Dissociative identity disorder

Definition
Previously known as multiple personality disorder, dissociative identity disorder (DID) is a condition in which a
person has more than one distinct identity or personality state. At least two of these personalities repeatedly assert
themselves to control the affected person's behavior. Each personality state has a distinct name, past, identity, and
self-image.
Psychiatrists and psychologists use a handbook called the Diagnostic and Statistical Manual of Mental Disorders ,
fourth edition text revision or DSM-IV-TR , to diagnose mental disorders. In this handbook, DID is classified as a
dissociative disorder. Other mental disorders in this category include depersonalization disorder , dissociative
fugue , and dissociative amnesia . It should be noted, however, that the nature of DID and even its existence is
debated by psychiatrists and psychologists.
Description
"Dissociation" describes a state in which the integrated functioning of a person's identity, including consciousness,
memory and awareness of surroundings, is disrupted or eliminated. Dissociation is a mechanism that allows the mind
to separate or compartmentalize certain memories or thoughts from normal consciousness. These memories are not
erased, but are buried and may resurface at a later time. Dissociation is related to hypnosis in that hypnotic trance also
involves a temporarily altered state of consciousness. Dissociation occurs along a continuum or spectrum, and may be
mild and part of the range of normal experience, or may be severe and pose a problem for the individual experiencing
the dissociation. An example of everyday, mild dissociation is when a person is driving for a long period on the
highway and takes several exits without remembering them. In severe, impairing dissociation, an individual
experiences a lack of awareness of important aspects of his or her identity.
The phrase "dissociative identity disorder" replaced "multiple personality disorder" because the new name emphasizes
the disruption of a person's identity that characterizes the disorder. A person with the illness is consciously aware of
one aspect of his or her personality or self while being totally unaware of, or dissociated from, other aspects of it. This
is a key feature of the disorder. It only takes two distinct identities or personality states to qualify as DID but there
have been cases in which 100 distinct alternate personalities, or alters, were reported. Fifty percent of DID patients
harbor fewer than 11 identities.
Because the alters alternate in controlling the patient's consciousness and behavior, the affected patient experiences
long gaps in memory gaps that far exceed typical episodes of forgetting that occur in those unaffected by DID.
Despite the presence of distinct personalities, in many cases one primary identity exists. It uses the name the patient
was born with and tends to be quiet, dependent, depressed and guilt-ridden. The alters have their own names and
unique traits. They are distinguished by different temperaments, likes, dislikes, manners of expression and even
physical characteristics such as posture and body language. It is not unusual for patients with DID to have alters of
different genders, sexual orientations, ages, or nationalities. Typically, it takes just seconds for one personality to
replace another but, in rarer instances, the shift can be gradual. In either case, the emergence of one personality, and
the retreat of another, is often triggered by a stressful event.
People with DID tend to have other severe disorders as well, such as depression, substance abuse, borderline
personality disorder and eating disorders, among others. The degree of impairment ranges from mild to severe,
and complications may include suicide attempts, self-mutilation, violence, or drug abuse.
Left untreated, DID can last a lifetime. Treatment for the disorder consists primarily of individual psychotherapy .
Causes and symptoms
Causes
The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:

an innate ability to dissociate easily

repeated episodes of severe physical or sexual abuse in childhood

lack of a supportive or comforting person to counteract abusive relative(s)

influence of other relatives with dissociative symptoms or disorders

The primary cause of DID appears to be severe and prolonged trauma experienced during childhood. This trauma can
be associated with emotional, physical or sexual abuse, or some combination. One theory is that young children, faced
with a routine of torture, sexual abuse or neglect , dissociate themselves from their trauma by creating separate
identities or personality states. A manufactured alter may suffer while the primary identity "escapes" the unbearable
experience. Dissociation, which is easy for a young child to achieve, thus becomes a useful defense. This strategy
displaces the suffering onto another identity. Over time, the child, who on average is around six years old at the time of
the appearance of the first alter, may create many more.
As stated, there is considerable controversy about the nature, and even the existence, of dissociative identity disorder.
One cause for the skepticism is the alarming increase in reports of the disorder since the 1980s. An area of contention
is the notion of suppressed memories, a crucial component in DID. Many experts in memory research say that it is
nearly impossible for anyone to remember things that happened before the age three, the age when some DID patients
supposedly experience abuse, but the brain's storage, retrieval, and interpretation of childhood memories are still not
fully understood. The relationship of dissociative disorders to childhood abuse has led to intense controversy and
lawsuits concerning the accuracy of childhood memories. Because childhood trauma is a factor in the development of
DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). In both DID and PTSD,
dissociation is a prominent mechanism.
Symptoms
The major dissociative symptoms experienced by DID patients are amnesia , depersonalization , derealization,
and identity disturbances.
AMNESIA. Amnesia in DID is marked by gaps in the patient's memory for long periods of their past, and, in some
cases, their entire childhood. Most DID patients have amnesia, or "lose time," for periods when another personality is
"out." They may report finding items in their house that they can't remember having purchased, finding notes written
in different handwriting, or other evidence of unexplained activity.
DEPERSONALIZATION. Depersonalization is a dissociative symptom in which the patient feels that his or her
body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of
their body, or as watching a movie of themselves.
DEREALIZATION. Derealization is a dissociative symptom in which the patient perceives the external environment
as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail
to recognize relatives or close friends.
IDENTITY DISTURBANCES. Persons suffering from DID usually have a main personality that psychiatrists refer
to as the "host." This is generally not the person's original personality, but is rather one developed in response to
childhood trauma. It is usually this personality that seeks psychiatric help. DID patients are often frightened by their
dissociative experiences, which can include losing awareness of hours or even days, meeting people who claim to know
them by another name, or feeling "out of body."
Psychiatrists refer to the phase of transition between alters as the "switch." After a switch, people assume whole new
physical postures, voices, and vocabularies. Specific circumstances or stressful situations may bring out particular
identities. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of
alternate personalities during examinations or other stressful situations. Each alternate identity takes control one at a
time, denying control to the others. Patients vary with regard to their alters' awareness of one another. One alter may
not acknowledge the existence of others or it may criticize other alters. At times during therapy, one alter may allow
another to take control.
Demographics

Studies in North America and Europe indicate that as many as 5% of patients in psychiatric wards have undiagnosed
DID. Partially hospitalized and out-patients may have an even higher incidence. For every one man diagnosed with
DID, there are eight or nine women. Among children, boys and girls diagnosed with DID are pretty closely matched
1:1. No one is sure why this discrepancy between diagnosed adults and children exists.
Diagnosis
The DSM-IV-TR lists four diagnostic criteria for identifying DID and differentiating it from similar disorders:

Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death
or injury, or a serious physical threat to him- or herself or others. During exposure to the trauma, the person's
emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors
caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic
than accidents, natural disasters, or "acts of God."

The demonstration of two or more distinct identities or personality states in an individual. Each separate
identity must have its own way of thinking about, perceiving, relating to and interacting with the environment
and self.

Two of the identities assume control of the patient's behavior, one at a time and repeatedly.

Extended periods of forgetfulness lasting too long to be considered ordinary forgetfulness.

Determination that the above symptoms are not due to drugs, alcohol or other substances and that they can't
be attributed to any other general medical condition. It is also necessary to rule out fantasy play or imaginary
friends when considering a diagnosis of DID in a child.

Proper diagnosis of DID is complicated because some of the symptoms of DID overlap with symptoms of other mental
disorders. Misdiagnoses are common and include depression, schizophrenia , borderline
personality disorder, somatization disorder , and panic disorder .
Because the extreme dissociative experiences related to this disorder can be frightening, people with the disorder may
go to emergency rooms or clinics because they fear they are going insane.
When a doctor is evaluating a patient for DID, he or she will first rule out physical conditions that sometimes produce
amnesia, depersonalization, or derealization. These conditions include head injuries, brain disease (especially seizure
disorders), side effects from medications, substance abuse or intoxication, AIDS dementiacomplex, or recent periods
of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph
(EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient
is malingering and/or offering fictitious complaints.
If the patient appears to be physically healthy, the doctor will next rule out psychotic disturbances, including
schizophrenia. Many patients with DID are misdiagnosed as schizophrenic because they may "hear" their alters
"talking" inside their heads. If the doctor suspects DID, he or she can use a screening test called the Dissociative
Experiences Scale (DES). If the patient has a high score on this test, he or she can be evaluated further with the
Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for Dissociative Disorders
(SCID-D).
Treatments
Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.
Psychotherapy
Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized
training is important because the patient's personality switches can be confusing or startling. In addition, many
patients with DID have hostile or suicidal alter personalities. Most therapists who treat DID patients have rules or
contracts for treatment that include such issues as the patient's responsibility for his or her safety. Psychotherapy for
DID patients typically has several stages: an initial phase for uncovering and "mapping" the patient's alters; a phase of

treating the traumatic memories and "fusing" the alters; and a phase of consolidating the patient's newly integrated
personality.
Most therapists who treat multiples, or DID patients, recommend further treatment after personality integration, on
the grounds that the patient has not learned the social skills that most people acquire in adolescence and early adult
life. In addition, family therapy is often recommended to help the patient's family understand DID and the changes
that occur during personality reintegration.
Many DID patients are helped by group therapy as well as individual treatment, provided that the group is limited
to people with dissociative disorders. DID patients sometimes have setbacks in mixed therapy groups because other
patients are bothered or frightened by their personality switches.
Medications
Some doctors will prescribe tranquilizers or antidepressants for DID patients because their alter personalities may
have anxiety or mood disorders. However, other therapists who treat DID patients prefer to keep medications to a
minimum because these patients can easily become psychologically dependent on drugs. In addition, many DID
patients have at least one alter who abuses drugs or alcohol, substances which are dangerous in combination with
most tranquilizers.
Hypnosis
While not always necessary, hypnosis (or hypnotherapy ) is a standard method of treatment for DID patients.
Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control
problematic behaviors that many DID patients exhibit, such as self-mutilation, or eating disorders likebulimia
nervosa . In the later stages of treatment, the therapist may use hypnosis to "fuse" the alters as part of the patient's
personality integration process.
Prognosis
Unfortunately, no systematic studies of the long-term outcome of DID currently exist. Some therapists believe that the
prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is
often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the
prognosis. Patients may find they are bothered less by symptoms as they advance into middle age, with some relief
beginning to appear in the late 40s. Stress or substance abuse, however, can cause a relapse of symptoms at any time.
Prevention
Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as
early as possible.
See also Dissociation and dissociative disorders
Resources
Acocella, Joan. Creating Hysteria: Women and Multiple Personality Disorder. San Francisco, CA: Jossey-Bass
Publishers, 1999.
Alderman, Tracy, and Karen Marshall. Amongst Ourselves, A Self-Help Guide to Living with Dissociative Identity
Disorder. Oakland, CA: New Harbinger Publications, 1998.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised.
Washington, DC: American Psychiatric Association, 2000.
Saks, Elyn R., with Stephen H. Behnke. Jekyll on Trial, Multipersonality Disorder and Criminal Law. New York, NY:
New York University Press, 1997.
Gleaves, D. H., M. C. May, and E. Cardena. "An examination of the diagnostic validity of dissociative identity
disorder." Clinical Psychology Review 21, no. 4 (June 2001): 577-608.
Lalonde, J. K., J. I. Hudson, R. A. Gigante, H. G. Pope, Jr. "Canadian and American psychiatrists' attitudes toward
dissociative disorders diagnoses." Canadian Journal of Psychiatry 46, no. 5 (June 2001): 407-12.
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