Split’ is a horror movie that followed the trilogy ‘Unbreakable’ and it stars Casey Cooke who is kidnapped by Kevin Crumb, a person who suffers from the dissociative identify disorder.

‘Split’ is a horror movie that followed the trilogy ‘Unbreakable’ and it stars Casey Cooke who is kidnapped by Kevin Crumb, a person who suffers from the dissociative identify disorder. ‘Glass’ is a thriller movie that is the final trilogy in ‘Unbreakable’, and it stars Elijah Prince, Kevin and David, who are in a criminally-insane institution. The chief physician in the institution seeks to treat these patients who view themselves as superhuman. In both films, the main characters suffer from the Dissociative Identity Disorder and healthcare professionals strive to help them attain healing.  However, as it is seen in both films, DID is a very difficult disorder to treat, and even people who have had access to treatment may face challenges attaining full healing. 

Dissociative identity disorder (DID) is a mental condition that manifests itself in multiple and distinct personality states or identities that are present within an individual(American Psychiatric Association, 2018). The different personalities usually take turns in controlling the patient, and people with this disorder usually experience extensive memory loss after they have been ‘possessed’ by the different personalities. Initially, the disorder was known as multiple personality disorder, but this changed in 1994 after psychologists acknowledged that DID reflects a splintering or fragmentation of identity as opposed to the growth or proliferation of separate personalities. 

The disorder manifests itself in symptoms that include inability to remember important information, mood swings, depression, sleeping disorders such as night terrors and insomnia, suicidal tendencies, panic attacks, substance abuse, phobias and anxiety attacks.  Its exact causality is unknown but some of the potential causes include childhood trauma and ineffective therapy interventions (American Psychiatric Association, 2018). This paper will evaluate some of the aspects of DID that were portrayed in the films ‘Glass’ and ‘Split’. 

Identify safety issues & concerns for identified disorders

There are several safety concerns that are linked to people with the disorder. Some patients may manifest harmful personality types that can be violent and self-harmful. If these violent personality types are dominant, then they will likely perform self-harm or harm other people. Moreover, many patients with DID are suspicious of other people and will not willingly allow therapists or their family and friends into their dominant personalities (Kellerman, 2009). Some fear that they will be marginalized by society once they reveal their mental disorder and they will therefore resist any attempts to diagnose or treat them.  This resistance may result in violent encounters.  In instances where patients receive care, then the chances of attaining total healing are also low, which means that the safety concerns will be in play. 

Symptoms

Patients with the dissociative identity disorder experience more than a single split or distinct identity which has power over the behavior of the person (Kellerman, 2009). Moreover, patients also experience the inability to remember important information, and they cannot explain this symptom by the ordinary forgetfulness that people face. Additionally, people with dissociative personality disorder have variation in memory depending on the split personality that they possess. The different identities that manifest themselves in people with the disorder usually vary in terms of race, sex and age (Kellerman, 2009). They also have distinct gestures, postures and ways of talking. Another symptom facing patients with the disorder is they experience switching, which is the ability of the split personality to manifest itself and control the patient. Sometimes patients view themselves as animals while at other times, they perceive themselves to be imaginary people. 

When patients experience switching, it may vary from days or minutes, and if the patient undergoes hypnosis from a therapist, then he or she may respond to the therapist’s requests. In addition to split and multiple personalities, people with the dissociative personality disorder may also experience other symptoms that may include mood swings, depression, sleeping disorders such as night terrors and insomnia, suicidal tendencies, panic attacks, phobias and anxiety attacks, as well as problems with drug and alcohol use(Kellerman, 2009). Other symptoms that may manifest themselves in people with DID include rituals and compulsions, eating disorders and mental problems such as visual and auditory hallucinations, as well as anxiety and depression. Moreover, patients with DID may have amnesia, headache, trances, time loss and out of body experiences. They will usually embrace self-sabotage and self-harm. 

Causes

It is not very clear on why people develop DID. However, many people who develop the disorder have experienced either sexual or physical abuse during childhood (American Psychiatric Association, 2018). Moreover, the disorder may manifest itself at any age. Additionally, many people with DID usually have experienced post-traumatic stress disorder and they face flashbacks, nightmares and state responses. One of the possible explanations of why people who face traumatic experiences during childhood may experience the disorder is that as people grow older and become aware of the adverse experiences they had growing up, the mind may attempt to shield them from these experiences. In some cases, then he brain might create an alter ego that deals with the hurt that DID patients experienced, thereby shielding their main personalities from harm. It is imperative to conduct research on the relationship between disorganized attachment, childhood abuse and lack of social support since these are essential components of DID. There is also research that has pointed out that lack of nurturing during childhood may make children to dissociate their experiences and memories from consciousness. 

Another cause of DID is therapy and there is occurs in therapy-induced forms of DID. When therapists use techniques such as hypnosis in their quest to retrieve memories, they may inadvertently trigger memories, alter egos or cause age regression in their patients. This view is supported by the socio-cognitive model of DID which explains that the disorder occurs when a person either unconsciously or consciously adopts behaviour through promotion of certain cultural serotypes. Therapists may promote stereotypes that may encourage patients to develop alter egos and develop the DID. 

Another explanation of the therapist-induced forms of DID is the false memory syndrome.  This is a term that represents the false memories of abuses that controversial therapies claim they retrieved from patients. These memories may for instance be used in developing false child abuse allegations, and inadvertently expose the patient to the trauma-induced causalities of DID. Some psychologists claim that therapists induce DID since they diagnose a disproportionate number of cases.

In children, diagnosis of DID is rare in spite of the first alter ego usually appearing at three years of age. One of the challenges in diagnosing children is that it is difficult to ascertain whether they are engaging in imaginary child play when they develop imaginary characters. Moreover, few studies on DID have ben performed on children and this has limited the access to scientific research on DID in children. 

Moreover, some studies have suggested the genetics play a role in the development of the disorder since there are many instances where relatives who are closely related face DID. The diagnosis of DID has increased in the recent past and one of the potential explanations for this phenomenon is that the diagnosis of the disorder usually relies on probing by the psychiatrist or psychologist who is treating the patient. People with the disorder rarely self-report. It is therefore possible that the increase in people who seek mental healthcare services may inadvertently lad to a higher rate of diagnosis. 

Diagnosis and evaluation (DSMV)

In order for a person to be diagnosed with DID, he/she should be evaluated by a mental health practitioner. The professional should use the DSMV manual for him/her to make an accurate diagnosis (Tracy, 2018). The patient should experience states of ‘possession’ that entail discontinuity in the sense of agency and sense of self. This discontinuity should be accompanied by alternation in behavior, affect, memory, consciousness, cognition, perception and sensory-motor functions. The individual may report these symptoms or other people may observe these changes. A major difference in the definition between DSMIV and DSMV diagnosis is that patients are allowed to report their personality shift as opposed to relying on other people to report such changes (Tracy, 2018). 

Moreover, a second symptom of the DSMV diagnosis is that patents must experience amnesia. These are gaps that occur in the daily events, traumatic events or personal information (Tracy, 2018). The third diagnosis is that the patient must have trouble functioning or be distressed such that it affects a major aspect of their lives. Moreover, the distress or disturbance facing the patient should not be as a result of cultural or religious practice, for example, a cultural practice where children have imaginary friends. Moreover, When diagnosing children, it is important to differentiate between the symptoms associated with the disorder from imaginative play that may include the use of fictional or imaginary characters. Finally, these lapses should not be attributable to use of substances such as drugs or alcohol as well as the use of other medication. According to the American Psychiatric Association (2018), clinical evaluation is used to make a correct diagnosis and special personality assessment tools and designed interviews are usually used. 

There is also a level of subjectivity that is linked to accurate diagnosis since most forms of diagnosis are made through self-disclosure. It is important to note that many people with the disorder are not diagnosed since they hide symptom for fear of being discriminated against by society. 

Plan of Care

In order for patients to attain a level of healing, it is imperative that the healthcare professional attempts to confront the different personalities that the individual has, with the goal of revealing and safeguarding the real personality of the patient (Nevid, 2011). It may be necessary to develop a relationship with the dominant personality since he/she holds the key towards the patient attaining healing. Moreover, therapists seek to reveal the multiple personalities to the patient, and dissociating him/her from them, while focusing on the true personality of the patient. In this way, the patient may be able to control the influences of the multiple personalities.

Medical interventions

There are various medical interventions for patients who have been diagnosed with DID.  Moreover, there exists no consensus in the treatment and diagnosis of the disorder.  Case studies have been primarily used in developing clinical approaches that have been used in treatment. Additionally, there is no consensus on the effectiveness of treatment since very few patients have ever attained healing. One of the most common forms of treatment involve psychotherapy including strategies such as cognitive behavioural therapy. Other forms of therapy include dialectical behavioral therapy, oriented therapy, eye movement desentization, hypnotherapy and others (International Society for the Study of Trauma Dissociation, 2011). 

Some psychotherapists usually use psychotherapy to treat an individual identity in patients and use other traditional therapy techniques in treating the other personalities. However, treatment is usually difficult since people with DID may not trust their therapists and they find it challenging being in a therapeutic environment with their therapist.  Such patients may require regular treatment with their therapist on a weekly or bi-weekly basis. For treatment to be successful, it is important for the therapist to familiarize himself or herself with one of the dominant personality traits inherent in the patient.  This is because the host personality may not represent the true personality of the patient and various alter egos may react negatively to contact with the therapist. Due to this reason, therapists should make an attempt to protect patients from negative responses that may cause injury, abuse and other threats that may harm their welfare. 

Psychopharmacology

There are different medications that are used in the treatment of DID. It is important to note that medications that directly treat the disorder do not exist.  Most of the medications that are available are used to address depressive symptoms in order to reduce the levels of depression in patents. Some of the main medications that are used in the treatment of the disorder include venlafaxine, citalopram, phenelzine, sertraline, and fluoxetine(Nevid, 2011). These medications are usually used in reducing depressive symptoms in patients with the disorder. 

Other medications are used to treat anxiety in patients and they include lorazepam and clonazepam. Additionally, there are certain medications that are used as tranquillizers and they include chlordiazepoxide. Finally, some patients may require mood stabilizers which regulate the mood and they include valporic acid and lithium (Nevid, 2011). Generally, venlafaxine, citalopram, fluoxetine and sertraline should not be taken with alcohol. For pregnant women, those in Category C pregnancy should not take these medications since animal studies have revealed that these medications have an adverse effect on animal foetuses. Moreover, there are no researches to show how the medications impact humans and it is therefore important that pregnant women do not use the medications(International Society for the Study of Trauma Dissociation, 2011). 

Moreover, there are certain guidelines that direct the use of medication in treatment of the disorder. It is important to note that different patients may elicit diverse responses to dissociative disorder especially when different alter personalities are in control of the person. Physicians who treat patients should develop an overall medication plan as opposed to changing medications frequently. Additionally, patients with DID should not be given antipsychotic medication if they report hearing voices (Nevid, 2011). This is because such voices are those of their alter egos. Additionally, patients with the disorder should not be given neuroleptics since even if DID patients face hallucinations, then these medications may not effectively treat the symptoms. Additionally, patients with DID who experience sleep challenges should not be medicated since sleep problems in people within the disorder are best addressed through the overall treatment strategy. 

Nursing interventions

Within the healthcare settings, nurses have an important role to play in the treatment of patients who suffer from DID. Patients in these settings may feel threatened due to the limits and rules that are present in healthcare facilities, which may trigger re-enactment of the trauma that they experienced during childhood. Additionally, the patient may subconsciously blame the hospital staff for the trauma they experience, and elicit negative reactions from them (Beidel et al., 2014). 

There are also certain alter personalities that are unhealthy in the hospital settings. One of these is a child alter which can disrupt the hospital activities. When confined within the hospital settings, child alters may become angry especially when there is a proctor alter ego within the person. When threatened, the alter ego may hide and patients may either elope or escape from the treatment facility they are in. 

When dealing with such a patient, the nurse should create a protective and supportive environment. They should strive to host and develop honest relationships with all the alter personalities and the host. For the alter ego to come out, it needs to be in an environment where it feels accepting, safe and empathetic. There are certain responsibilities that nurses should perform and some of these are listed below; 

• Providing a protective and safe environment for the patient and especially for those with the impulse to embrace self-destruct behaviors either from hostile alter egos or during therapy. 
• To provide a support and acceptance environment for the patient
• To provide consistent treatment 
• To provide an environment where patients can socialize 
• To help patients in development of effective coping skills as they interact with them.  

Nurses should continuously monitor patients to prevent them from engaging in destructive behaviour that either targets hospital staff or the patients themselves(International Society for the Study of Trauma Dissociation, 2011). Nurses may help the patient in creating an agreement to safeguard the safety of all alter egos. In cases where the alter egos do not have the same agreement regarding safety, then nurses and other healthcare professionals may engage in precautions to prevent patient suicides. 

Additionally, when patient commence treatment and they attempt to overcome the obstacles they faced such as childhood trauma, they may be dysfunctional, exhausted hyper somnolent (Beidel et al., 2014). Nurses have a role to play in such situations since they can help the patients engage in projects such as arts that can be used in avenues for introduction of the different alter egos to each other. Finally, when patients experience somatic behaviors, the nurses should appreciate that patients with DID usually respond better to conventional therapy techniques as opposed to the use of medications. 

Conclusion

The films ‘Glass’ and ‘Split’ reveal how the main characters struggled with the dissociative identity disorder. The patient with DID usually has two or more personalities that control him or her and he/she also experiences a memory lapse regarding essential information. Many people who develop the disorder have experienced either sexual or physical abuse during childhood. Other causes include therapy-induced forms of DID and biological factors even though the research on causalities is limited. Treatment involves psychotherapy, which is the most effective approach. However, medication may be used to alleviate the symptoms facing the patient. In conclusion, nurses have various roles to play for people with DID.  Thy should provide a protective and safe environment for the patient and a 

support and acceptance environment for the patient to overcome the disorder and face healing. Nurses should also assist patients in development of effective coping skills during therapy, as these are instrumental in avoiding destructive behaviors by patients. It is important to note that few patients will ever achieve complete healing, but though therapy, many will be able to control their alter egos and protect them from destructive behaviors. 

References

American Psychiatric Association. (2018). Diagnostic and Statistical Manual of Mental 

Disorders, Fifth Edition.Arlington: American Psychiatric Publishing

Beidel, D. C.; Frueh, B. & Christopher, H. (2014). Adult psychopathology and diagnosis 

(Seventh ed.). Hoboken, N.J.: Wiley

International Society for the Study of Trauma Dissociation. (2011). “Guidelines for Treating 

Dissociative Identity Disorder in Adults, Third Revision” (PDF). Journal of Trauma & Dissociation. 12 (2): 188–212.

Kellerman, H. (2009). Dictionary of Psychopathology. Columbia University Press.

Nevid, J. S. (2011). Essentials of Psychology: Concepts and Applications. Cengage Learning. 

Tracy, N. (2018). Dissociative Identity Disorder (DID) DSM-5 Criteria. Retrieved from 

https://www.healthyplace.com/abuse/dissociative-identity-disorder/dissociative-identity-disorder-did-dsm-5-criteria