Background

Dissociative identity disorder (DID) is a complex mental illness in which individuals experience consistent impairments in identity, memory disturbance and disruption in behaviour. There is a significant correlation with early trauma, especially sexual trauma. Around 94% may have experienced childhood physical or sexual abuse and over 80% may meet diagnostic criteria for post-traumatic stress disorder (PTSD).1 Childhood trauma and maltreatment lead to increased risk of not only DID and PTSD but also suicidal and self-harm behaviours.2

Schizotypal personality disorder (SPD) is an under-recognised personality disorder characterised by consistent themes of interpersonal relations, cognitive-perceptual disturbances and disorganised speech and behaviours. The fantastic and bizarre thought processes related to SPD can lead to excessive interests and beliefs in paranormal and pseudoparanormal ideas.

Here, we present a case of atypical SPD in a patient who presented to an inpatient psychiatric unit for apparent DID symptomatology. We focus on diagnostic clarity and psychologic assessment and interventions.

Case presentation

A 20-year-old man, active duty military service member, was admitted to a military inpatient psychiatric unit after he had informed a coworker about his experience of multiple personalities. On the intake evaluation, the patient reported several unique personalities, which he described as ‘alters’. These personalities included a variety of human figures and nonhuman beings, including a nerdy man, an ethereal gatekeeper or protector, a child with trauma, a charismatic Casanova and “one who should not be named”. The patient had a full recollection of the experiences of each persona and appeared to jump easily between them. Through the first days of hospitalisation, he drew intricate and elaborate diagrams of the relationships between personalities and added a personality during the admission. He described competition for control between the personalities and was engaged and excited to discuss them.

The patient reported the perception that his adoptive parent’s divorce was traumatic but described the divorce as amicable and denied signs and symptoms consistent with a primary trauma disorder. He further denied any childhood physical or sexual trauma. He was placed in foster care at 4 years old and adopted at around 8 years old. He appeared to harbour resentment towards his adoptive mother. The patient reported consistent difficulties with close interpersonal relationships through his high school years until the present day. His language reflected poor self-esteem and excessive concern for the opinions of others. The patient described a general dysthymic and socially anxious temperament through much of his early life and worsening while in high school. He was not specific in the ages of onset or worsening of the dysthymic and anxious mood symptoms. Collateral was not obtained from family.

The emergence of the self-reported multiple personalities began in high school during a period of increased interpersonal conflict with peers and family. It was observed by the care team that the personalities emerged around the time that the film Split entered the box office. A correlation was also noticed regarding the characteristics of the patient’s personalities and those in the film, which also portrayed a childlike character, a charismatic personality and a dangerous persona with a nonhuman name (‘The Beast’). Although the patient aware of the film, he had consistently denied watching the film at the time and denied any connection.

Investigations

Medically, the patient was stable. He presented without any acute or chronic medical illnesses. Vital signs and laboratory results including serum alcohol and urine drug testing were within normal limits. He was not taking medications or supplements. There were no signs or symptoms consistent with substance intoxication or withdrawal. The patient was evaluated for delirium and other alterations of consciousness, but no dysfunction was observed. In this case, head imaging was neither considered medically nor diagnostically necessary.

A thorough history was taken at intake, with clarifying investigation on subsequent days. The primary treatment team, led by a psychiatrist, performed daily clinical interviews, which explored the patient’s thought patterns, beliefs and childhood experiences. He was evaluated for signs and symptoms associated with psychotic disorders, mood disorders, trauma disorders, dissociative disorders and personality disorders. No accurate family history could be obtained due to his adopted status. An independent clinical evaluation by interview was performed by a psychologist.

Differential diagnosis

Given the unusual characteristics of the patient’s presentation, a significant range of diagnoses was initially considered, including psychotic disorders, mood disorders, trauma-related disorders, factitious disorder, malingering, dissociative disorders and personality disorders. The patient’s lack of reported history of trauma or significant mood symptoms were not consistent with a primary trauma-related disorder or mood disorder.

Psychotic disorders were considered early in the hospitalisation. The patient denied any hallucinations and did not present with disorganised thinking or other negative symptoms. Delusional disorder, in particular, was considered. Delusions are not typically amenable to change when faced with conflicting evidence and require a strong degree of conviction. The patient’s response to psychotherapeutic techniques within a relatively short period of time lends more credibility to the thoughts presenting more as strongly held odd beliefs than as true delusions. His constellation of symptoms outside the odd belief system was inevitably better explained by another mental disorder.

Malingering and factitious disorder were considered. Malingering requires clear secondary gain and may be found at a higher prevalence in military populations.3 Factitious disorder presents as falsification of symptoms to take a sick role. Malingering was ruled out due to a lack of clear secondary gain. The patient was admitted in response to a concerning report by another service member and not by his request. He reported contentment with his military service and was supported by his leadership. Though the patient exhibited passion in talking about his personalities, he appeared to do so more out of a need for nonjudgmental validation.

Despite his report of multiple personalities, the patient denied any amnesia, dissociation, depersonalisation and derealisation. He also denied frank physical or sexual abuse, which is highly correlated with presentations of DID.4 This quickly ruled out DID and other dissociative disorders.

Due to the chronic nature of his abnormal thought patterns, uncommon beliefs and interpersonal struggles, the treatment team evaluated the patient for personality disorders. His symptom constellation was found to be consistent with SPD. The findings were consistent between the primary treatment team and the independent evaluation by the psychologist. Consistent with the fifth edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders, he demonstrated a ‘pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as cognitive or perceptual distortions and eccentricities of behaviour’, which began in early adulthood, around 14 or 15 years old.5

He clearly and consistently reported five criteria of SPD. He demonstrated ideas of references including incorrect interpretation of causal incidents and attributing his successes to the reported personalities. He presented with odd beliefs and magical thinking, in which the personalities were a pseudoparanormal phenomenon that empowered the patient and allowed him to feel special. His thought process could be considered odd or at least abnormal. At times, his speech was overly digressive and not always logical, though not to the point of psychotic disorganisation. The patient reported paranoia regarding the intentions of others including his family, workmates and the treatment team. He lacked close friends and confidants, and his relationship with his family was quite limited.

Treatment

Though there are indications for psychopharmacological interventions in DID, there is limited data on the use of psychopharmacological interventions in SPD. Due to a combination of limited data in SPD and patient preference, the treatment team decided against psychopharmacological interventions. The literature that exists focuses on the use of psychotropics to target specific symptoms. For example, antipsychotics have been used in the treatment of related paranoia and stimulants in the treatment of cognitive dysfunction and disorganised thinking.6 7

Treatment focused on psychotherapeutic interventions. There are no randomised controlled studies supporting the use of a specific psychotherapeutic technique in SPD. Due to the patient’s initial emotional distress and paranoia, therapy was primarily supportive, with a focus on nonjudgmental rapport building, reflection and summarisation. Reflection and summarisation techniques were modified to combat the use of ‘we’ in the patient’s description of self. For example, when the patient made a statement such as ‘we feel that we are not understood’, the psychiatrist would reply ‘I understand that you feel that you are not understood. I imagine that it a difficult situation’. A consistent effort was made to validate the patient’s emotional distress while focusing away from the personalities and towards other notable aspects of the patient’s interpersonal struggles and internal processes. Through consistent reinforcement of the singular and redirection of the therapeutic content from the personalities to other aspects of the patient’s reality, the daily therapeutic sessions shifted from focus on the personalities to focus on other aspects of the patient’s life and experiences. By the end of his hospitalisation, the patient did not discuss the personalities in the therapeutic sessions or with other patients.

Therapy also incorporated interpersonal and psychoeducational elements. The interpersonal therapy focused on ‘theory of mind’, how to understand others’ thoughts and feelings and incorporate that into socially appropriate responses. Emphasis was placed on familial and occupational interactions. Psychoeducation was provided regarded the patient’s diagnosis. He exhibited a strong emotional reaction, tearful for the only time in his hospitalisation. The moment was used as an opportunity to emphasise the patient’s strengths, including his powerful imagination and creativity and instil hope in the future. He emotionally recovered quickly and was discharged on the eighth day of hospitalisation.

Outcome and follow-up

The patient engaged in outpatient individual and group therapy for approximately 4 months after discharge. He fluctuated between focus on interpersonal problems and his diagnosis. At times, he did report multiple personalities, though outpatient therapists reinforced his SPD diagnosis. He continued to deny a connection or causation between media influence and his symptom presentation. The patient experienced temporary occupational limitations due to his hospitalisation but otherwise continued in his military obligation without significant problems. The patient is alive at the time of this publication.