Identity disturbance as a Symptom in Psychiatry

I have been very interested in the concept of identity and its role in mental health ever since I saw "identity disturbance" and "lack of sense of self" as a diagnostic criteria for a mental illness in the Diagnostic Manual for psychiatric disorders. It was not elaborated more upon in my training, just another symptom, like a cough or fever, we were told to ask about and then move on.

Interestingly, the patients who have this disorder are one of the highest users of mental health services. They also end up accumulating multiple diagnoses and in my opinion, are one of the most inappropriately over-medicated patient populations. Because when identity is what is "broken" and is the source for many other symptoms, it is no surprise that medications are prescribed for each symptom leaving the main issue unaddressed. Given the profound, complex and central role identity plays in being human, everything I was taught and the care I see these patients receive have been grossly insufficient.

In working closely with this patient population, I now have a better understanding of what an identity does for someone's mental health. Its absence or disturbance is far-reaching and not surprisingly affects every facet of a person's life.

Identity is instrumental in creating healthy and rewarding relationships with yourself and others. Without an identity, patients describe moments where they wonder if their existence matters, and they question if they even exist at all. When by themselves, they are stricken with anxiety not knowing what to do with themselves. I had a patient describe it as "utter despair", and it is in these states that she would drink heavily and do something impulsive like pleasure-seek with sex or self-harm with cutting her forearms. I wonder if this helps her test the limits of her physical being, that at least physical sensation confirms she is physically still here.

When with others, these patients will take on the personality they feel the group wants them to have. They will adopt opinions and hobbies of the group and can act in ways that conflict with previously stated values. They will be who they think you want them to be. These patients are on a repetitive, never-ending quest for belonging and acceptance into any group, and often describe themselves socially as chameleons. What this means is that a healthy identity does not mean everybody likes you, but actually the opposite, that it is and should be an acquired taste to the group in which you are meant to belong.

Quite naturally, patients who struggle with their identities are often stuck in roles of care-taking because it is a dynamic, an exchange they can understand and so it feels secure. Care-taking emphasizes the service and the person receiving care, rarely the caretaker, which allows these patient's true identities to remain invisible. So long as they are providing a service to someone, they feel worthy. They exist! This means that these patients are acutely sensitive to rejection or disappointment, like prey sensing a tiger about to pounce, their inner selves fear annihilation and will do desperate, extreme things to avoid what they fear is about to happen: a relationship they have come to rely on to define them, ending. Afterall, without the other, they no longer know their purpose and this is a state of extreme suffering. As a result, this means that even if the relationship is toxic and degrading, it is still better than nothing. To avoid rejection and abandonment I have seen self-harm or suicidal gestures and attempts. This can also manifest as self-sabotage, many will end good, stable relationships first so they are still in control and are not the one left behind. Some avoid relationships altogether.

When it comes to emotions, these patients tell me that their moods are impossible to control and hard to explain. Their moods are dependent on others too and when the other is not there as their reference point, more often than not, these patients can not tell me their mood at all. They will describe the feeling of extreme anxiety and emptiness almost all the time. This is when these patients may defer to more impulsive actions like binge-eating or excessive shopping to feel something. They do not know to look for hobbies, to prioritize self-care, because as far as they are concerned, what for?

This is just the tip of the iceberg of what a patient with a disrupted identity contends with every moment of every day.

My work with these patients involves introducing the idea that they do have an identity. It is just in hiding and that their job is to be open to discovering who they are and to nurture and care for their identities as they emerge. I also emphasize that this journey will be the most meaningful and courageous one of their lives.

Very often, when we go back far enough in their histories, they remember a time when they had things they enjoyed for themselves, before a narcissistic parent or invalidating boyfriend took over. I encourage them to simply start there and to journal anything else that comes up. The work involves reconnecting them to their true feelings and asking what they may be telling us about a situation. It involves teaching them to trust themselves over others.
They often lament over their loneliness. "I have so much love to give another" is a common phrase I hear. "You are giving it to the wrong person," is often my reply and we open up a dialogue about self-love and self-compassion.
We will discuss boundaries and the many purposes they serve in healthy relationships. I use the analogy that each person is a puzzle piece, meant to find their way and fit into a bigger community. Not having an identity softens the edges and makes them fuzzy and malleable so that they can be crammed into many places, but they are not meant to simply be a place-filler. That is not healthy for anyone. So we talk about what it would be like to firm up their borders to know where they are truly meant to belong.

The stigma for these patients can be particularly strong and divisive, especially in the medical field. It is for this reason I never name the disorder here. Issues with identity formation are also not exclusive to this diagnosis. But these patients are going through a magnified, amplified struggle that we all go through whether we are aware of it or not. Treating these patients has really forced me to give a second, third and fourth look at what so many of us take for granted. Questions about purpose, love, belonging, individuality and responsibility surface in every conversation I have with these patients. And my work in this area has made me a better psychiatrist and a better person, because these are the questions that matter to us all.