Dissociative Identity Disorder

What is dissociative identity disorder?

Dissociative identity disorder, also referred to as multiple personality disorder, is a psychiatric condition characterized by the presence of several identities, each functioning independently, with potentially differing personas, views, and mannerisms ^[1].

These identities are often referred to as alters or parts, each of whom is usually assigned their own name and may dress, behave, and think differently from one another ^[2]. The collective group of identities is often referred to as a system, with one as the main or host identity ^[3].

Someone with DID might switch identities regularly and may be fully aware of their condition and each individual identity, may be aware of some but not all identities, or may have no awareness of them at all, which can cause a great deal of distress and confusion ^[1][4].

DID is part of a spectrum of dissociative disorders, typically caused by traumatic experiences in childhood. DID happens when the brain responds to traumatic stress by dissociating as a defense mechanism ^[5]. Without the ability to process experiences of abuse and trauma, people retreat internally to escape from abusive situations, creating this dissociative state ^[6].

Often DID is diagnosed in adulthood, following several years of symptoms that may be missed or diagnosed as other conditions ^[5][7]. Historically it has been poorly understood, although more recent research into the condition has helped to improve understanding and allowed for developments in diagnosing and treating DID ^[8].

Symptoms of dissociative identity disorder

Symptoms of dissociative identity disorder vary but may include ^[1][3][9]:

• Recurrent switching between identities, which may occur within a matter of seconds, or may occur after several hours or days
• Speaking in different voices depending on the presenting identity, using different accents, tones, pitch, language, or expressions
• Changes of views between identities, such as differences in food or clothing preferences
• Changes of attitudes between identities, such as one who is often angry and loud or one who is often calm and quiet
• Regularly feeling different or strange, such as a feeling of being a different age, gender, or size
• Gaps in memory of childhood experiences and more recent occurrences, such as forgetting details of childhood trauma, or finding items moved around the house with no memory of moving them
• Difficulties with daily functioning, such as impaired performance at school or work or issues with social interactions
• Signs of switching between identities, which may include eye-rolling, rapid blinking, or trance-like states
• Identities being aware of one another and communicating internally or reporting on one another’s behaviors, or alternatively, not having any knowledge of the presence of alternative identities
• Regularly presenting to the emergency room or doctor with severe self-harming injuries
• Recurrent thoughts or attempts of suicide
• Mood changes and emotional dysregulation
• Impulsive risk-taking behaviors

Causes of dissociative identity disorder

Childhood trauma

Dissociative identity disorder is most often caused by severe and prolonged childhood trauma and abuse ^[5][7].

Research shows that up to 90% of people with a diagnosis of DID have experienced sexual, physical, or emotional abuse in childhood, involving repetitive and severe traumatic experiences ^[1][4]. The likelihood of developing DID is also increased if this abuse began before the age of five ^[10].

Dissociation occurs as a result of this trauma, as a way of retreating or escaping from reality by becoming disconnected from the self and current experiences, thus prompting a splitting in the self and the creation of new and distinct identities ^[9].

This typically occurs in those who had a lack of support and stability in their environment, with no means of preventing or avoiding abusive situations, thus requiring attempts at self-soothing and self-protection during and following these traumatic events, resulting in dissociation ^[5].

Genetics

Studies suggest that there may be a genetic component to the development of dissociative disorders, that causes an increased likelihood of responding to trauma with dissociation ^[11].

Other trauma

In some cases, dissociative identity disorder may be caused by exposure to other traumatic events, such as natural disasters or war, also as a means of psychological defense ^[6].

Diagnosing dissociative identity disorder

People with dissociative identity disorder are often misdiagnosed with other conditions, such as borderline personality disorder, posttraumatic stress disorder, or psychotic disorders, due to overlapping or similarities in symptoms, or a reluctance to discuss dissociative symptoms and childhood trauma because of feelings of shame or fear ^[7][8].

Many people with DID require professional intervention due to self-harming injuries or suicide attempts and may therefore utilize mental health services for several years before receiving a diagnosis of DID ^[4][8].

If DID is suspected, the doctor must rule out the presence of any physical conditions that could cause similar symptoms, such as tumors, brain injuries, or substance abuse ^[6]. They will then likely make a referral to a mental health specialist who can make an appropriate diagnosis.

To diagnose DID, diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5) ^[12] will be used, which include:

• The presence of at least two distinct identities, with differences in behavior, thoughts, and memories
• Gaps in memory relating to daily occurrences, childhood trauma, and personal information
• Distress and impairments in functioning caused by the presenting symptoms
• Symptoms that are not due to cultural norms or religious practices

To gather appropriate information a thorough history will be taken, including details of presenting symptoms relating to self-identity, loss of memory, or control; childhood experiences and trauma; family mental health history; and any other information provided by family members or people involved with the individual, that may be relevant for diagnosis ^[6][9].

Questionnaires may be used to help ascertain relevant information, such as the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for Dissociative Disorders ^[8].

Prevention of dissociative identity disorder

Typically, those who go on to develop DID do not have access to supportive or caring environments in childhood, while enduring prolonged abuse. As DID is often not diagnosed until adulthood, children and adolescents commonly experience symptoms of the condition for many years without appropriate professional support ^[5][7].

Where possible, removing children from abusive circumstances and ensuring that they have access to a support system and a safe environment, or by providing appropriate therapeutic support and treatment to those with traumatic experiences as early as possible, is the only way in which to potentially prevent prolonged and pervasive psychological impact ^[5][13].

Treatment for dissociative identity disorder

Treatment for dissociative identity disorder requires a multidisciplinary approach, with input from experienced professionals, such as experienced physicians, psychiatrists, and mental health professionals who specialize in treating trauma ^[2].

Treating DID requires strong therapeutic relationships to provide safe and trusting environments in which to process and recover from trauma ^[5]. Treatment involves first attempting to stabilize mood and ensure the safety of the individual. Next, the therapist and client will process, grieve, and resolve the trauma. Then, finally, the therapist and client will work to integrate the identities and increase normal daily functioning ^[9].

This may involve the use of various interventions, such as behavioral therapy, EMDR, medication, hospitalization, or family therapy.

CBT and DBT

Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) can be utilized prior to initiating trauma therapy to first mitigate harmful behaviors and ensure safety. CBT and DBT can help to regulate emotions, tolerate distress, improve functioning, and reduce negative emotions, while teaching helpful coping strategies ^[2][4].

EMDR

Eye movement desensitization and reprocessing (EMDR) is a specialized therapeutic treatment designed to help individuals overcome distress caused by traumatic experiences.

EMDR can be retraumatizing if the individual has not already undertaken therapeutic intervention to stabilize and manage their emotions with positive coping strategies, so should only be provided to those who have learnt to tolerate some level of distress ^[2].

Traumatic memories are revisited, gradually desensitizing the individual to the negative thoughts and feelings associated, which are eventually adapted to form more positive beliefs about the self in relation to the traumatic memories, thereby reprogramming the response to these experiences and reducing symptoms of dissociation ^[15].

Medication

There are no approved medications specifically for the treatment of dissociative personality disorder, but medications may be prescribed to treat symptoms of associated conditions, such as antidepressants or mood stabilizers ^[1][13].

Family Input

If possible or appropriate, family therapy and education can be useful in the treatment of DID, as it can help to improve understanding and acceptance of the condition and symptoms and provide information and guidance on helping the individual to manage their symptoms and maintain their safety ^[2].

Inpatient treatment

If the safety of the individual or others is at risk, it may be necessary to provide treatment in hospital, with a view to discharge the individual back into the community once they are stabilized ^[9].

Self-care for dissociative identity disorder

If you have dissociative identity disorder, you can manage your symptoms by ^[3]:

• Learning about your condition: Learning more about DID can help you to better understand your condition, which may help to reduce any distress that your symptoms cause.
• Speaking with others: Communicating with loved ones about your symptoms can help you feel better supported and make it easier to manage triggering situations.
• Attending a support group: Attending a group or speaking with others with DID can also help to reduce negative feelings associated with your condition and provide an opportunity to discuss symptoms with others who have had similar experiences.
• Utilizing grounding exercises: Grounding exercises, such as walking, breathing exercises, or putting your face or hand in ice water, can help you to cope with overwhelming memories or thoughts, bringing attention back to the present.
• Managing practical issues: Practical strategies, such as using a calendar or reminders, writing notes to yourself, or wearing a watch with the date and time, can help to reduce the impact on daily functioning caused by dissociation.
• Looking after your wellbeing: Eating healthily, getting plenty of sleep, and engaging in regular exercise can help reduce anxieties and negative emotions, improving your overall physical and mental wellbeing.

FAQs about dissociative identity disorder

What are the complications of dissociative identity disorder?

Left untreated, dissociative identity disorder can cause severe social, mental, and physical complications, including:

• Suicide risk: Research shows that around 70% of people with a diagnosis of DID attempt suicide, so receiving appropriate treatment is crucial to mitigating this risk and ensuring safety ^[1][4].
• Social withdrawal: People with DID may experience stigmatization, particularly as DID is generally poorly understood by both the public and many professionals, which can cause feelings of shame and result in social withdrawal and isolation, potentially worsening distress and negative emotions associated with the condition ^[8].
• Substance abuse: People with traumatic experiences may turn to alcohol and drugs as a coping strategy for their emotional distress, thus creating further risks to personal safety ^[13].
• Worsening mental wellbeing: Delayed diagnosis, misdiagnosis, or inappropriate treatment can worsen and prolong symptoms of DID, including emotional distress and impairment in daily functioning ^[4][6].

How common is dissociative identity disorder?

Various studies report that dissociative identity disorder affects around 1-1.5% of the population and is believed to more commonly diagnosed in females than males ^[5][6].