This is a real life case presentation on a young patient with significant traumatic childhood experiences who is presenting with extremely severe psychotic symptoms. The presentation summarizes the patient's background, current admission, and debates the diagnostic labels. It is a very useful presentation for education and teaching.

1. “Meet My Altered Minds”
Trauma, personality and
psychosis
Dr Y Hameed (ST6)
Dr A Wagle (Consultant Psychiatrist)
Dr J Durance-Clark (Clinical Psychologist)
Dr D Liu (CT1)
Dr F Sunassee (FY2)
Glaven ward. Hellesdon Hospital. Norwich.
26 November 2015
By Yasir Hameed at 10:29 pm, Dec 02, 2015

2. What is the Presentation About?
Description of a case
Highlight specific features of diagnoses and
phenomenology
Psychological Assessment
Differential Diagnosis
Conclusions

3. “Frank told me to do it”
Donnie Darko

4. Meet Mr K
18 year old single man (born 1997).
Under CAMHS and Youth services since the age of 12.
Admitted to Glaven ward in September 2015.
Currently in the PICU (since 05/11/2015).
Expected to be transferred back to Glaven in near
future.

5. Early development
Birth: No reports of problems during pregnancy
and delivery.
Developmental Milestones: Normal apart from
delay in language development.

6. School
Significant scholastic and behavioural problems in
school(s).
Referred to educational psychologist in 2008 (11
years old) for concerns about learning and his
behaviour.
Spent 2 years in a specialist language college.
Taught 1:1 in the general class room.
Required high level of adult support in order to
engage with learning.

7. School (2)
Did not appear to build friendship, did not socialise
with other children
Very short attention span, easily distracted.
Excluded from school for defiant behaviour.
Probably left school without any qualifications.

8. Childhood Traumas
9-10 years old: Alleged sexual abuse by biological
father.
13-14 years old: Alleged that he was sexually
assaulted by two male strangers.
Throughout his childhood: History of witnessing
domestic violence when growing up in. Mother fled
to Norfolk from London when Mr K was 10 YOA.
Initially lived in a refuge.
Multiple moves to different schools during primary
school years.

9. Family History
Biological parents separated when Mr K was 9-10
YOA.
Biological father lives in Scotland. Allegedly a
registered schedule 1 sex offender (according to
patient’s mother).
Biological mother has history of mental health
problems (Depression, anxiety, phobia).

10. Family History (2)
One elder biological sister (3 years older than Mr
K) who has learning disability, autism, ADHD and
bipolar disorder and lives in London.
Three younger half-siblings (2 brothers, aged 10
and 9; and a sister, who is 6 YOA). The half-
siblings live with their parents in Norfolk.

11. Summary of Involvement with
Services: Paediatric & Psychiatric
 2005: Diagnosis of Asperger’s syndrome made by the
community paediatrician when 8 YOA.
 2010: Age 12, referred to CAMHS for low mood and problems at
school.
 2012: Referred again to CAMHS. Attempted to hang himself in
February 2012. Regular and heavy use of cannabis and cocaine
& sniffing butane gas. ADHD was diagnosed. PTSD &
Depression.
 From 2012 onwards, regular contact with mental health services.
 July 2015: Transferred to 18+ Youth services.

12. Summary of Diagnoses and
Treatment by Under 18 Services (2)
2013-2014: Fluoxetine->Citalopram. Risperidone
on and off. Concerta used but stopped due to
psychotic symptoms.
February 2015: Increased dose of Risperidone (4
mg / day, and then 6 mg / day) + Mirtazapine (30
mg / day).
May 2015: Oral Risperidone->Depot Paliperidone.
Mirtazapine->Sertraline then stopped. Referred to
EI team.

13. Substance Misuse
Past history substance misuse, which began in
early adolescence.
Regularly using cannabis and cocaine since age
15.
Not prominent prior to current admission.

14. Forensic History
Currently facing rape allegations. This dates back to
March-May this year. Two victims involved, his then-
girlfriend (who is 15 years old) and her sister (13
years old).
The bail conditions.
Younger half-sister has recently exhibited disinhibited
behaviour of sexual nature. CSS involved.
Never been to prison.

15. Possible Confusion about
Sexual Orientation
 Befriending a boy who was under 18 years old, Mr
K’s mother found them in an intimate position
(with their clothes on), and Mr K’s hands around
the boy’s throat.
 As per the notes, at a later time Mr K claimed it
was ‘Philip’ who did it.

16. Circumstances Leading to Recent
Admissions to Adult Inpatient Units
Increased auditory hallucination. The voice of
“Phillip”, Mr K’s “altered ego”.
Increased intensity of suicidal ideation and
gestures.
Increased irritability and aggression.
Possible trigger: Police investigation of allegation
of rape. He is still on bail.

17. Recent admission(s)
 17/08/2015-15/09/2015: Informal admission to Thurne
ward.
 No ‘hallucinatory behaviour’ despite his reports. Two
attempts at self-harm in front of staff. Diagnoses at
discharge: Depression and PTSD. Medications:
Olanzapine (oral) + Paliperidone depot.
 Discharged to his sister’s address. Heavy substance
misuse.
 28/09/2015: Readmitted informally due to self harm
and auditory hallucinations. Transferred to Glaven
ward.

18. Progress during Current
Admission (Glaven Ward)
 Initially informal.
 Chronic low mood and chronically disturbed sleep.
 Auditory hallucination, one of which is “Phillip”.
Commanding him to harm self and others. Mr K has no
control over the “voice”.
 Mr K harm himself, instead of harming others.
 Who is “Phillip”? “Two different persons sharing the
same body. He is 15 y/o. We like different things. He
enjoys putting me in troubles”.

19. Progress during Current
Admission (Glaven Ward) (2)
 ‘Philip’ is antisocial, psychopathic and does nasty
things. ‘Philip’ fantasies about hurting people sexually.
 Duration of this duality? (“He has always been there.”)
 Triggers? Following childhood trauma. Philip is more
likely to emerge when Mr K is “pissed off”.
 While on the ward, Mr K alternated with ‘Phillip’ and
had different behaviour. “Philip” was not happy about
the admission and insisted on leaving the ward. “You
can keep K here, but you can’t keep me”.

20. Progress during Current
Admission (Glaven Ward) (3)
Relationship between Mr K’s mental state and
‘Phillip’.
Some discrepancies noticed by the staff.
Mr K always acknowledged, afterwards, that
‘Philip’ had ‘taken over’, because ‘Philip’ told him
what he (i.e. ‘Philip’) had done. Mr K declines to
take responsibility for ‘Philip’s’ actions, claiming no
primary memory of what ‘Philip’ does. This
includes alleged rape (“I didn’t do it, ‘Philip’ did.”)

21. Progress during Current
Admission (Glaven Ward) (4)
Poor nutrition.
No concerns of aggression towards others.
Generally settled and docile.
Frequent verbalised suicidal ideation.
Attempts at self-harm in the presence of staff.
Offered no resistance when staff intervened.

22. Progress during Current Admission
(Glaven Ward & PICU) (5)
Detained on section 5(2) one weekend when
repeatedly tried to leave the ward declaring
intention to harm himself.
Subsequently put on section 3, and transferred to
PICU on 05/11/2015.
In the PICU: no attempts at self-harm. Has
persisted with his account of ‘Philip’, but no
episodes of acting as ‘Philip’. Keen to get back to
Glaven, not happy in the PICU.

23. Information from Family
Mr K has spoken about ‘Philip’ (both as a voice
and alter ego) prior to rape allegations (around 5
years ago).
‘Philip’ has become more prominent in the past
one year, in particular in the past few months.
Family would appear to have accepted Mr K’s
account of ‘Philip’ at face value. (“‘Philip’ is bad.
We don’t want him; we want ‘K’. ‘K’ is nice and
caring.”)

24. Treatment Since Current
Admission
Pharmacological
Clopixol depot (200 mg IM, every 2 weeks)—
switched over from Paliperidone depot which did
not help.
Sodium Valproate (oral)—500 mg / day.
Reports 40% improvement in ‘voices’ since
admission.
Psychological
Referred to psychology services for psychological
assessment. Assessment completed by the clinical
psychologist over 3 sessions.

25. Psychological Assessment

26. Differential Diagnosis
 Borderline Personality Disorder (quasi-psychotic (auditory
pseudohallucinations) and dissociative symptoms parts of
Borderline Personality organization).
 Multiple personality Disorder (ICD 10) or Dissociative Identity
disorder—DID (DSM V)
 Schizophenia/schizo-affective disorder
 ADHD and comorbid mood disorder with psychotic symptoms

27. Factors For
Borderline Personality Disorder
 Unstable, intense relationships
 Impulsivity
 Recurrent suicidal behaviour
 Mood Instability
 Difficulty in controlling anger
 Severe dissociative symptoms
All of the above pose significant
distress to the patient and family

28. Factors Against
Borderline Personality Disorder
 Chronic auditory
pseudohallucinations—
unrelated to stress.
 Dissociative symptoms—
chronic and unrelated to
stress.
 Has not displayed some of
the reported behavioural
criteria (e.g. anger,
impulsivity, mood instability)
during current admission
Factors For
 Unstable, intense relationships
 Impulsivity
 Recurrent suicidal behaviour
 Mood Instability
 Difficulty in controlling anger
 Severe dissociative symptoms
All of the above pose significant
distress to the patient and family

29. Factors For
Dissociative Identity Disorder
Prima facie case of
 Two personalities in the same
individual—only one evident at
a time (ICD 10 & DSM 5).
 Each personality—own
preferences & behaviour that
take control (ICD 10)
 h/o inability to recall personal
information that can’t be
explained by forgetfulness
(DSM 5)

30. Factors Against
Dissociative Identity Disorder
 Primary Personality (KK—
the patient) fully aware of
the secondary personality
(‘Philip’)—unusual.
 Psychological amnesia not
evident during current
admission.
 Scored well below the
threshold on the
Dissociative Experience
Scale (DES II)
Factors For
Prima facie case of
 Two personalities in the same
individual—only one evident at
a time (ICD 10 & DSM 5).
 Each personality—own
preferences & behaviour that
take control (ICD 10)
 h/o inability to recall personal
information that can’t be
explained by forgetfulness
(DSM 5)

31. Factors For Factors Against
Schizophrenia
 Presence of auditory
pseudohallucinations.
 ‘Paranoia’ mentioned
repeatedly in the notes of
under-18 services.
 Age
 Parents report
change/deterioration in
functioning in the past 1
year
 Absence of delusions.
 Absence of Schneiderian first
rank symptoms
 Absence of formal thought
disorder.
 Behaviour not grossly
disorganized.
Does not fulfil criterion A of
DSM 5

32. What about Adult
ADHD?

33. What about Adult ADHD?
 ADHD diagnosed and treated in childhood
 Mood lability, irritability/short temper, impulsivity, impaired stress
tolerance—supposed to be features of Adult ADHD (Utah Criteria for
Adult ADHD).
BUT
 No evidence during current admission.
 Currently will not fulfil DSM 5 clinical criteria of ADHD.
 The most dramatic current clinical presentation (dissociative
identity) can’t be explained by Adult ADHD diagnosis.
 Utah criteria advise clinicians to not diagnose ADHD in adults in the
presence of severe personality difficulties.

34. Dissociative Identity Disorder
(DID) or Malingering?
 DID—DSM 5 (Multiple Personality—MPD—ICD 10): thought to
be rare.
 ICD 10 describes MPD as a “controversial diagnosis”.
 Possible incentive to produce symptoms.
 Difficulty in determining whether symptoms of ‘dissociation’ are
the result of unconscious defence mechanism or are under
voluntary control.

35. Dissociative Identity Disorder
(DID) or Malingering?
Malingering
 Symptoms are feigned or grossly exaggerated.
 Excessive symptom production must be intentional.
 The symptom production is motivated by external incentive.
DSM 5 provides 4 conditions under which malingering “should be
strongly suspected”
 Medicolegal context
 Discrepancy between self-report and ‘medical findings’.
 Poor patient cooperation
 Antisocial Personality Disorder

36. Is it Really Malingering?
A dubious symptom report, in and of itself, is not
sufficient to diagnose malingering.
Vague and inconsistent reporting, and poor
participation—not enough to diagnose malingering.
Criticism of DSM 5 conditions

37. Dissociative Identity Disorder
(DID)
 Diagnosis of DID—recognised to be appropriate for a range of
conditions, including less severely ill patients.
 Prevalence—0.5-1% in community samples (no rarer than
Borderline PD or Schizophrenia), and 5% in hospitalised patients.
 “Most often—personalities have proper names.”
 “Often personalities are disparate and may even be opposites”
 “DID is consistently linked to childhood trauma [sexual abuse].”
Kaplan & Saddock (1998)

38. Psychotic Symptoms & DID
 Individuals with DID have auditory hallucinations “emanating from
both inside and outside of the head” (Dorhay et al, 2009).
 Patient with DID are “more likely to hear more than two voices,
including those of children and adults, beginning before 18 YOA”
(Dorhay et al, 2009).
 DID patients do not show true delusions (e.g. do not endorse
delusional perception) (Kluft, 1987).
 DID patients have self-reflective capacities and insight is in the
non-psychotic range (Sar et al, 2012).

39. DID and Multiple Diagnoses
 No study to-date has found DID without multiple, non-
dissociative, psychopathology (Dorhay et al, 2014).
 Mood lability & suicidal ideation— “commonest symptoms”
(Middleton & Butler, 1998).
 PTSD present in “majority of cases” (Vermetten et al, 2006).
 Self-harm & substance misuse— “typically found in 50% of
patients” (MacDowell et al, 1999).
 Borderline PD is the commonest personality disorder and present
in more than ½ to 2/3rd of patients (Lipasanen et al, 2003; Sar et
al, 2003).

40. True DID versus Feigned DID
“Some psychiatric patients consciously or
unconsciously imitate DID” (Draijer & Boon, 1999).
Self-report dissociative scales—not useful, as lack
validity (Dorhay et al, 2014).
‘Fake bad’ scales in psychological tests not useful to
identify true DID, as they include items experienced by
traumatised individuals, including DID. (Butcher et al,
2001; Brand & Chasson, 2015).

41. True DID versus Feigned DID (2)
 Structured Dissociative Interview (SCID-D) shows most utility and
effectiveness in “distinguishing genuine DID from malingered or
factitious DID” (Friedlr & Draijer, 2000; Welburn et al, 2003).
 A structured Forensic Interview (Structured Interview of Reported
Symptoms—SIRS 2, Rogers et al, 2010), when used along with a
Trauma Index, distinguished feigners from DID patients (Brand et
al, 2006 & 2014).
 Neurobiological tests: true DID showed different neural and
psychophysiological patterns from those shown by DID
simulators (even those with high suggestibility) while listening to
autobiographical trauma scripts (Reinders et al, 2012).

42. What to do with the Patient who
has ‘Everything’

43. What to do with the Patient who
has ‘Everything’
Endorsing ‘everything’ means something in itself:
Patients with Borderline PD and DID, Adult ADHAD
often present with myriad disparate diagnoses and
urgent requests for care.
Consider secondary gains if the descriptions of
symptoms is unusual or the patients endorse highly
unusual symptoms.

44. What to do with the Patient who
has ‘Everything’
Are the symptoms valid?:
 State versus trait: has the symptoms lasted for < 12 weeks?
 Accessibility: can the symptom be measured?
 Face validity: does the symptom clearly affect the patient’s
behaviour and functioning?
 Ecological validity: is the symptom valid with our knowledge of its
occurrence?
 Rule out 3 Ps: is the symptom Persistent; Pathologically
disruptive and different than usual; and Pervasive across normal
domains?
Targum et al, 2008

45. What to do with the Patient who
has ‘Everything’
Focus on the most impairing symptom
This might help to put other symptoms in context.
Find a common goal
If you can’t pick up a symptom, help the patient to
move on by helping them identify their goals.
Picking an achievable (possibly measurable) goal
might be therapeutic.

46. What to do with the Patient who
has ‘Everything’
Multiple diagnoses might be in play, but start treating one
 Many patients meet criteria of multiple categorical DSM
diagnoses.
 Clinical judgment to pick “the best first step” and treat
accordingly.
Avoid Polypharmacy
 Target specific symptoms or goals until a clear diagnostic
picture arises.

47. What Should be the Approach in
this Case?
 Diagnosis of malingering can have serious negative
consequences for the patient.
 “The term malingering should be reserved for cases where the
evidence for the diagnosis is incontrovertible.” (Boone, 2011;
Young, 2014).
 When it is unclear whether the patient is malingering, “It may be
more appropriate to describe the patient’s behaviour with terms
such as unreliability, deception, atypical or nondisclosure
(Rogers, 2008)

48. What Should be the Approach in
this Case?
Try to extend beyond categorical thinking of the
conditions.
Try to understand the function of the deceptive
behaviour.
May help those individuals whose deception is rooted
in poor coping or potentially remediable psychological
problems.
Hamilton et al (2008)

49. Conclusions
 Diagnosis of DID has to be taken into consideration in this
case.
 The possibility of multiple diagnoses.
 “Watch and wait”
 Malingering?
 Specialist assessment
 The general management approach

50. References
 Boone KB (2011): Somatoform disorders, factitious disorder and
malingering. In Schoenberg MR, Scott JG eds. The Little Black
Book of Neuropsychology. New York, Springer, 551-566.
 Brand BL et al (2006): Assessment of genuine and simulated
dissociative identity disorder on the structured interview of
reported symptoms. J Trauma & Dissociation, 7: 63-85.
 Brand BL et al (2014): Utility of SIRS-2 in distinguishing genuine
from simulated dissociative identity disorder. Psychological
Trauma: Theory, Research, Practice & Policy, 6: 308-317.
 Brand BL & Chasson GS (2015): Distinguishing simulated from
genuine dissociative identity disorder on the MMPI 2.
Psychological Trauma: Theory, Research, Practice & Policy, 7:
93-101.
 Butcher et al (2001): Manual for the administration and scoring of
MMPI 2. Minneapolis, University of Minnesota Press.

51. References
 Dorhay et al (2009): Auditory hallucinations in dissociative identity
disorder and schizophrenia, with or without childhood traumatic
history: similarities and differences. J Nervous Mental Disease,
197:892-898.
 Dorhay et al (2014): Dissociative Disorder: an empirical overview.
Aust Nz J Psychiatry, 48: 402-417.
 Draijer N & Boon S (1999): The imitation of dissociation identity
disorder: patients at risk, therapist at risk. J Psychiatry & Law, 27:
423-458.
 Friedl MC & Draijer N (2000): Dissociative Disorders in Dutch
psychiatric inpatients. A J Psychiatry, 157: 1012-1013.
 Hamilton JC et al (2008): Factitious disorders in medical and
psychiatric practices. In Rogers R, ed. Clinical assessment of
malingering and deception. 3rd ed, New York, The Guildford Press,
128-144.
 Kaplan H & Saddock B (1998): Dissociative Disorders. In Synopsis
of Psychiatry, 8th edition, 428-438.

52. References
 Kluft RP (1987): First rank symptoms as a diagnostic clue to multiple
personality disorder. A J Psychiatry, 144: 293-298.
 Lipasanen T et al (2004): Dissociative disorders amongst psychiatric
patients: comparison with a non-clinical sample. European
Psychiatry, 19: 53-55.
 McDowell et al (1999): Dissociative identity disorder and substance
abuse: a forgotten relationship. J Psychoactive Drugs, 31: 71-83.
 Middleton W and Butler J (1998): Dissociative Identity Disorder, an
Australian series. Aust Nz J Psychiatry, 32: 794-804.
 Reinders et al (2012): Fact or factitious? A psychobiological study of
authentic and simulated dissociative identity disorder. PLoS One, 7:
e39279.
 Rogers R (2008): An introduction to response styles. In Roger R, ed.
Clinical Assessment of Malingering and Deception, 3rd ed, New York,
the Guilford Press, 3-13.

53. References
 Rogers R et al (2010): Structured interview of reported symptoms-2 (SIRS-2)
and professional manual. Lutz FL: Psychological Assessment Resources.
 Ross CA et al (1990b): Structured interview data on 102 patients of multiple
personality disorder from 4 centres. A J Psychiatry, 147: 596-601.
 Sar V et al (2003): Axis I dissociative disorder comorbidity of borderline
personality disorder amongst psychiatric outpatients. J Trauma &
Dissociation, 4: 119-136.
 Targum et al (2008): Redefining affective disorders: relevance for drug
development. CNS Neurosc Ther, 14: 2-9.
 Vermetten et al (2006): Hippocampal and amygdalr volume in dissociative
identity disorder. A J Psychiatry, 163: 630-636.
 Welburn KR et al (2003): Discriminating dissociative identity disorder from
schizophrenia and feigned dissociation on psychological tests and structured
interview. J Trauma and Dissociation, 4: 109-130.
 Young G (2014): Malingering, feigning and response bias in
psychiatric/psychological injury: implications for practice and court. New
York, Springer.
Yasir Hameed
(MRCPsych)
Digitally signed by Yasir Hameed (MRCPsych)
DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United
Kingdom l=GB o=Norfolk and Suffolk NHS Trust e=yasirmhm@yahoo.com
Reason: I am approving this document
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Date: 2015-12-02 22:31Z