Differential diagnosis: DID vs schizophrenia

by **Una+** » Mon Mar 12, 2012 4:33 pm

Here are abstracts of some technical articles on the topic of differential diagnosis of dissociative disorders vs schizophrenia. Omitted is one article making the argument that because differential diagnosis is a challenge these two disorders should be considered to be related. Um, no. By this argument, we should also throw in epilepsy, borderline personality disorder, and bipolar disorder.

Seishin Shinkeigaku Zasshi. 2011;113(9):906-11.
[Differential diagnosis between dissociative disorders and schizophrenia].
[Article in Japanese]
Shibayama M.

The differential diagnosis of dissociative disorders includes many psychiatric disorders, such as schizophrenia, bipolar disorders (especially bipolar II disorder), depressive disorder (especially atypical depression), epilepsy, Asperger syndrome, and borderline personality disorder. The theme of this paper is the differential diagnosis between dissociative disorders and schizophrenia. Schneiderian first-rank symptoms in schizophrenia are common in dissociative disorders, especially in dissociative identity disorder (DID). Many DID patients have been misdiagnosed as schizophrenics and treated with neuroleptics. We compared and examined Schneiderian symptoms of schizophrenia and those of dissociative disorders from a structural viewpoint. In dissociative disorders, delusional perception and somatic passivity are not seen. "Lateness" and "Precedence of the Other" originated from the concept of "Pattern Reversal" (H. Yasunaga)" is characteristic of schizophrenia. It is important to check these basic structure of schizophrenia in subjective experiences in differential diagnosis between dissociative disorders and schizophrenia.

PMID: 22117396

Fortschr Neurol Psychiatr. 2010 Jan;78(1):33-7. Epub 2009 Oct 21.
[Dissociative identity disorder or schizophrenia?].
[Article in German]
Tschöke S, Steinert T.

We present a case of dissociative identity disorder in which Schneiderian first rank symptoms were present besides of various states of consciousness. Thus the diagnosis of schizophrenia had to be considered. Formally, the symptoms met ICD-10 criteria for schizophrenia. However, taking into account the lack of formal thought disorder and of negative symptoms as well as a typical history of severe and prolonged traumatisation, we did not diagnose a co-morbid schizophrenic disorder. There is good evidence for the existence of psychotic symptoms among patients with dissociative disorders. However, in clinical practice this differential diagnosis is rarely considered.

PMID: 19847739

J Nerv Ment Dis. 1995 Apr;183(4):236-41.
Positive and negative symptoms in dissociative identity disorder and schizophrenia: a comparative analysis.
Ellason JW, Ross CA.

A substantial number of patients with dissociative identity disorder have had previous diagnoses of schizophrenia, due to the presence of positive symptoms of schizophrenia. The authors investigated the pattern of positive and negative symptoms in patients with dissociative identity disorder, and compared it with norms in schizophrenia. A total of 108 patients with a clinical diagnosis of dissociative identity disorder were administered the Positive and Negative Syndrome Scale. The positive symptom and general psychopathology scores were significantly more severe in the dissociative identity group than the norms for schizophrenia, while the negative symptoms were significantly more severe in schizophrenia. Since patients with dissociative identity disorder report more positive symptoms of schizophrenia than do schizophrenics, while schizophrenics report more negative symptoms, a primary emphasis on positive symptoms may result in false-positive diagnoses of schizophrenia and false-negative diagnoses of dissociative identity disorder.

PMID: 7714512

J Nerv Ment Dis. 1994 Sep;182(9):495-502.
Distinguishing between multiple personality disorder (dissociative identity disorder) and schizophrenia using the Structured Clinical Interview for DSM-IV Dissociative Disorders.
Steinberg M, Cicchetti D, Buchanan J, Rakfeldt J, Rounsaville B.

The authors describe the systematic assessment of dissociative symptoms using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) in 50 psychiatric outpatients with a referring DSM-III-R diagnosis of either schizophrenia or schizoaffective disorder (N = 31) and subjects with multiple personality disorder (MPD [DSM-IV name change: dissociative identity disorder]; N = 19). Results indicate that patients with MPD experience significantly higher scores for five specific dissociative symptoms than patients with schizophrenia or schizoaffective disorder. The range, severity, and nature of the five dissociative symptom areas evaluated by the SCID-D distinguish MPD from the occasional occurrence of dissociative symptoms which may be seen in schizophrenia. Systematic assessment of dissociative symptoms using the SCID-D can assist in accurate differential diagnosis of MPD and schizophrenia.

PMID: 8083678

Wikipedia: Differential diagnosis
Wikipedia: Positive and Negative Syndrome Scale

J Nerv Ment Dis. 2009 Dec;197(12):892-8.
Auditory hallucinations in dissociative identity disorder and schizophrenia with and without a childhood trauma history: similarities and differences.
Dorahy MJ, Shannon C, Seagar L, Corr M, Stewart K, Hanna D, Mulholland C, Middleton W.

Little is known about similarities and differences in voice hearing in schizophrenia and dissociative identity disorder (DID) and the role of child maltreatment and dissociation. This study examined various aspects of voice hearing, along with childhood maltreatment and pathological dissociation in 3 samples: schizophrenia without child maltreatment (n = 18), schizophrenia with child maltreatment (n = 16), and DID (n = 29). Compared with the schizophrenia groups, the DID sample was more likely to have voices starting before 18, hear more than 2 voices, have both child and adult voices and experience tactile and visual hallucinations. The 3 groups were similar in that voice content was incongruent with mood and the location was more likely internal than external. Pathological dissociation predicted several aspects of voice hearing and appears an important variable in voice hearing, at least where maltreatment is present.

PMID: 20010024

by **Una+** » Wed Aug 08, 2012 8:09 pm

Here is the abstract of a new article on this topic:

J Trauma Dissociation. 2012 Jul;13(4):397-413.
Dissociation and psychosis in dissociative identity disorder and schizophrenia.
Laddis A, Dell PF.

Dissociative symptoms, first-rank symptoms of schizophrenia, and delusions were assessed in 40 schizophrenia patients and 40 dissociative identity disorder (DID) patients with the Multidimensional Inventory of Dissociation (MID). Schizophrenia patients were diagnosed with the Structured Clinical Interview for the DSM-IV Axis I Disorders; DID patients were diagnosed with the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised. DID patients obtained significantly (a) higher dissociation scores; (b) higher passive-influence scores (first-rank symptoms); and (c) higher scores on scales that measure child voices, angry voices, persecutory voices, voices arguing, and voices commenting. Schizophrenia patients obtained significantly higher delusion scores than did DID patients. What is odd is that the dissociation scores of schizophrenia patients were unrelated to their reports of childhood maltreatment. Multiple regression analyses indicated that 81% of the variance in DID patients' dissociation scores was predicted by the MID's Ego-Alien Experiences Scale, whereas 92% of the variance in schizophrenia patients' dissociation scores was predicted by the MID's Voices Scale. We propose that schizophrenia patients' responses to the MID do not index the same pathology as do the responses of DID patients. We argue that neither phenomenological definitions of dissociation nor the current generation of dissociation instruments (which are uniformly phenomenological in nature) can distinguish between the dissociative phenomena of DID and what we suspect are just the dissociation-like phenomena of schizophrenia.

PMID: 22651674

by **Una+** » Thu Mar 13, 2014 2:41 pm

Here is an older medical journal article on the problem of accurate diagnosis of DID and the risk of misdiagnosing DID as schizophrenia if the diagnostician uses the MMPI, a broad spectrum personality test. The MMPI has over 500 questions, all requiring a yes or no answer. Clients with DID typically experience severe distress trying to complete the MMPI, due to internal conflict over how to answer the questions. We know all too well what that feels like, don't we? I experience this conflicted "splitting" even on the DES, which has only 28 questions and a 0-10 choice Likert scale. Also, the MMPI, including the MMPI-2, has been shown not to distinguish between valid DID and faking. The SCID-D-R does distinguish these.

J Nerv Ment Dis. 1995 Oct;183(10):615-22. Dissociation and vulnerability to psychotic experience. The Dissociative Experiences Scale and the MMPI-2. Allen JG, Coyne L.

Abstract

Prior research on the MMPI has cautioned against misdiagnosing schizophrenia in patients with dissociative identity disorder. The present study examined the full spectrum of the dissociative experience in relation to MMPI-2 profiles. Ninety-eight women in treatment for trauma-related disorders completed the Dissociative Experiences Scale and the MMPI-2 in routine inpatient diagnostic evaluations. Consistent with prior research, severe dissociation was associated with high elevations on MMPI-2 scales typically associated with psychotic symptoms. Contrary to hypotheses, the ostensibly most benign form of dissociation, absorption and imaginative involvement, was somewhat more strongly related to MMPI-2 scores than the more pathognomonic forms of dissociation, depersonalization and amnesia. Although it should not be misdiagnosed, severe impairment on the MMPI in conjunction with dissociation should be taken seriously as suggesting vulnerability to psychotic experience. The dissociative retreat from the stressors of outer reality opens the door to the inner world of traumatic images and affects, along with compromised reality testing and disorganized thinking.

PMID: 7561806

by **Nina11** » Sun Mar 16, 2014 1:58 am

deleted

by **Seangel** » Sat Apr 19, 2014 9:24 pm

I recently watched this TED talk, that talks about schizophrenia:

A Tale of mental illness -- from the inside

I like what Elyn Saks says at the end:

"Everything about this illness says I shouldn't be here, but I am. And I am, I think, for three reasons: First, I've had excellent treatment. Four- to five-day-a-week psychoanalytic psychotherapy for decades and continuing, and excellent psychopharmacology. Second, I have many close family members and friends who know me and know my illness. These relationships have given my life a meaning and a depth, and they also helped me navigate my life in the face of symptoms. Third, I work at an enormously supportive workplace at USC Law School. This is a place that not only accommodates my needs but actually embraces them. It's also a very intellectually stimulating place, and occupying my mind with complex problems has been my best and most powerful and most reliable defense against my mental illness."

Sea

by **JustHelpful** » Sun Apr 20, 2014 5:26 am

Well it's not necessarily a vs. thing in everyone. Some one can be schizophrenic with dissassocciative symptoms at the same time. But putting that case aside I think you can generalize some key differences.

Hallucinations and delusions in dissociative people tend to be flashback phenomena rather than dominantly protective operations.

Schizophrenics withdrawal from reality and relatedness trends to start in the teens and continue into adulthood compared to Individuals with dissociative identity disorder who live compartmentalized lives, doing better in some areas and worse in others.

Also in general people with DID are very relatable vs. Schizophrenic which is generally a lot less relatable to others.

In Nancy McWilliams book Psychoanalytic Diagnosis she orders all the personality organizations from least relatable (psychopaths) to most relatable (DID). Schizophrenia is on the less relatable end of the spectrum.

by **Una+** » Sun Apr 20, 2014 1:40 pm

JustHelpful wrote:Also in general people with DID are very relatable vs. Schizophrenic which is generally a lot less relatable to others.

Yes. That has been my experience interacting with someone living with severe schizophrenia. In this respect, this TED talk speaker is not typical of someone with schizophrenia. She seems to have been exceptionally able to relate to others, at least when not in crisis.

In general, people with DID do tend to have good relationships with others, albeit the relationships tend to be limited, compartmentalized. And most of us, most of the time, pass for normal without the supports of medication and intensive psychotherapy. Even when we are very symptomatic, we may still appear to be normal.

This is in contrast to someone with schizophrenia. Without medication and other supports their condition is very apparent to other people. Also, people with schizophrenia do not exhibit identity alteration nor, generally, amnesia.

by **micky_** » Sun Apr 20, 2014 6:10 pm

Very interesting thread and discussion! Many thanks to all contributors, and especially to Una+.
Differentiation between schizophrenia and DID is important, and as we know, sometimes very difficult.

Getting a correct diagnosis can become even more complicated if there are (true) psychotic symptoms on top of the DID symptoms, a “dissociative psychosis”. (See also this topic.)
The article / book part "Psychotic Presentations of Dissociative Identity Disorder" presents an excellent discussion of the phenomenon of dissociative psychosis (link to pdf).

It mentions a lot of psychotic symptoms that are commonly regarded as typical for schizophrenia and atypical for DID, like impaired reality testing, discontinuity in thought flow, and disorganized behavior.
So displaying a lot of symptoms typical to schizophrenia but atypical to DID doesn’t necessarily rule out DID.

Yet, incidentally there are cases that remain a mystery from diagnostic point of view, see e.g. this article Long-Term Atypical Psychoses

The background of my contribution to this thread is that (a long time ago) I myself had a (waxing and waning) dissociative psychosis for years and couldn’t get a better diagnosis than something like “an atypical chronic psychosis resistant to any treatment”. The medical team treating me was on the verge of giving up

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Differential diagnosis: DID vs schizophrenia

Differential diagnosis: DID vs schizophrenia

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