Background: We wish to add to the current body of knowledge by investigating the different factors that play into the development of dissociative identity disorder, particularly trauma. DID in accordance with the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) is defined as a disruption in the identity by the presence of two or more distinct personality states, which often occurs after significant trauma. Ferenzci’s explored this with the theory on trauma-inducing neurosis. This theory was applied to our case presentation.

Case presentation: We present a 19-year-old female patient who presented with active shifting of personalities was visualized in the clinical setting. This patient had experienced various forms of traumatic abuse, including sexual, verbal, physical, and even neglectful abuse from multiple family members. The patient developed dissociative states in which characteristics of the aggressors were mimicked.

Conclusion: Ferenzci’s idea that traumatic situations likely trigger dissociative states during the early years in this patient was noticed in ⅗ personalities, while ⅖ did not support this claim. The other two dissociative states included the host, being the decision-maker and leading figure, and also a euphoric character that exhibited regression when she felt comfortable. Although this case report supports some aspects of Ferenzci’s ideas on trauma-inducing neurosis, other theories must be explored to understand further the personalities that do not display aggressiveness.

Keywords: dissociative identity disorder, introjection, aggressor, ferenczi, personality, stress-diathesis model

Traumatic induction and the ensuing dissociative state, with resulting fragmentation of the personality, has been thoroughly discussed by Ferenczi. This has resulted in several publications, which contributed to the current understanding of the medical condition, Dissociative Identity Disorder (DID).¹ DID in accordance to the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) is defined as a disruption in the identity by the presence of two or more distinct personality states, with a discontinue in sense of self and agency, and with variations in effect, behavior, consciousness, memory, perception, cognition, or sensory-motor functioning.² Those suffering from DID endure recurrent gaps in autobiographical memory, and the signs and symptoms of DID may be observed by others or be reported by the patient.³ Ferenczi introduced the concept and term, introjection with the aggressor, in his seminal paper, Confusion of Tongues. In this, he describes how the abused child becomes transfixed and robbed of their senses. After being traumatically overwhelmed, the child is hypnotically transfixed by the aggressor’s wishes and behavior.¹ Fereneczi suggests the emerging personality is constructed around the characteristics of the aggressor as a result of traumatic introjection. That said, DID etiology is associated with complex combinations of developmental and cultural factors, including childhood trauma, and has a 1% prevalence of the general population.⁴ Due to the several developmental and cultural factors and low incidence, the emergence of unique patient presentations should be reviewed to further our medical knowledge. By expanding our understanding of the development of dissociative identity personalities, more appropriate treatment regimens may be established. This particular patient case offered the rare opportunity to explore the concept of introjection in response to an aggressor and the development of different identities in a DID patient. In addition, an unusual aspect of this patient’s presentation was the emergence of some personalities that did not align with Ferenczi’s introjection of the aggressor. This case report will discuss the development of the characters in a DID patient, by allowing the patient to describe each personality, when each personality became evident, and who in the patient’s life (relatives, friends, etc.) the personality most likely portrays. This will help demonstrate Freneczi’s concept of introjection of the aggressor and highlight the unique emergence of dissociative identities that do not align with Fereneczi’s viewpoint.

This case report presents a 19 year-old female who was admitted to the psychiatric unit due to suicidal ideations after relapsing to illicit drug abuse. The patient had a significant past medical history of depression and anxiety, bipolar disorder, ADHD, and DID. The patient admitted to being sexually abused between 4-7 years old by her older cousins, one of which is deceased and the other resides in jail for rape and murder. The patient stated she is from Missouri and had lived with her abuser, her paternal grandmother, from the ages of 7-17. Her biological mother had been her primary caregiver until the age of 7 when the state removed the patient from her mother’s care due to a substance abuse disorder, neglect, and physical abuse. The patient states her relationship with her biological father is distant now that she had moved to New York to reunite with her biological mother. She reports an extensive history of substance abuse over the past 1.5 years. She states she started to use meth with her biological father before coming to New York. The patient came to New York to reunite with her biological mother, who has been sober for the past eleven years. She has been living with her biological mother and her stepfather for the past ten months. She reports that when she originally came to New York, she had tried several drugs, including cocaine, marijuana, crack, and heroin. The patient also states she has been very sexually active the past year with greater than ten partners and will perform sexual favors to manipulate others into getting her drugs. The patient reports attempting to become sober with the support of her mother for the past several months before relapsing. The patient’s psychiatric history is significant for depression and anxiety (diagnosed at ten), ADHD (diagnosed at seven), bipolar disorder and DID. From ages 14-17, the patient attempted suicide multiple times by overdosing on pills and by cutting herself. Finally, regarding the patients' DID, the patient was able to provide a significant amount of information. The patient states that she was diagnosed 1.5 years ago. The patient was instructed to continue supportive, group, and milieu therapy along with appropriate pharmacotherapy. This included, Latuda 40mg PO daily for psychosis, Hydroxyzine 25mg PO TID PRN for anxiety, Haldol 5mg Q6hr PO PRN for agitation, Ativan 2mg Q6hr PO PRN for agitation, and Benadryl 50mg PO HS PRN for insomnia. Psychoeducation regarding the patient’s illness and medication side effects were also provided to the patient.

This patient meets the diagnostic criteria of Dissociative Identity Disorder (DID)⁵ according to DSM-5. Further investigation of this patient’s identities allowed for an analysis of present theories outlining the emergence and pathogenesis of these developing personalities. Literature has described two possible models of pathogenesis: The stress-diathesis model and the sociocognitive model.^6,7 Emphasis has been made on the emergence of DID concerning the stress-diathesis model. The stress-diathesis model, also referred to as the trauma model of dissociation, explains that dissociation is an important aspect of the psychobiological response to a threat or danger. It allows for automatization of behavior, analgesia, depersonalization, and isolation of catastrophic experiences to enhance survival during and in the aftermath of these events.⁶ This patient follows this trauma-based model as this patient has suffered several childhood experiences involving mental, physical, and sexual abuse. This patient’s case offers a unique aspect as they can recognize and relate particular identities to some of the perpetrators. This helps draw some validity to Ferenczi’s concept of introjection with the aggressor. As suggested by Fereneczi some of the emerging identities are constructed around the characteristics of the aggressor as a result of traumatic introjection. This was most notably demonstrated with the personalities known as Brenda, “The Mother,” Jaysee “The Manic,”, and It “The Mean.”

Brenda, also referred by the patient as “The Mother,” holds the role of a caregiver over the other identities and the patient as a whole (Table 1). The patient recalls Brenda emerging around the age of 10 years old. Brenda emerges when the patient is subjected to performing duties like cleaning and cooking or when the patient is responsible for completing particular chores (Table 1). The patient also describes this identity present during moments of criticism. When she is being criticized for her schoolwork or employment performance by teachers and managers, respectively, Brenda will emerge. When evaluating the traits of this personality, the patient identifies Brenda as having similar characteristics of her biological mother (Table 1). When elaborating on the relationship between the patient and her biological mother, it is discovered the patient was physically abused and also suffered from neglect at the hands of her biological mother. The relationship between DID and childhood exposure to abuse and neglect has been well established.⁸ As is the case with the emergence of this identity, the trauma- based model holds when evaluating this patient. Also, the patient further elaborates that Brenda has similar mannerisms and behaviors to that of her biological mother. This is a clear demonstration of introjection by the aggressor with resulting changes in the patient’s construct of identity. The patient’s identity, Brenda, embodies similar attributes as her biological mother and emerges when exposed to similar situations that relate to her previous abusive experiences committed by the aggressor, her biological mother. The response of the patient’s abuse by her biological mother follows Ferenczi’s concept of identification with the abuser. Rather than a reaction of rejection, hatred, disgust, and energetic refusal, a paradoxical reaction occurs. The child feels physically and morally helpless, and their present personalities are not sufficiently consolidated to be able to protest the aggressor.⁹ The child, as in this patient, is overwhelmed by and is compelled to subordinate themselves to the aggressor with the child becoming “hypnotically transfixed on the aggressor's wishes”.¹ This subordination is merely a survival response and progresses to the child introjecting the aggressor to adapt more precisely. This results in an internal model the child can identify. As described by Freneczi the introjection process involves the child’s experiential reality being replaced by the will of what is terrifying her. This allows the suffering part of the person to be repressed, leaving an emotionless “guardian angel”.⁹

In addition to Brenda, another identity by the name of Jaysee emerged and stems from the characteristics of the patient’s biological mother. This is particularly unique as the aggressor, the biological mother, is one individual and is the foundation of two distinct identities. These identities are separated by the biological mother’s exposure to illicit drug use. Brenda is based on the aggressor before illicit substance exposure, while Jaysee is founded on the characteristics displayed by the aggressor when struggling with substance abuse. During this time in the patient’s life, she recalls her mother abandoning her for days and being physically abusive. Jaysee, sometimes referred to as “The Manic '' by the patient, emerges when the patient feels alone or distant from those around her (Table 1). The patient’s most recent recollection of Jaysee emerging was when she had an argument with her current guardians. The patient was unable to recall the next 24hrs but recalled waking up in a home she did not recognize and being referred to as Jaysee by the homeowner. Jaysee portrays drug-seeking behavior and is willing to perform sexual acts for narcotics (Table 1). The patient recalls witnessing these same behaviors in her mother as a child. In a similar fashion to the development of Brenda, Jaysee emerges in response to the overwhelming environment as the child identifies with the aggressor for survival.⁹ The identity of Jaysee, however, offers a unique aspect of Fereneczi’s traumatic introjection by the aggressor. This is because the perpetrator, the patient’s biological mother, provides the foundation of two distinct introjected identities. The effort of the patient to identify with the aggressor as the characteristics of the aggressor drastically shift from one dynamic to another result in the present establishing two different identities of the aggressor, and as a result, two personalities emerged.

Finally, the third identity that follows the pattern of identification with the aggressor is known as “It”, also referred to as “The Mean”. This personality is founded on characteristics of another family member, in particular the patient’s paternal grandmother (Table 1). The patient describes the maternal grandmother as both verbally and physically abusive. The maternal grandmother was described as someone who was extremely violent and aggressive to the people surrounding her but did have a priority of protecting her family. “It,” aka “The Mean,” is described as the meanest and most violent personality of them all. “It” is always brought out with some conflict in progress (Table 1). The patient states that “It” was created to protect “us.” This would mirror the behavior of the paternal grandmother, and even though she was the most aggressive and most violent, her priority was her family. “Ferenczi wrote about how splitting, dissociation, and introjection combine to minimize the child’s fear and psychic pain by creating a soothing false reality alongside her frightened, urgent focus on the real aggressor”.⁹ One can argue that this new personality, “It,” aka “The Mean” now gave a false sense of security to the patient that now felt no one could harm it. The creation of “It” aka “The Mean,” is a continuation of using introjection as a means of developing an alternate personality. Brenda, Jaysee, and It mirror the characters of the patient's mother, and paternal grandmother had similar, if not identical, characteristics.

The three distinct personalities discussed above seem to follow Ferenczi’s concept of introjection with the aggressor. Brenda, Jaysee, and It all emerged through traumatic introjection, and all have distinct features of the aggressors. However, two more personalities did not follow this pattern. Haley is described by the patient as the “baseline” personality that inspires her to be a lawyer. The patient states that this is the personality that most people meet. Ella, on the other hand, is a 4-year- old girl that may or may not be the patient's actual past self. Ella spends her time fantasizing and watching cartoons. Though Ferenczi’s concept would explain the emergence of three of the personalities, it cannot explain as to how the other two have emerged. Looking into the latest research, we do not come across other theories of how personalities emerge in DID. Further research is necessary for a more thorough understanding of how characters develop in DID.

DID has been outlined in previous literature to follow two main constructs. These include the stress-diathesis model and the sociocognitive model.⁶ A focus has been directed with respect to the stress-diathesis model with the emergence of DID being a psychobiological response to a threat or danger.⁶ Ferenczi’s concept of introjection with the aggressor attempts to establish the emergence of these personalities with respect to the perpetrator. This case allowed for a first-hand observation of Ferenczi’s concept of introduction in a DID patient. That being said, three out of five personalities of the present case can be explained by Ferenczi's theory of aggressors' introjections. However, the remaining two personalities cannot be explained with this theory and suggest the need for further study. In addition, further study will help differentiate acute psychosis, drug induced or not, within DID patients from the emergence of new personalities. Furthermore, a thorough analysis of the emergence of identities in DID patients could lead to a more specific intervention that addresses the underlying source of these personalities.

None.

No further acknowledgments.

The authors have no conflicts of interest to declare.

The patient's consent was obtained orally.

All authors have participated in the procurement of this document and agree with the submitted case report.

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