The Differences Between Schizophrenia and Dissociative Identity Disorder

In this episode, W. Clay Jackson, MD, DipTH, speaks about the differences between schizophrenia and dissociative identity disorder, how patients with schizophrenia should be managed, and the gaps in the research of schizophrenia. 

For more information on schizophrenia, visit the Resource Center. 

W. Clay Jackson, MD, DipTh, is an assistant professor of clinical psychiatry and family medicine at the University of Tennessee College of Medicine (Memphis, TN).

TRANSCRIPTION:

Jessica Bard: Hello everyone and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360, a multidisciplinary medical information network.

Schizophrenia affects approximately 24 million people, or 1 in 300 people worldwide, according to the World Health Organization. Dr Clay Jackson is here to speak with us about schizophrenia today. Dr Jackson is an Assistant Professor of Clinical Psychiatry and Family Medicine at the University of Tennessee College of Medicine in Memphis, Tennessee.

Thank you for joining us today, Dr Jackson. What are the differences between schizophrenia and dissociative identity disorder?

Dr Clay Jackson: I think this is very important because there's a lot of lay person confusion around most of the serious psychiatric disorders. There's a popular song from a popular singer recently where one's lover is not behaving as one would like, and the artist sings, "I think we have a case of bipolar." And so, it's very common for people to say in a negative in pejorative sense, "They're schizo," or "I think they have multiple personalities." And so, when human behaviors, moods, and thoughts exceed the normal boundaries of societal expectations laypersons, sometimes even clinicians, can label people, or persons with pejorative labels that might or might not be accurate. And almost always in those cases are injurious to the patient's sense of self-esteem and sometimes can be injurious to our own diagnostic process.

Well, let's get beyond those problems, and let's talk about an honest clinician trying to make an honest diagnosis. What we're really looking at here is psychosis. A difference in perception and thinking, and that's sort of a sine qua non of schizophrenia. Schizophrenia involves disturbed perceptions and disturbed thoughts. Both DID, or dissociative identity patients and schizophrenia patients may hear voices. They may have hallucinations. But, typically, the DID patient, or the so-called multiple personalities patient, will hear those voices much earlier in life. They will hear multiple voices. And typically those voices will actually converse with one another. Whereas in schizophrenia patients, the voices tend to be later in life, and they tend not converse with one another, but rather with the patient himself, or the patient herself.

Think of DID as a fracturing of the personality at the time of personality formation. Often, DID patients have an early life trauma at the time of consolidation. All of us have imaginary friends at age three, and at age four. We all have those. The sense of self, the sense of a unified personality is really not formed until a little bit later in development. And think about a trauma that would prevent that normal synthesis of personality. That's typically what drives DID. Whereas, schizophrenia is a neurodegenerative disorder that occurs later in adolescence, or early adulthood. And that becomes the problem with perception.

So, DID has much more of a developmental feel, whereas schizophrenia has more of a neurodegenerative feel in terms of how you might frame it theoretically. But clinically, those are some distinguishing characteristics that we can see. Yes, voices on both sides. But a careful history of childhood and development, a careful history of thinking about the demographics of presentation, and the other symptoms associated with the illness should distinguish for a listening, and careful clinician fairly quickly between DID and schizophrenia.

Jessica Bard: How should these patients, patients with schizophrenia be managed?

Dr Clay Jackson: With respect, with compassion and, frankly, in almost all cases with robust pharmacology. There are many mental health diagnoses for which, excuse me, personal engagement, exercise, non-pharmacologic interventions, such as meditation, can be extremely helpful. And with schizophrenia, it can be as well. Yet, most of these patients will not do well unless they have intervention at the dopaminergic pathway. And so antipsychotics, first-generation, second generation, can be incredibly helpful in helping patients to organize their thoughts, to improve their effect, and to manage their behaviors.

Now, there are a number of pharmacologic targets that are involved in schizophrenia. There's the dopamine hypothesis, there's the serotonergic hypothesis. There are those who are studying the effects of GABA and glutamate in these patients. But, classically, alteration of dopaminergic challenges in these patients has been the sine qua non, or the cornerstone of treatment. So typical or atypical antipsychotics will be the foundation of pharmacologic treatment.

Now, having said that, and emphasizing the importance of pharmacology, I do want to say that we don’t just give these patients tablets, or inject them with medications, and then say, "Go your way. We'll see you at the next appointment." Community support, psycho-education, and social work support can be so valuable in preserving the relational, and vocational vitality of patients with schizophrenia. The goal is not just deinstitutionalization. The goal is maximal societal integration, and having these patients reach their fullest potential. And that's not possible with pharmacology alone.

To paraphrase, our former secretary of state who was then paraphrasing an African proverb, it does indeed take a village. It takes all of us working together to help patients with schizophrenia to achieve their potential. So, treat them pharmacologically, but also be aware of some of the non-pharm interventions that can supplement that, and help patients to achieve their brightest potential.

Jessica Bard: How about the gaps in the research of schizophrenia?

Dr Clay Jackson: Oh, wow. They're everywhere. Understanding GABA, understanding glutamate, understanding NMDA antagonists and their role, the serotonin hypothesis, and how some of the newer atypical antipsychotics, which have serotonergic modulation effects, how they might affect some of the negative symptoms of schizophrenia so important. Anything that helps us with the negative symptoms is critical.

We do a pretty good job of treating the positive symptoms of schizophrenia, but we need to improve the treatment of negative symptoms. Having agents which have robust efficacy, and yet don't have the adverse event profile that's always helpful. Understanding this contribution of genetic, or even obstetric, and epigenetic influences, early life adversity influences on schizophrenia, teasing out what is there a westernized society problem with schizophrenia? Probably not prevalence is fairly similar worldwide. But if you actually cut that with urban versus rural epidemiology, it does look like urban living may have an important role to play. So, there are a number of sociological, genetic, and pharmacologic avenues that excite us who are interested in the research of psychiatric illness because schizophrenia certainly there are more answers in front of us than are behind us.

Jessica Bard: Is there anything else that you'd like to add today, Dr. Jackson?

Dr Clay Jackson: Well, thank you so much for having me. Let's be compassionate and collaborative with these patients. Let's don't be hierarchical. Let's truly hear their stories, sit with them, partner with them. And let's see them maximize their potential in society because there's a lot we can give these patients, but there's actually a lot that they can give to us as well.

Jessica Bard: Well, thank you for being here. We appreciate your time today.

Dr Clay Jackson: Appreciate it so much.