Not at all painless

I still just don't even know what to say.

Tuesday night, someone I care about very much tried very hard to take her own life.

Except, here's the thing - "she" didn't...my cousin, whom I love so very much, struggles with something called Dissociative Identity Disorder, or DID. It used to be called Multiple Personality Disorder. Very, very bad things happened to her when she was in her most formative early years. When significantly traumatic things happen during the development of one's personality, if the predisposition is there (and we're not really sure what that is), the personality structure can fracture. It's a complicated and confusing situation, and more than it's worth getting into here. But the thing is, while a few decades ago this was the diagnosis du jour, it's now one of the most hotly contested diagnoses in psychiatry.

I feel like people often try to diminish things they don't understand. Even the people who have this don't understand it. But bigotry and bias, as always, will not make it better.

I'm not going to argue the validity of the diagnosis. I think it's ridiculous that we even have controversy like this in a scientific pursuit. The "because it's weird and I don't get it" defense doesn't hold up, folks. And anyone who doubts the existence of this disorder needs to spend a couple of days with my cousin, or my ex, or my good friend in Florida. Herschel Walker, football great and Heisman Trophy winner, recently wrote a book about his struggle with DID. It's out there, folks. And no, it's not a "convenient excuse" that allows you to disavow responsibility for your actions ("It's not my fault, my alter did it"). Yes, it can be malingered for some sort of secondary gain, but so can every other psychiatric illness, or for that matter, most medical ones (factitious disorder, anyone?).

Imagine for a moment that you wake up tomorrow morning, and walk into the kitchen, and pour your coffee as usual. And on the counter you find a bag full of things you don't remember buying. Maybe they're clothes that are so totally not your style, or expensive electronic gizmos you really can't afford. You wonder who bought them, and look at the receipt, and the name on the credit card is yours. Except the signature doesn't look quite right. Imagine how confusing that would be. Did someone steal your card, break in, and leave the stuff there? Maybe one of your family members bought it with your card? You look at the time on the receipt and try to remember where you were at that time yesterday, and...strangely...for the life of you, you can't. And you wonder why this keeps happening...

Now imagine what you find is cocaine. Or cuts and bruises all over your body. Or you wake up in jail. Or in the ICU.

Imagine you wake up safe in your own bed with overwhelming feelings of guilt, shame, depression, worthlessness, and have no idea what you've done. Imagine people coming up to you on the street and seeming to know you, including details of your life, except you have no idea who they are and they're calling you by a different name. Imagine losing big chunks of time, finding yourself in places you don't remember getting to, or hearing voices running commentary on your life while you're trying to live it. Imagine feeling like the only way to end the chaos was suicide. Imagine not thinking that and waking up in a puddle of blood or with a tube down your throat.

Not every case is this extreme, or dramatic, of course; these disorders all exist on a continuum, like depression, or schizophrenia, or anything else. People with DID (or any disorder on the dissociative spectrum) can be very ill and still remarkably high-functioning. Remember that the whole point of the disorder is survival. It's a very primitive but powerful form of adaptation.

I gave a lecture on DID last year to the interns, and the take-home point I tried to make to them was this: the real myth is that we have one cohesive, integrated personality. Think about it; you're constantly altering what parts of yourself are most prominent. I think of myself as generally consistent within the circles of people who know me, but at work, I'm more reserved and professional. I don't drink at work, of course. I don't wear my pajamas. Even the difference in closing our office door reveals a much more sarcastic, silly, sassy version of me than my patients will ever see, but if you ask those same patients about my personality, many of them would cite sarcastic and sassy. Some of them wouldn't - some of them see the more overtly maternal traits that I have, and think of me as soft and supportive and positive. Some of them would call me a hard-ass bitch. None of the above things are not who I am, all the time. They're just not always who I am in the moment.

DID is an extension of this process, as I conceptualize it. Most personality-related pathology is just an exaggeration of normal traits, right? We all have our moments when we're particularly narcissistic, or borderline, or avoidant, especially in times of crisis when our defenses are strained. When it becomes the defining aspect of our interactions, when it severely impacts our ability to function in a healthy way, psychiatry calls this a personality disorder. DID is no different - it's an exaggerated expression of a normal structural phenomena, in response to an event or series of events that exceed the capacity of the existing defenses to protect the psyche from painful or destructive emotions.

And, in case you were curious, the above is a lovely example of the defense mechanism of "intellectualization."

My own painful and destructive emotions? Too numerous to count in this instance. The dominant one is, I'm so terrified for her.

The other point of this post? Again, I hearken back to suicide. It's never just you that you're trying to kill. Even though my cousin survived, and is expected to be medically fine, and is finally in a safe place (finally....well, that's another story for another day), a little bit of all of us who love her died on Wednesday. It sounds overdramatic, but it really isn't; any sensitive person who's been in this situation can tell you.

But, we all do what we can, you know? We try to help, we mobilize the resources we have, both internal and external. We hope that someday we can look down at the well-healed scar and appreciate it as a memory of damage overcome. We try to learn what we can and move forward. I deal with suicide every day at work, and know this provides me an invaluable perspective. I know it strengthens my own resolve not to ever go down that path, regardless of how bad my own internal chaos might get. I know it makes me all the more grateful for the time and interactions and moments I have with people interspersed within the minutia of my life. It fuels my academic interest and professional development. And it makes me hope that I never, ever, ever have to deal with a similar experience again.