Dissociative Identity Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Previously known as multiple personality disorder, dissociative identity disorder (DID) is a condition in which those affected have more than one distinct identity or personality state. At least two of these personalities repeatedly assert themselves to control the behavior of the affected people. 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.

“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. In severe, impairing dissociation, individuals experience a lack of awareness of important aspects of their identities.

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. People with the illness are consciously aware of one aspect of their personality or self while being totally unaware of, or dissociated from, other aspects of it. This is a key feature of the disorder. It requires only 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 patients with DID harbor fewer than 11 identities.

Because the alters alternate in controlling the consciousness and behavior of those affected, patients experience 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, one primary identity exists in many cases. The primary identity 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. It typically takes just seconds for one personality to replace another but the shift can be gradual in rarer instances. 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

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 supportive or comforting people 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. Manufactured alters may suffer while primary identities “escape” the unbearable experiences. Dissociation, which is easy for young children to achieve, thus becomes a useful defense. This strategy displaces the suffering onto another identity. Over time, children, who on average are 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. The causes are disputed, with some experts identifying extensive trauma in childhood as causative, while others maintain that the cause of the disorder is iatrogenic, or introduced by the news media or therapist. In this latter form, mass media or therapists plant the seeds that patients suppressed memories and dissociation severe enough to have created separate personalities. One cause for the skepticism is the alarming increase in reports of the disorder since the 1980s; more cases of DID were reported between 1981 and 1986 than in the previous 200 years combined. In some cases, people reporting DID and recovered memory became involved in lawsuits related to the recovered memories, only to find that the memories were not, in fact, real. Another disorder, false memory syndrome, then becomes the explanation. Thus, an area of contention is the notion of suppressed memories, a crucial component in DID. Many experts in memory research say that it is almost impossible for anyone to remember things that happened before the age of three, the age when some patients with DID 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 patients with DID are amnesia, depersonalization , derealization, and identity disturbances.

AMNESIA

Amnesia in patients with DID is marked by gaps in their memory for long periods of their past, and, in some cases, their entire childhood. Most patients with DID have amnesia, or “lose time,” for periods when another personality is “out.” They may report finding items in their house that they cannot remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

DEPERSONALIZATION

Depersonalization is a dissociative symptom in which patients feel that their bodies are unreal, are changing, or are dissolving. Some patients with DID experience depersonalization as feeling outside of their bodies, or as watching a movie of themselves.

DEREALIZATION

Derealization is a dissociative symptom in which patients perceive the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. Patients with DID may fail to recognize relatives or close friends.

IDENTITY DISTURBANCES

People with 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. Patients with DID 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 with DID 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.

Studies in North America and Europe indicate that as many as 5% of patients in psychiatric wards have undiagnosed DID. Partially hospitalized patients and outpatients may have an even higher incidence. For every man diagnosed with DID, eight or nine women are diagnosed. 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.

The DSM-IV-TR lists four diagnostic criteria for identifying DID and differentiating it from similar disorders:

Traumatic stressor: Patients have been exposed to catastrophic events involving actual or threatened death or injury, or a serious physical threat to themselves or others. During exposure to the trauma, their 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 cannot 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 children.

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, the first step is to rule out physical conditions that

KEY TERMS

Alter —An alternate or secondary personality in a person with dissociative identity disorder. Each alter has a unique way of looking at and interacting with the world.

Amnesia —A general medical term for loss of memory that is not due to ordinary forgetfulness. Amnesia can be caused by head injuries, brain disease, or epilepsy, as well as by dissociation.

Borderline personality disorder —A severe and usually lifelong mental disorder characterized by violent mood swings and severe difficulties in sustaining interpersonal relationships.

Depersonalization —A dissociative symptom in which patients feel that their bodies are unreal, are changing, or are dissolving.

Derealization —A dissociative symptom in which the external environment is perceived as unreal.

>Dissociation —A reaction to trauma in which the mind splits off certain aspects of the traumatic event from conscious awareness. Dissociation can affect a patient’s memory, sense of reality, and sense of identity.

Dissociative identity disorder (DID) —Term that replaced multiple personality disorder. A condition in which two or more distinctive identities or personality states alternate in controlling a person’s consciousness and behavior.

Host —The dominant or main alter in a person with DID.

Hypnosis —The means by which a state of extreme relaxation and suggestibility is induced. Hypnosis is used to treat amnesia and identity disturbances that occur in people with dissociative disorders.

Malingering —Knowingly pretending to be physically or mentally ill to avoid some unpleasant duty or responsibility, or for economic benefit.

Multiple personality disorder (MPD) —An older term for dissociative identity disorder (DID).

Panic disorder —An anxiety disorder in which an individual experiences sudden, debilitating attacks of intense fear.

Post-traumatic stress disorder (PTSD) —A disorder caused by an extremely stressful or traumatic event (such as rape, act of war, or natural disaster), in which the trauma victim is haunted by flashbacks. In the flashbacks, the event is reexperienced in the present. Other symptoms include nightmares and feelings of anxiety.

Primary personality —The core personality of a patient with DID. In women, the primary personality is often timid and passive, and may be diagnosed as depressed.

Schizophrenia —A severe mental illness in which a person has difficulty distinguishing what is real from what is not real. It is often characterized by hallucinations, delusions, language and communication disturbances, and withdrawal from people and social activities.

Shift —The transition of control from one alter to another in a person with DID. Usually shifts occur rapidly, within seconds, but in some cases a more gradual changeover is observed. Also referred to as a switch.

Somatization disorder —A type of mental disorder in which the patient has physical complaints that serve as coping strategies for emotional distress.

Trauma —A disastrous or life-threatening event that can cause severe emotional distress. DID is associated with trauma in a person’s early life or adult experience.

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 dementia complex, 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 misdiag-nosed as having schizophrenia because they may “hear” their alters “talking” inside their heads. Doctors who suspect DID can use a screening test called the Dissociative Experiences Scale (DES). Patients with high scores on this test can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for Dissociative Disorders (SCID-D).

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 patients with DID have rules or contracts for treatment that include such issues as responsibility for the patient’s safety. Psychotherapy for patients with DID 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 patients with DID, recommend further treatment after personality integration, on the grounds that the patients have not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help families understand DID and the changes that occur during personality reintegration.

Many patients with DID are helped by group therapy as well as individual treatment, provided that the group is limited to people with dissociative disorders. Patients with DID 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 patients with DID because their alter personalities may have anxiety or mood disorders. However, other therapists who treat patients with DID prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many patients with DID have at least one alter who abuses drugs or alcohol, substances that are dangerous in combination with most tranquilizers.

Hypnosis

Although not always necessary, hypnosis (or hypnotherapy ) is a standard method of treatment for patients with DID. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many patients with DID exhibit, such as self-mutilation, or eating disorders like bulimia 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.

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 of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

See alsoDissociation and dissociative disorders.

BOOKS

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 ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Saks, Elyn R., and Stephen H. Behnke. Jekyll on Trial, Multipersonality Disorder and Criminal Law. New York: New York University Press, 1997.

PERIODICALS

Gleaves, D. H., M. C. May, and E. Cardena. “An Examination of the Diagnostic Validity of Dissociative Identity Disorder.” Clinical Psychology Review 21.4 (June 2001): 577–608.

Lalonde, J. K., and others. “Canadian and American Psychiatrists’ Attitudes Toward Dissociative Disorders Diagnoses.” Canadian Journal of Psychiatry 46.5 (June 2001): 407–12.

Spitzer, Carsten, and others. “Recent Developments in the Theory of Dissociation.” World Psychiatry 5 (2006): 82–86.

Stickley, T., and R. Nickeas. “Becoming One Person: Living with Dissociative Identity Disorder.” Journal of Psychiatric and Mental Health Nursing 13 (2006): 180–87.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. Fax: (202) 682-6850.

International Society for the Study of Dissociation. 60 Revere Drive, Suite 500, Northbrook, IL 60062. <http://www.issd.org/>.

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22021. <http://www.nami.org/helpline/did.html>.

OTHER

The Mayo Clinic. “Dissociative Disorders.” <http://www.mayoclinic.com/health/dissociative-disorders/DS00574/DSECTION=5>.

Merck Manual for Healthcare Professionals. The Merck Manuals Online Medical Library. “Dissociative Identity Disorder.” 2005.

Rebecca J. Frey, PhD

Dean A. Haycock, PhD

Emily Jane Willingham, PhD