the environment and self.

II. EPIDEMIOLOGI
Few systematic epidemiological data exist for dissociative identity disorder. Clinical
studies report female to male ratios between 5 to 1 and 9 to 1 for diagnosed cases.
A recent general population study found that 13% of the population met diagnostic
criteria for DID. This study has been criticized; some have suggested that this figure is too
high, considering a more realistic prevalence to be about 0.5% of the population. Still
others have suggested that this figure is too low, citing the high rates of childhood
maltreatment in the general population. Several studies have shown that DID and other
dissociative disorders occur frequently in the family members of patients with DID.
Multigenerational families with DID have been described (Braun, 1985).


III. ETIOLOGI DAN PATOGENESIS
Dissociative identity disorder is strongly linked to severe experiences of early
childhood trauma, usually maltreatment. The rates of reported severe childhood trauma for
child and adult patients with dissociative identity disorder range from 85 to 97 percent of
cases. Physical and sexual abuse are the most frequently reported sources of childhood
trauma. The contribution of genetic factors is only now being systematically assessed, but
preliminary studies have not found evidence of a significant genetic contribution.
The current view is that DID is a developmentally based posttraumatic disorder
usually beginning before the age of 6. In DID, overwhelming and/or traumatizing
circumstances, accompanied by disturbed caretaker-child attachment and parenting, lead to
extreme states of consciousness in the child. These disrupt the normal consolidation of
personal identity across shifts in state, mood, and personal and social context. In addition,
trauma causes encapsulation of intolerable memories and affects in dissociative
behavioral states. These dissociative responses may preserve relationships with caretakers,
even abusive ones, and allow segregation of traumatic experiences to permit development
in other life areas such as academics and social life. Once formed, these entities may show
some degree of development relatively independent of other identities in the person. In
addition, dissociation and alter identity creation may be used subsequently to cope with
more routine, nontraumatic life circumstances. The outcome is a person embodying a
number of relatively concretized, more-or-less independent self-states, often in significant
conflict with each other.
Recent media-based depictions of DID have posited that the condition is the product
of suggestion by clinicians to highly influenceable patients. There are no research studies in
clinical populations that have supported this opinion. Conversely, a wealth of studies
support the notion of the posttraumatic origin of DID (Gleaves, 1996).





IV. KRITERIA DIAGNOSTIK
Table 20-6 DSM-IV-TR Diagnostic Criteria for Dissociative Identity Disorder
A. The presence of two or more distinct identities or personality states (each with its own
relatively enduring pattern of perceiving, relating to, and thinking about the
environment and self).
B. At least two of these identities or personality states recurrently take control of the
person's behavior.
C. Inability to recall important personal information that is too extensive to be explained
by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g.,
blackouts or chaotic behavior during alcohol intoxication) or a general medical
condition (e.g., complex partial seizures). Note: In children, the symptoms are not
attributable to imaginary playmates or other fantasy play.
V. GAMBARAN KLINIS
Dissociative identity disorder or DID (previously known as multiple personality
disorder or MPD) is characterized by the existence of two or more identities or personality
states (also called alters, parts, alter identities, etc) within a single individual. Alter
identities are defined as mental constructs, each with its own relatively enduring pattern of
thoughts, memories, emotions, perceptions, and subjective experience. Individuals with this
disorder demonstrate transfer of behavioral control among alter identities either by state
transitions (switching) or interference and overlap of alters who manifest themselves
simultaneously. DA is also present in almost all patients with DID.
The florid, dramatic patient with DID depicted in the media and old psychiatric
textbooks probably represents fewer than 5% of patients with this disorder. In most patients
with DID, the dissociative disorder presents in a covert and subtle fashion. The most
typical clinical presentation is one of a refractory psychiatric disorder, usually a mood
disorder, or, of particular relevance to primary care, multiple somatic symptoms. Many
patients with DID meet diagnostic criteria for somatization disorder and/or other
somatoform disorders. Overuse of medical resources is typical of a significant subgroup of
these patients.
Alter identities vary in complexity and psychological structure. In some cases, highly
developed alter identities are present with marked presentational differences in posture,
voice tone, manifest mood, energy, interests, talents, capacities, manifest age, gender, etc.
In the majority of cases, however, the alters are relatively limited in their psychological
depth and do not manifest with dramatic differences on switching. Alter identities may
develop with polarized perceptions and viewpoints: eg, a male multiple with an actively
homosexual alter and a hypermasculine homophobic alter. Others seem to sequester neutral
information, talents, capacities, and historical information. Alter identities are not separate
people, although they may perceive themselves as separate persons inhabiting different
bodies, unaffected by what happens to one another. All the alters together make up the
personality of a single human being. In general, all alters should be held responsible for the
behavior of any other alter, despite subjective amnesia or disavowal of behavior.
Developmental, cultural, and social factors, as well as more extensive traumatization,
may influence the structuring, complexity, and elaboration of the alter identity system.
For example, some patients with DID with substantial creativity and intelligence may
develop far more elaborate alter systems. This secondary structuring is not the sine qua non
of this disorder. The essential features are the development of the subjectively experienced
alter identity states accompanied by state transitions and amnesia.

DSM-IV diagnostic criteria for dissociative identity disorder.
A. The presence of two or more distinct identities or personality states (each with its own
relatively enduring pattern of perceiving, relating to, and thinking about the
environment and self).
B. At least two of these identities or personality states recurrently take control of the
person's behavior.
C. Inability to recall important personal information that is too extensive to be explained
by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (eg,
blackouts or chaotic behavior during alcohol intoxication) or a general medical
condition (eg, complex partial seizures). Note: In children, the symptoms are not
attributable to imaginary playmates or other fantasy play.


VI. DIFFERENSIAL DIAGNOSIS
DID can be mistaken for most other psychiatric disorders. Comorbid mood, anxiety,
somatoform, personality, and posttraumatic disorders are common, as are eating disorders
and substance abuse. Patients with DID may be mistakenly considered psychotic because
they hear the voices of their alter identities and/or experience other bizarre hallucinatory
phenomena. However, the dissociative patient commonly experiences hearing voices
within the mind, not outside it as with true hallucinations. Patients with DID are often
frightened of being labeled crazy for having pseudopsychotic experiences. True paranoid
delusions are uncommon in patients with DID, although mistrust and suspicion of the
intentions of others are common, usually secondary to abuse and maltreatment.
Mood swings are common in patients with DID, but often occur over minutes to
hours, not days or weeks as in bipolar patients. These very rapid mood changes usually do
not respond to mood stabilizers, such as lithium. Chronic depression, anxiety, and
dysphoria are common in these patients. They are only partially responsive to psychiatric
medications. Severe sleep problems are also present in most cases.
A subgroup of patients with DID may have a somatoform presentation with refractory
pain, apparent paralysis, pseudoseizures, multiple sclerosis-like symptoms, etc. A complex
subgroup of these patients suffers from bona fide chronic medical disorders such as
systemic lupus erythematosus or myasthenia gravis. Their psychiatric pathology
complicates their medical management and vice versa. Joint medical and psychiatric
management is frequently essential in these cases.
Careful history taking to help recognize chronic amnesia, symptoms of PTSD, a
history of early maltreatment, and the presence of alter identities may allow diagnosis of
DID, even in cases in which other symptom clusters appear to predominate.



VII. Treatment & Prognosis
Patients with DID range from severely chronically psychiatrically ill individuals with
poor psychosocial function to very high functioning people who may be successful
professionally and socially. In general, DID is treated as a complex, chronic, trauma-based
disorder. Accordingly, a three-stage model is used. In the first, patients are taught
techniques to manage symptoms and stabilize their dysfunctional lives. A broad range of
psychotherapies may be employed, including cognitive-behavioral, psychodynamic,
supportive, and hypnotherapy, to assist the patient with these tasks. Psychopharmacological
interventions may be helpful to treat comorbid affective, anxiety, and PTSD conditions.
Family, marital, social, and educational interventions may be needed. Homogeneous group
therapy for patients with DID may be effective, if carefully structured to focus on current
life adaptation, not past traumas. Expressive therapies, such as art and dance therapy, may
be helpful for many patients with DID.
After stabilization, some patients may elect to intensively process traumatic memories
per se. Premature intensive focus on trauma material, before symptom stabilization is
accomplished, usually leads to regression and decompensation in most patients with DID.
Finally, once trauma issues are fully resolved, the patient may focus primarily on
successful living without domination by posttraumatic symptoms and beliefs. A subgroup
of patients with DID may achieve fusion in which all identities consolidate into one. The
person experiences himself or herself as unified.
On the other hand, another group of patients with DID will never move beyond work
on basic symptom and life stabilization. They are seriously and persistently psychiatrically
ill and may require repeated psychiatric hospitalizations and partial hospital treatment.
Studies of outcome and cost efficacy in the United States and Canada suggest that
proper treatment for patients with DID results in improvement for many of them, as well as
reduction in costs for psychiatric and medical care, even for the most severely ill group.
Treatment may take years, however, particularly in the more severely ill patients.