Dissociative Identity Disorder

Individuals with DID often also suffer from other mental illnesses, including posttraumatic stress disorder (PTSD), borderline and other personality disorders, and conversion disorder.

Dissociative identity disorder (DID), formerly called multiple personality disorder (in previous diagnostic manuals, like the DSM-IV), is a mental illness that involves the sufferer experiencing at least two clear identities or personality states, also called alters, each of which has a fairly consistent way of viewing and relating to the world. Some individuals with DID have been found to have alternate personalities that have distinctly different ways of reacting, in terms of emotions, pulse, blood pressure, and even blood flow to the brain. Health care professionals used to call the disorder multiple personality disorder (MPD), and people often colloquially referred to it as split personality disorder.

Statistics regarding this disorder indicate that the incidence of DID is about 1% of all adults (general population) in the United States, from 1%-20% of patients in psychiatric hospitals and is described as occurring in girls equally to boys and up to nine times more often in women compared to men. However, this female preponderance may be due to difficulty identifying the disorder in males. Disagreement among mental health professionals about how this illness appears clinically and controversy about whether DID even exists adds to the difficulty of estimating how often it occurs.

Some professionals continue to be of the opinion that DID does not exist. The nature of this skepticism is sometimes due to questions about why many more individuals who have endured the stress of terrible abuse as young children do not develop the disorder, why more children are not diagnosed as having DID, and why some DID sufferers have no history of significant trauma. One explanation for what some believe to be these inconsistencies is that given the highly complex and unknown nature of the human brain and psyche, many of those whom one would expect to develop dissociative identity disorder are spared due to their resilience. Another concern about the diagnosis of DID involves having to rely on the traumatic memories of those who suffer from this disorder. That DID is significantly more often assessed in individuals in North America compared to the rest of the world, for the most part, leads some practitioners to believe that DID is a culture-based concoction rather than a true condition.

As with many other mental health issues, symptoms of the same disorder in children look very different from symptoms in adults. Studies that verify the presence of DID using multiple resources add credibility to the diagnosis. Research on individuals with DID that have little to no media exposure to information on the illness lends further credibility to the reliability of the existence of this mental health condition.

While there is no proven specific cause of DID, the prevailing psychological theory about how the condition usually develops is as a reaction to severe childhood trauma. Specifically, it is thought that one way that some individuals respond to being severely traumatized as a young child is to wall off altered states of consciousness, in other words to dissociate, those memories. When that reaction becomes extreme, DID may be the result. As with other mental disorders, having a family member with DID may be a risk factor, in that it indicates a potential vulnerability to developing the disorder but does not translate into the condition being literally hereditary.

Signs and symptoms of dissociative identity disorder include

• lapses in memory (dissociation), particularly of significant life events, like birthdays, weddings, or birth of a child;
• experiencing blackouts in time, resulting in finding oneself in places but not recalling how one got there;
• being frequently accused of lying when they do not believe they are lying (for example, being told of things they did but do not remember, not related to the influence of any drug or medical condition);
• finding items in one's possession but not recalling how those things were acquired;
• encountering people with whom one is unfamiliar but who seem to know them sometimes by another identity;
• being called names that are completely unlike their own name or nickname;
• finding items they have clearly written but are in handwriting other than their own;
• hearing voices inside their head that are not their own;
• not recognizing themselves in the mirror;
• feeling unreal (derealization);
• feeling detached from oneself, like they are watching themselves move through life rather than living their own life (depersonalization);
• feeling like more than one person.

There is no specific definitive test, like a blood test, that can accurately assess that a person has dissociative identity disorder. Therefore, mental health practitioners like psychiatrists, psychoanalysts, or clinical psychologists conduct a mental health interview that gathers information, looking for the presence of the signs and symptoms previously described. Using structured interviews like the Structured Clinical Interview for Dissociative Disorders (SCID-D) is thought to be particularly helpful in distinguishing DID from other mental illnesses.

The diagnostic criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for dissociative identity disorder are as follows:

1. The presence of two or more distinct identities or personality states (each with its own relatively persistent pattern of perceiving, relating to, and thinking about him or herself and the world)
2. At least two of the identities or personality states repeatedly take control of the person's behavior.
3. An inability to recall important personal information that is too severe to be explained by ordinary forgetfulness
4. The illness is not the result of the direct physiological effects of a substance (for example, blackouts or other abnormal behavior during alcohol or other drug intoxication) or a general medical condition (for example, seizures). In children, imaginary playmates or other fantasy play do not cause the symptoms.

Professionals usually gather information about the individual's childhood and ask questions to explore whether the symptoms that the client is suffering from are not better accounted for by another mental health condition, dissociative or otherwise. Other types of dissociative disorders include depersonalization/derealization disorder (feeling detached from themselves or surroundings), dissociative amnesia (memory problems associated with a traumatic experience), other dissociative disorder (episodes of dissociation that do not qualify for one of the specific dissociative disorders just described but the professional determining the diagnosis describes the reason why the criteria for a specific dissociative disorder is not met, as in when a person is in a trance), and unspecified dissociative disorder, formerly called dissociative disorder, not otherwise specified (DD,NOS), which is characterized by episodes of dissociation that do not qualify for one of the specific dissociative disorders just described). As part of the assessment, mental health professionals also usually ask about other mental conditions and ensure that the person has recently received a comprehensive physical examination and any appropriate medical tests so that any physical conditions that may mimic symptoms of DID are identified and addressed.

Dissociation, a major symptom of DID, occurs in a number of other mental illnesses. For example, an individual with this disorder may seek to relieve overwhelming trauma-related memories by engaging in the self-mutilation and other forms of self-harm/self-injurious and self-destructive behaviors found in those with borderline personality disorder. Also, feelings and behaviors that may appear to be caused by dissociation, but are not, make it all the more difficult to distinguish DID from other conditions. Somatic symptom disorder, conversion disorder, and schizophrenia are just a few such disorders. Rape and other adult trauma victims are quite vulnerable to developing dissociative symptoms. The controversy about whether DID exists, as well as the overlap of symptoms it has with a number of other conditions, sometimes results in misdiagnosis.

Symptoms of some other mental disorders may be mistaken for dissociation. The apparent impulsivity of bipolar disorder or wide mood swings associated with bipolar disorder, borderline personality disorder, or narcissistic personality disorder when triggered by minor slights are examples. People may also confuse the unstable self-image of borderline personality disorder with dissociation. Blackouts related to substance use disorders (formerly described as substance abuse or dependence) are other instances of an individual being unaware of his or her surroundings that mimic dissociation.

DID often co-occurs with other emotional conditions, including posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), and a number of other personality disorders, as well as conversion disorder. DID is sometimes feigned by individuals who may be seeking attention, as in Munchausen's syndrome. It has also been appropriately diagnosed as well as feigned in individuals involved in the criminal justice and civil or family court systems (for example, forensic cases). Adding to the diagnostic difficulty is that people like pedophiles and other sex offenders, as well as people with antisocial personality disorder, may legally stand to gain from having DID. While some of those individuals may feign the diagnosis in an effort to benefit legally, others genuinely suffer from significant dissociative symptoms, as well as full-blown DID. In cases where there may be an ulterior motive for being diagnosed with DID, studies show that using a screening test or structured interview may be the best way to determine if the person truly suffers from this condition.

Psychotherapy is generally considered the main component of treatment for dissociative identity disorder. In treating individuals with DID, therapists usually use individual, family, and/or group psychotherapy to help clients improve their relationships with others and to experience feelings they have not felt comfortable being in touch with or openly expressing in the past. It is carefully paced in order to prevent the person with DID from becoming overwhelmed by anxiety, risking a figurative repetition of their traumatic past being inflicted by those very strong emotions. Dialectical behavior therapy is a form of cognitive behavior therapy that emphasizes mindfulness and works on helping the DID sufferer soothe him- or herself by decreasing negative responses to stressors.

Mental health professionals also often guide clients in finding a way to have each aspect of them coexist, and work together, as well as developing crisis-prevention techniques and finding ways of coping with memory lapses that occur during times of dissociation. The goal of achieving a more peaceful coexistence of the person's multiple personalities is quite different from the reintegration of all those aspects into just one identity state. While reintegration used to be the goal of psychotherapy, it has frequently been found to leave individuals with DID feeling as if the goal of the practitioner is to get rid of, or "kill," parts of them.

Hypnosis sometimes helps increase the information that the person with DID has about their symptoms/identity states, thereby increasing the control they have over those states when they change from one personality state to another. This occurs by enhancing the communication that each aspect of the person's identity has with the others. In this age of insurance companies regulating the health care that most Americans receive, having time-limited, multiple periods of psychotherapy rather than intensive long-term care provides what may be another effective treatment option for helping people who are living with DID.

Physicians increasingly use eye movement desensitization and reprocessing (EMDR), a type of treatment that integrates traumatic memories with the patient's own resources, in the treatment of people with dissociative identity disorder. It results in enhanced information processing and healing.

Medications are often used to address the many other mental health conditions that individuals with DID tend to have, like depression, severe anxiety, anger, and impulse-control problems. However, particular caution is appropriate when treating people with DID with medications because any effects they may experience, good or bad, may cause the sufferer of DID to feel like they are being controlled, and therefore traumatized yet again. As DID is often associated with episodes of severe depression, electroconvulsive therapy (ECT) can be a viable treatment when the combination of psychotherapy and medication does not result in adequate relief of symptoms.

As with other mental health conditions, the prognosis for people with DID becomes much less optimistic if not appropriately treated. Individuals with a history of being sexually abused, including those who go on to develop dissociative identity disorder, are vulnerable to abusing alcohol or other substances as a negative way of coping with their victimization. People with DID are also at risk for attempting suicide more than once. Violent behavior has a high level of association with dissociation as well. Other debilitating outcomes of DID, like that of other severe chronic mental illnesses, include inability to obtain and maintain employment, poor relationships with others, and therefore overall lower productivity and quality of life.

Research indicates that people with dissociative identity disorder have their best opportunity for living a well-adjusted life if they receive comprehensive treatment for their multiple symptoms. However, differences in how practitioners diagnose and treat this illness make it difficult to quantify or predict outcomes.

Given that the origin of dissociative identity disorder in the majority of individuals remains related to exposure to traumatic events, prevention for this disorder primarily involves minimizing the exposure to traumatic events, as well as helping survivors of trauma come to terms with what they have been through in a healthy way.