Peer Support for Abuse Survivors
Guidelines for Treating Dissociative Identity Disorder in Adults (2005)
The duration of treatment depends on the patient’s presenting functional ability, ego strengths, and any past treatment and its impact. Some early reports on treatment outcome showed that over two to three years of intensive outpatient psychotherapy, many patients could reach a relatively stable condition in which they did not experience a sense of internal separateness (Kluft, 1984). However, the treatment needs of DID patients vary enormously, and many patients require three to five years following the diagnosis of DID as a minimum length of treatment, with many more complex patients often requiring lengthier outpatient psychotherapy, sometimes with inpatient stays during crises. M ore severe personality pathology (especially obsessive-compulsive, borderline, narcissistic, and passive-aggressive types) is associated with longer treatment. Some therapists who are experienced in treating DID patients with severe comorbid Axis II disorders have suggested that incremental improvement may continue for as long as two decades of treatment or more in this population.
The most commonly cited treatment orientation is individual psychodynamically oriented psychotherapy, often eclectically incorporating other techniques (Putnam & Loewenstein, 1993). For example, cognitive behavioral therapy techniques can be modified to help patients explore and change dysfunctional trauma-based belief systems or to manage stressful experiences or impulsive behavior (e.g., stress inoculation training, dialectical behavioral therapy [DBT]). However, standard cognitive therapy protocols for depression and anxiety usually require modification when used in the treatment of DID. Many therapists employ hypnosis as an adjunctive modality in the treatment of DID (Putnam & Loewenstein, 1993; see below). The most common uses of hypnosis are for calming, soothing, containment, and ego strengthening. In addition to individual psychotherapy, patients may benefit from specialized interventions such as family or expressive therapy, educational programs such as bibliotherapy, and other treatments. Some patients require specialized substance abuse or eating disorder treatment.
Because DID patients often have difficulties with self-harming behaviors and impulse control, Dialectic Behavioral Therapy (DBT; Linehan, 1993) is now often incorporated in modified form or added as adjunctive group therapy. Some authors have published articles advocating the use of Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2001) as an adjunctive treatment modality in dissociative disorders. However, this modality of treatment may have considerable risks for the DID patient (e.g., flooding with too much traumatic material) and only should be used in the context of an overall comprehensive treatment plan that includes interventions to ensure stabilization and specific work with the alternate identity system (see below).
Behavior modification techniques may be useful when taught to the patient as self-control strategies for symptom management. For example, work on PTSD triggers may involve systematic desensitization strategies. As in any psychotherapy, learning theory is useful in understanding how some elements of psychotherapeutic practice are helpful to patients. For example, exploration and processing of traumatic material can be conceptualized as a form of exposure therapy that permits traumatic memories to be transformed into narrative memories. Experienced therapists pay attention to rewarding healthy behaviors with attention and praise. Expressing mild disappointment in response to maladaptive behaviors may be helpful to some patients, leading to a discussion of the factors related to those behaviors. However, it is unhelpful at best, and counterproductive in many cases, to make use of behavior modification techniques to punish the expression of dissociation itself, e.g., to ignore or attempt to extinguish the expression of the alternate identities. Further, the therapist should generally avoid the use of aversive conditioning or extinction procedures since these may strongly evoke many types of abuse experiences commonly reported by DID patients.
Many specific techniques and interventions have been developed to facilitate DID treatment. These include imagery and hypnotic techniques, approaches to transference and countertransference, cognitive techniques, etc. Further, much of the literature on therapy for complex PTSD may be helpful as well in this regard. A detailed discussion of these interventions and techniques is beyond the scope of these Guidelines. There are numerous excellent sources in the literature that detail aspects of the treatment of complex PTSD (cf. Briere, 1989; Chu, 1988, 1998; Courtois, 1999; Gold, 2000; Herman, 1992a; Ross, 2000, among others), and for the treatment of DID (cf. Fraser, 2003; Kluft, 1993a, 1993b, 1999; Kluft & Fine, 1993; Putnam, 1989; Rivera, 1996; Ross, 1997; Steele et al., 2005; Van der Hart et al., 1998; Watkins & Watkins, 1988, among others).
Treatment for DID is optimally provided by an individual psychotherapist. However, additional clinicians may be helpful in comprising a treatment team. Depending on individual circumstances, treatment teams may include a variety of professional disciplines including psychopharmacologists, case managers, family therapists, expressive therapists, and medical professionals. It is vital that members of the treatment team co-ordinate their treatment of the DID patient and that there is clarity about who is the clinician responsible for overall treatment management and decision-making. It is problematic when the DID patient has two or more individuals providing simultaneous intensive psychotherapy (e.g., seeing the medicating psychiatrist one hour per week and seeing the psychologist psychotherapist two hours per week for intensive therapy). Because of the DID patient’s divided mental processes and amnesia, it is easy for the patient to develop relationships in which one set of alternate identities interacts with one clinician and another set with another clinician, even without confusion of treatment team roles. This can thwart the goals of more integrated functioning, and tends to externalize the patient’s conflicts amongst different treatment team members.
The treatment structure for DID should be based on the principle that therapy optimally occurs on an outpatient basis, including processing traumatic material when necessary. This notion should be conveyed to the patient as part of the informed consent process. However, inpatient treatment may be necessary at times when patients are at risk for harming themselves or others, and/or when their posttraumatic or dissociative symptomatology is overwhelming or out of control. Inpatient treatment should occur in the context of a goal-oriented strategy designed to restore patients to a stable level of function to resume outpatient treatment expeditiously. Efforts should be made to identify the factors that have destabilized or threaten to destabilize the DID patient, such as family conflicts, significant losses, etc., and to determine what must be done to ameliorate these. Emphasis should be placed on building strengths and skills to cope with the destabilizing factors.
Hospitalization may at times provide an opportunity for diagnostic clarification. In addition to elucidating trauma-related disorders, an inpatient evaluation can screen for the presence of other co-morbid condition that require immediate treatment, e.g., a major depressive episode that manifests with both depression and increased PTSD symptoms.
With current constraints imposed by third party payers, most hospitalizations are brief and only for the purpose of stabilization. However, in some cases, the structure and safety of a hospital setting make possible therapeutic work that would be impossible or prohibitively destabilizing in an outpatient setting. Inpatient treatment in programs that are conducive to treating trauma patients can include planned and judicious processing of traumatic material, and work with aggressive and self-destructive alternate identities and their behaviors, assuming that there are resources to support a more prolonged hospitalization.
Specialized inpatient units dedicated to the treatment of trauma and/or dissociative disorders may be particularly effective in helping patients develop the skills they need to become more safe and stabilized as outpatients. These programs provide a setting where patients can receive specialized diagnostic assessments, intensive individual psychotherapy, psychopharmacological interventions, and work on symptom management and skill-building that are not possible in usual general hospital psychiatric programs. To be sure, patients’ participation in such programs may be limited by third party payers, due to the longer length of stay usually found in such programs. However, in some cases, insurance companies have referred refractory patients to specialized programs with the hope that costs may be reduced in the long-term by specialized interventions.
Decompensation or failure to improve during a hospitalization may occur in several circumstances. A small minority of DID patients, including massively decompensated and dysfunctional individuals, and those destabilized by severe present-day trauma, may require prolonged inpatient treatment in order to be restabilized. Treatment-related factors that may impede clinical improvement include unfocused inpatient treatment, or, conversely, inpatient treatment overly focused on trauma, e.g., with global and unrealistic goals, such as “getting out all of the memories,” or with an extensive focus on past traumatic material to the exclusion of contemporary issues and development of symptom management skills.
In inpatient treatment, seclusion and physical or chemical restraints may be indicated for the DID patient who is acting out violently and has not responded to verbal or pharmacological interventions. However, these restrictive measures often can be avoided by careful planning in advance for symptom management and containment strategies to help in crises. These can include accessing helper alternate identities, using imagery to find a “safe place” for overwhelmed or self-destructive alternate identities, and imagery to “dial down” or otherwise attenuate strong affects. As needed medications for anxiety and/or agitation such as benzodiazepines or neuroleptics also may be helpful in reducing agitation or providing sleep to abort a crisis (see below).
The use of “voluntary” physical restraints to control a violent alternate identity while working through trauma is no longer considered an appropriate intervention.
Many partial hospital programs (PHPs) are focused on management of the psychotic or bipolar patient and may not meet the needs of the DID patient. However, despite this, the DID patient may be able to gain some assistance from PHP programs as a step-down from inpatient treatment. Programs that allow an individualized focus for the trauma survivor and that are cognizant of trauma related issues may be most helpful for this purpose.
Specialized partial hospital or residential treatment for DID patients and others with severe trauma can be very helpful as either a step-down from inpatient care, or as a more intensive outpatient modality to prevent inpatient hospitalization and/or to provide intensive skills training. In general, these specialized programs use multiple daily groups to educate about trauma related disorders, to teach symptom management skills, and to provide training in relationships and other life skills. DBT or other more formal, structured techniques for symptom management may be incorporated into these programs. Unfortunately, few of these programs exist so that patients may need to travel to a distant location to receive these services, and many insurance plans will not reimburse a residential component of the treatment that would allow the patient to attend a PHP far from home.
Group psychotherapy is not a viable primary treatment modality for DID. Also, DID patients generally do poorly in generic therapy groups made up of individuals with heterogeneous diagnoses and clinical problems. However, certain types of time-limited groups for selected patients with DID or complex PTSD, can be valuable adjuncts to individual psychotherapy. These types of groups can help educate patients about trauma and dissociation, assist in the development of specific skill sets, and help the patients understand that they are not alone in coping with dissociative symptoms and traumatic memories. In general, task-oriented, educational, and skill building groups that teach coping strategies, social skills, and symptom management techniques have proved to be most helpful. In general, these task-oriented groups should be time limited, highly structured, and clearly focused.
Some clinicians have found that many DID patients have difficulty tolerating the strong affects elicited by traditional process-oriented psychotherapy groups or those that encourage discussion, even in a limited way, of participants’ traumatic experiences. Some open-ended therapy groups have resulted in symptom exacerbations and/or dysfunctional relationships among group members . However, other clinicians have reported carefully selected DID patients may benefit from longer-term, homogenous, more process-oriented groups for DID and complex PTSD patients. These groups tend to focus more on improvement of interpersonal functioning, coping with the demands of individual treatment, support during life crises, and use of the group to buttress development of affect tolerance, insight, and awareness of posttraumatic reactivity and cognitive distortions. Successful groups of this type require an explicit, firm, comprehensively articulated treatment frame with unambiguous expectations and rigorous boundaries for the participants’ actions inside and outside group (e.g., limitations on detailed discussion of trauma memories in group, no socializing outside group among group members, etc.).
Some patients may make good use of 12-step groups such as AA, NA, or Al-Anon when addressing substance abuse problems. However, the therapist should caution the patient about situations that may arise in these groups that may lead to exacerbation of posttraumatic or dissociative symptoms. This may occur due to graphic discussions of trauma or violence by group participants, and/or the possibility of meeting exploitative or abusive individuals who attend these groups and to whom the DID patient may be vulnerable.
It is the consensus of DID experts that 12-step “incest survivor” groups or non-professional “self-help” groups for DID patients have resulted in extremely poor outcomes for DID patients, especially for those in the first two phases of treatment. These groups commonly result in clinical deterioration due to the unregulated discussion of trauma material, poor boundaries between group members, and the disturbed or exploitative behavior of some group members. Many experienced clinicians will refuse to continue to treat DID patients who insist on involving themselves in these types of groups.
Marathon groups of any type (i.e., longer than two hours) may prove destabilizing for some DID patients and are not recommended.
Psychotropic medication is not a primary treatment for dissociative processes, and specific recommendations for pharmacotherapy of most dissociative symptoms await systematic research. However, most therapists treating DID report that their patients have received medication as one element of their treatment (Putnam & Loewenstein, 1993). Clinical and research reports support the use of various medications to treat co-morbid disorders such as PTSD (particularly hyperarousal and intrusive symptoms) and coexisting affective disorders, among others (Loewenstein, 1991b). Physicians and nurse specialists who prescribe medication should make patients aware, as part of the informed consent process for psychopharmacology, that medication protocols for DID are mostly empirical in nature and designed to target specific symptoms.
Alternate identities within the DID patient may report different responses to the same medication. This may be due largely to the different levels of activation in different identities and/or to their subjective experience of separateness, rather than actual, differential biological effects of the medications on the different alternate identities. In general, medications are more effective if the targeted symptoms are reported across “the whole human being,” rather than in only one or a few identities.
Medications in DID are usually best conceptualized as “shock absorbers,” rather than as curative interventions. Partial responses are the rule with DID patients as well as in similar complex PTSD patients with multiple co-morbidities and dysphoria and despair based on multiple adverse life experiences. The goal is to find the best medication or medications at a given time that most effectively moderate the patient’s symptoms. Not uncommonly, the DID patient will report that medications work for a while, and then stop doing so. Sometimes, these medications will work again if the patient is given them at a later time. Because of the potential for partial responses to many different medications, prescribers should be alert to the potentially negative effects of polypharmacy.
Nearly all classes of psychotropic medications have been used empirically with DID patients. Most often, antidepressant medications are used to treat depressive symptoms and/or PTSD symptoms. PTSD and Major Depressive Disorder are common outcomes of trauma. Accordingly, they are the most frequent co-morbidities diagnosed in DID patients. Currently, the most commonly used medications for these indications are the selective serotonin re-uptake inhibitor (SSRI) antidepressants. Several of these (e.g., paroxetine [Paxil], sertraline [Zoloft]) have been found, in well-designed clinical trials, to be efficacious for patients with relatively uncomplicated PTSD. Fluoxetine (Prozac) has been reported to be helpful in treating mood and PTSD symptoms in patients with complex PTSD. Other SSRIs (e.g., citalopram [Celexa], escitalopram [Lexapro]), and non-SSRI antidepressants (e.g., venlafaxine [Effexor], bupropion [Wellbutrin]) have been found to be empirically effective in moderating depressive symptoms, PTSD symptoms, panic symptoms, and irritability in many DID patients. Antidepressants with anti-obsessive efficacy such as clomipramine (Anafranil) and fluvoxamine (Luvox) may be particularly helpful for the subgroup of DID patients with significant obsessive-compulsive symptomatology. Also, older antidepressant groups such as the monoamine oxidase inhibitors (MAOIs) and the tricyclic antidepressants (TCAs) are effective in some DID patients, but have largely been replaced by the SSRIs due to the SSRIs’ more favorable side effects profile and safety.
Anxiolytics may be used primarily on a short-term basis to treat anxiety, but the clinician must keep in mind that the commonly used benzodiazepine medications (BZDs; lorazepam [Ativan], clonazepam [Klonopin], diazepam [Valium], chlordiazepoxide [Librium] and others) have addictive potential and that some patients with DID are vulnerable to substance abuse. Patients with PTSD may be tolerant to seemingly quite high doses of BZDs. This is thought to be due to the severe chronic hyperarousal and putative alterations in benzodiazepine receptor binding in these patients. Some DID patients can successfully be maintained on a stable long-term BZD regimen. Others may require increased dosages to overcome tolerance to the beneficial effects of the medications. However, clinicians should be aware that increasingly higher dose regimens carry the potential of diminishing benefits and higher adverse effects. Usually, in these cases, the BZDs will eventually have to be discontinued, by a careful taper to prevent a BZD discontinuation syndrome.
Other sedating medications (e.g., trazodone [Desyrel], diphenhydramine [Benadryl], mirtazapine [Remeron], low dose tricyclic antidepressants, etc.) have been used for anxiety and especially for insomnia in this population. Unfortunately, DID patients commonly suffer from a complex sleep disorder including PTSD nightmares and flashbacks, sleep problems related to affective disorders, triggered fear reactions at night due to recall of reported nocturnal abuse, and the activities of the alternate identities (some of whom are nocturnal). Accordingly, sleep problems in DID are usually best addressed in the overall framework of the treatment using symptom management strategies for fearful alternate identities, negotiating sleep for the nocturnal identities, and cognitive behavioral strategies to decrease PTSD reactivity at night, along with judicious use of medications. In general, barbiturates, chloral hydrate, and similar medications should be avoided in DID patients due to their addictive qualities and lethal potential in overdose.
Neuroleptic or antipsychotic medications, particularly the newer atypical agents (e.g., risperidone [Risperdal], quetiapine [Seroquel], olanzapine [Zyprexa], ziprasidone [Geodon]), have been used to treat successfully the overactivation, thought disorganization, intrusive PTSD symptoms as well as the chronic anxiety, insomnia and irritability experienced by many DID patients. Although antipsychotic medications have also been used to treat the inner auditory hallucinatory experiences in DID, usually these “hallucinations” are unaffected by even high dose neuroleptics. In a few cases, they may be decreased or somewhat quieted; but they do not disappear. In rare cases individuals with DID have true comorbid psychotic symptoms that are responsive to antipsychotic medication (for example, the patient can distinguish the “inside voices” of the alternate identities that are medication non-responsive from the “outside” psychotic voices that do respond to neuroleptics).
Neuroleptics have many side effects, most prominently significant weight gain has been reported in several of the newer agents (e.g., olanzapine [Zyprexa]). Weight gain is often very problematic for DID patients and can cause glucose intolerance and other significant metabolic side effects. Accordingly, careful monitoring by the psychiatrist, often including metabolic testing, is mandatory if the patient is receiving these medicines. Some extremely ill DID patients have responded well to clozapine (Clozaril) for severe PTSD symptoms and chronic thought disturbance. The latter manifests itself with refractory, often bizarre or severely concrete, cognitive distortions. Other atypical symptoms, more characteristic of chronically psychotic patients, like mistrust bordering on true paranoia, may be found in these patients as well. The patient on clozapine must be able to obtain weekly blood tests to monitor the blood count for agranulocytosis (disappearance of the body’s white blood cells).
Mood stabilizers are medications that specifically target mood swings in bipolar patients. Many mood stabilizers are anticonvulsants that have also been used in open label studies in PTSD. Because many DID patients suffer from rapid mood swings, psychiatrists frequently diagnose them with rapid-cycling bipolar disorder or Type II bipolar disorder. However, a careful history usually shows that the mood swings are actually due to PTSD intrusions and/or the switching of alternate identities or interference by alternate identities. There is no evidence that bipolar disorder is more common among DID patients than in the general population. Accordingly, only a small minority of DID patients derive benefit for mood swings from these medications. However, some patients describe a moderation in PTSD symptoms, anxiety and mood instability on anticonvulsant mood stabilizers such as valproate (Depakote), lamotrigine (Lamictal), carbamazepine (Tegretol), oxcarbazepine (Trileptal), gabapentin (Neurontin), or topiramate (Topomax). To be sure, DID patients with true intercurrent bipolar disorder often will receive benefit from appropriate mood stabilizing medications.
Other medications used to treat DID patients include naltrexone, an opiate antagonist that may have some efficacy in decreasing the pressure for self-mutilation or other self-destructive and self stimulatory behaviors, especially if the patient reports a “high” from self harm. Some patients have responded to centrally active beta blockers such as propranolol (Inderal) for PTSD hyperarousal and panic. Clonidine (Catapres), a centrally acting alpha agonist whose primary indication is as an antihypertensive medication, has been used to treat PTSD and may be effective for hyperarousal and intrusive PTSD symptoms including nightmares in some DID patients. Prazosin (Minipress), another antihypertensive medication, has been reported to be helpful for PTSD nightmares in a study of combat veterans.
Hospitalized DID patients experiencing acute anxiety, agitation, intrusive PTSD symptoms, chaotic switching and/or urges to harm themselves or others may respond to “prn” (as needed) oral or intramuscular benzodiazepines (primarily lorazepam) and/or oral or intramuscular neuroleptics. Either typical or atypical neuroleptics may be given for this indication. Typical neuroleptics used for acute agitation in inpatient DID patients include haloperidol (Haldol), fluphenazine (Prolixin), and others. Intramuscular ziprasidone (Geodon) and sublingual olanzapine (Zyprexa) may also be useful for this indication. Administration of ziprasidone should not be commenced without a screening electrocardiogram (ECG) to rule out a prolonged QT interval that may predispose to lethal arrhythmias that can occur when ziprasidone is administered. Droperidol (Inapsine) is also useful for acute agitation in hospitalized DID patients. However, it can only be given with cardiac monitoring due to reports of fatal arrhythmias with its administration. Thus, it is usually impractical to use droperidol routinely any longer in most inpatient settings.
Unfortunately, systematic research on medications for DID does not exist and most studies of pharmacotherapy for PTSD have not been performed on female survivors of repeated childhood maltreatment and adversity. Until that time, the pharmacological treatment for DID will remain almost entirely empirical and based on clinical experience.
Recent studies suggest high rates of a variety of medical problems in individuals who report adverse childhood experiences such as maltreatment and parental mental illness, substance abuse, suicide, and similar problems (cf. Felitti et al., 1998, Schnurr & Green, 2003). In these studies there was a “graded relationship” between adverse childhood experiences and adult diseases including cancer, ischemic heart disease, chronic lung disease, liver disease, and fractures. Multiple exposures to adverse life events in childhood predicted multiple health risk factors in adulthood.
In addition, these, and other studies, have shown higher rates of high-risk sexual behaviors, adolescent pregnancy, sexually transmitted diseases, obesity (including morbid obesity), earlier smoking, pelvic inflammatory disease, alcohol and drug abuse, and abnormal PAP smears in association with childhood maltreatment. Further, childhood maltreatment may be associated with a variety of direct medical consequences of physically traumatic abuse such as orthopedic problems, head trauma, seizure disorders, sexually transmitted diseases, and uro-genital and rectal pathology, among others. Neglect may lead to problems with growth and development, hearing and vision problems, failure to obtain immunizations and vaccinations, dental problems, and other difficulties (Salmon & Calderbank, 1996; Springs & Friedrich, 1992).
Further, a history of childhood sexual abuse is commonly associated with several medical disorders including gastro-esophageal reflux disease (GERD), irritable bowel syndrome (IBS), chronic pelvic pain, headache and other chronic pain syndromes, fibromyalgia, and morbid obesity (Scarcini, McDonald-Haile, Bradley, & Richter, 1994, Walker, Katon, Neraas, Jemelka, & Massoth, 1992; Walker, Katon, Roy-Byrne, Jemelka, & Russo, 1993).
Although these medical and related problems have not been systematically studied in DID, Guidelines Task Force Members have commonly encountered these conditions in DID patients.
Somatoform disorders and dissociative disorders have been historically linked through the concept of hysteria. Until the DSM-III, somatoform and dissociative conditions were conceptualized as having similar underlying processes or mechanisms. The DSM-III made a heuristic decision to place somatoform and dissociative disorders in separate categories. The ICD-9, however, has continued to conceptualize these disorders as sharing an underlying relationship. Recent research has found high rates of somatization and somatoform disorders in DID patients and high rates of childhood maltreatment, particularly sexual abuse, in patients with somatization disorder (Briquet’s Syndrome), somatoform pain disorder, hypochondriasis, and conversion disorder, particularly pseudoseizures (Barsky, Wool, Barnett, & Cleary, 1994; Bowman & Markand, 1996; Goodwin & Attias, 1999; Loewenstein, 1990; Loewenstein & Goodwin, 1999; McCauley et al., 1997; Morrison, 1989; Sar, Akyuz, Kundakci, Kiziltan, & Dogan, 2004 ; Saxe et al., 1994).
In addition, recent research has described in detail the symptoms of somatoform dissociation (Nijenhuis, 1999). A well-validated psychometric measure, the Somatoform Dissociation Questionnaire (SDQ), has been developed and used in a variety of research studies (see above). One study of 148 DID patients found an average of 15.72 somatic symptoms per patient (Loewenstein, 2002). Common somatoform symptoms in DID patients include abdominal pain, pelvic pain, joint pain, face and head pain, lump in the throat, back pain, pseudoseizures, and pseudo-asthma, among others.
There is a long history of reports of psychophysiological differences between the alternate identities in DID. Case reports include markedly different handwritings, variable visual acuity, medications responses, allergies, plasma glucose levels in diabetic patients, heart rate, blood pressure readings, differential EEG patterns, neural network patterns on functional magnetic resonance imagery (FMRI), and differences in brain activation and regional blood flow using single positron emission computed tomography (SPECT), among others (Loewenstein & Putnam, 2004, Putnam, 1984, 1991b; Sar, Unal, Kiziltan, Kundakci, & Ozturk, 2001). Systematic studies using small groups of DID patients and controls who simulate different personality states have found significant differences in DID subjects compared to controls. These include significantly greater variation in visual evoked potential patterns, 16-lead EEG, galvanic skin response, muscle tension, laterality, immune function, fMRI activation, and visual acuity and related ophthalmological variables. In general, these studies have found relatively subtle, but salient, differences between DID patients and controls. Overall, DID patients, as a group, show greater variability on psychophysiological variables compared to controls, rather than the kinds of reproducible differences found between different individuals.
The implications of these findings for treatment of DID have not been systematically explored, although clinicians have reported changes and greater stability in glucose control in DID patients achieving final fusion. (Kluft, 1986a) They do suggest, however, that DID patients may offer important insights into brain, mind, body relationships that should form the basis for important future systematic research.
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