Dissociative Identity Disorder

Dissociative identity disorder (DID), also known as multiple personality disorder is a rare mental disorder in which a person develops multiple distinct identities or selves in a body. It is a psychological condition in which a person called a “host” carries several identities called “alters”, each with their own distinct personalities, memories, thoughts, and actions.

What Is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is a very rare but complex mental disorder in which a person develops two or more personality states with their own distinctive identities, memories, thoughts, and behavior patterns. It falls within the spectrum of dissociative disorders and is also known as multiple personality disorder (MPD).

A 2021 study [mfn] Mitra P, Jain A. Dissociative Identity Disorder. [Updated 2021 Nov 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568768/ [/mfn] describes a person with DID as someone who “experiences separate identities that function independently of each other and are autonomous of each other.” The patient’s main personality is called the “ego” or “host” state and the unconscious identities are called “alter” states. These alter personalities can have different histories, names, ages, genders, races, moods, knowledge, and vocabularies.

However, these personalities are not fully developed and are fragments of a disconnected personality. It is believed that, in the ego state, the patient is consciously in control of her/his experiences, thoughts, and actions. But she/he lacks a sense of ownership over the alter personalities. In most cases, the alter states function and take control of the ego state—with or without the host’s knowledge.

Social and environmental stressors [mfn] Rehan, M. A., Kuppa, A., Ahuja, A., Khalid, S., Patel, N., Budi Cardi, F. S., Joshi, V. V., Khalid, A., & Tohid, H. (2018). A Strange Case of Dissociative Identity Disorder: Are There Any Triggers?. Cureus, 10(7), e2957. https://doi.org/10.7759/cureus.2957 [/mfn] can trigger personality switches in a sufferer. When they switch their personality states, there is a noticeable change in the person’s behavior, voice, hand-writing, etc. She/he completely gets detached from the immediate environment and time and experiences changes in mood, lifestyle, thoughts, and actions. She/he experiences hallucinations and memory loss and feels like she/he is living in a dream-like sequence or out-of-body reality.

Most of the time, DID is often accompanied by other mental disorders, such as post-traumatic stress disorder, personality disorders (especially borderline and avoidant), depression, sleep disorders, etc.

Read More About Major Depressive Disorder (Depression) Here

Dealing With Dissociative Identity Disorder

Research shows that dissociative identity disorder has roots in experiences of childhood abuse and trauma. Most scholars consider it to be a dysfunctional coping mechanism [mfn] Brand, B. L., Sar, V., Stavropoulos, P., Krüger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder. Harvard review of psychiatry, 24(4), 257–270. https://doi.org/10.1097/HRP.0000000000000100 [/mfn] in which a DID patient devises certain people or realities in her/his mind to survive negative experiences and environments. In some countries, it is often associated with terms such as “outer world possession” and “possession by demons”. Even psychiatric literature fails to agree when it comes to understanding dissociative identity disorder.

Dissociative identity disorder affects only about 1.5% of the global population, with patients never fully recovering [mfn] Powell, R. A., & Howell, A. J. (1998). Effectiveness of treatment for dissociative identity disorder. Psychological reports, 83(2), 483–490. https://doi.org/10.2466/pr0.1998.83.2.483 [/mfn] in their lifetime. This condition has life-long symptoms and its patients require continuous reality-based and grounding interventions, supportive care, and safety planning.

Treatment methods [mfn] Brand, B. L., Loewenstein, R. J., & Spiegel, D. (2014). Dispelling myths about dissociative identity disorder treatment: an empirically based approach. Psychiatry, 77(2), 169–189. https://doi.org/10.1521/psyc.2014.77.2.169 [/mfn] for DID tends to be lengthy and expensive and this affects its prognosis rates. For instance, a 2008 study [mfn] Jans, T., Schneck-Seif, S., Weigand, T., Schneider, W., Ellgring, H., Wewetzer, C., & Warnke, A. (2008). Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence. Child and adolescent psychiatry and mental health, 2(1), 19. https://doi.org/10.1186/1753-2000-2-19 [/mfn] shows that short-term outcomes of DID is high, around 44–97%, but the rates are rather unfavorable in middle-term or long-term outcomes.

Types Of Dissociative Identity Disorder

Dissociative identity disorder is often considered a spectrum disorder with multiple subtypes that can also be standalone disorders in their own right. For clinical purposes, researchers identify its 3 main subtypes, with other dissociative disorders existing in varying degrees. These include:

1. Dissociative Amnesia

Dissociative amnesia is caused by the impairment of a person’s autobiographical memory, because of which she/he cannot remember important information about her/his identity or life.

2. Dissociative Fugue

According to a 2013 study [mfn] Igwe M. N. (2013). Dissociative fugue symptoms in a 28-year-old male Nigerian medical student: a case report. Journal of medical case reports, 7, 143. https://doi.org/10.1186/1752-1947-7-143 [/mfn], “Dissociative fugue is a psychiatric disorder characterized by amnesia coupled with sudden unexpected travel away from the individual’s usual surroundings.” As the person wanders, she/he is in denial of all memory.

A dissociative fugue usually lasts for a long period of time and exists with several other mental disorders, such as depressive disorders, bipolar disorders, panic disorders, eating disorders, etc.

3. Depersonalisation And Derealization Syndrome

Depersonalization and derealization (DPDR) syndrome, as one 2004 study [mfn] Simeon D. (2004). Depersonalisation disorder: a contemporary overview. CNS drugs, 18(6), 343–354. https://doi.org/10.2165/00023210-200418060-00002 [/mfn] puts it, is “characterized by prominent depersonalization and often derealisation, without clinically notable memory or identity disturbances”.

People suffering from this disorder often feel that they are not real [mfn] Sutar, R., & Chaturvedi, S. K. (2020). Symptom profile and diagnostic utility of depersonalization-derealization disorder: A retrospective critical review from India. Indian journal of psychiatry, 62(1), 91–94. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_347_19 [/mfn] and are existing in a dream or seeing themselves from outside their bodies. The course of the disorder is usually long and continuous.

4. Other Dissociative Disorders

One 2014 study [mfn] Şar V. (2014). The many faces of dissociation: opportunities for innovative research in psychiatry. Clinical psychopharmacology and neuroscience : the official scientific journal of the Korean College of Neuropsychopharmacology, 12(3), 171–179. https://doi.org/10.9758/cpn.2014.12.3.171 [/mfn] sees DID as a spectrum with many other dissociative disorders, such as:

• Dissociative stupor
• Dissociative disorders of movement and sensation
• Dissociative motor disorders
• Dissociative convulsions
• Dissociative anesthesia and sensory loss

Signs And Symptoms Of Dissociative Identity Disorder

Dissociative identity disorder is a somewhat misunderstood disorder, with ongoing research trying to decipher its true nature. Despite being acknowledged as far back as the 1880s, experts are yet to attribute it to a concrete definition or specific medical parameters.

But, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has given us a rough framework of dissociative identity symptoms. These include:

1. Amnesia

People suffering from DID often feel detached from their immediate surroundings. Studies show that DID causes gaps in memory about a person’s sense of self, consciousness, and passage of time-related to:

• Everyday events
• Personal information
• Past events
• Traumatic experiences, etc.

2. Multiple Personalities

DID causes loss of self-identity and compartmentalization of a person’s memory—resulting in “the presence of two or more distinct personality states”.

But, researchers are still unsure about the number of alter personalities a DID patient can have. According to a 2012 study [mfn] Lynn, S. J., Lilienfeld, S. O., Merckelbach, H., Giesbrecht, T., & van der Kloet, D. (2012). Dissociation and Dissociative Disorders: Challenging Conventional Wisdom. Current Directions in Psychological Science, 21(1), 48–53. https://doi.org/10.1177/0963721411429457 [/mfn], people with DID can have 10–100 personalities, with even 4500 alter identities being reported in the most severe cases.

3. Cognitive Impairment

People suffering from DID usually experience hallucinations and other “extrasensory experiences” like living in a dream, hearing voices, periods of extreme emotions, etc.

They also suffer from cognitive malfunctioning and behavioral and mental disorders, such as:

• Self-harm
• Suicide ideation
• Somatization
• Psychosis
• Sexual dysfunction
• Dissociation
• Mood changes
• Agitation
• Irrationality
• Insomnia
• Different handwriting
• Frequent changes in voice
• Inconsistent work history, etc.

Read More About Insomnia Here

4. Inability To Cope With Stress

DID is sometimes considered [mfn] Şar, V., Dorahy, M. J., & Krüger, C. (2017). Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychology research and behavior management, 10, 137–146. https://doi.org/10.2147/PRBM.S113743 [/mfn] a chronic post-traumatic disorder, because of which its patients find it difficult to deal with stressful situations, such as emotional or professional stress.

Read More About Stress Here

What Causes Dissociative Identity Disorder?

DID is a controversial disorder, because of which its diagnosis and treatment have been revised [mfn] Lynn, S. J., Polizzi, C., Merckelbach, H., Chiu, C. D., Maxwell, R., van Heugten, D., & Lilienfeld, S. O. (2022). Dissociation and Dissociative Disorders Reconsidered: Beyond Sociocognitive and Trauma Models Toward a Transtheoretical Framework. Annual review of clinical psychology, 10.1146/annurev-clinpsy-081219-102424. Advance online publication. https://doi.org/10.1146/annurev-clinpsy-081219-102424 [/mfn] several times by psychiatric manuals like DSM-5 and ICD-11. However, over the years, psychiatrists and other medical practitioners have tried to identify some of the basic dissociative identity disorder causes, such as:

1. Trauma

The post-traumatic model (PTM) considers DID to be an extreme coping mechanism for traumatic experiences, because other normally adaptive systems have failed. This “self-soothing” strategy comes with predisposing factors such as the ability “to dissociate, overwhelming traumatic experiences that distort reality, [the ability to create] alters with specific names and identities, and lack of external stability”.

Such experiences include:

• Physical, emotional, or sexual abuse
• Loss of a loved one
• Prolonged illness
• Childhood abuse and neglect
• Experiences of child trafficking and prostitution
• War
• Terrorism

2. Neuroanatomy

A 2020 study [mfn] Blihar, David & Delgado, Elliott & Buryak, Marina & Gonzalez, Michael & Waechter, Randall. (2020). A Systematic Review of the Neuroanatomy of Dissociative Identity Disorder. European Journal of Trauma & Dissociation. 4. 100148. 10.1016/j.ejtd.2020.100148. [/mfn] suggests that DID is caused by structural changes in the brain, specifically in the hippocampus, amygdala, white matter tracts, and other parts of the brain associated with:

• Neurotic behavior
• Dissociation
• Body movements
• Learning from fear, etc.

Read More About Fear Here

3. Proneness To Fantasy

According to one 2021 study, the fantasy-related model proposes that people who are imaginative and fantasy-prone are more vulnerable to DID. They are usually the ones with:

• High levels of vulnerability
• Predisposition of psychological symptoms
• Media portrayals of certain ideas
• Social isolation

4. Mental Disorders

People are more vulnerable to DID if they have mental disorders that cause behavioral changes, like:

• Borderline personality disorder [mfn] Gillig P. M. (2009). Dissociative identity disorder: a controversial diagnosis. Psychiatry (Edgmont (Pa. : Township[/mfn], 6(3), 24–29. [/mfn]
• Post traumatic stress disorder (PTSD)
• Bipolar disorders [mfn] McAllister M. M. (2000). Dissociative identity disorder: a literature review. Journal of psychiatric and mental health nursing, 7(1), 25–33. https://doi.org/10.1046/j.1365-2850.2000.00259.x [/mfn]
• Schizoaffective disorders [mfn] Mitra, P., & Jain, A. (2021). Dissociative Identity Disorder. In StatPearls. StatPearls Publishing. [/mfn]

Read More About Post-Traumatic Stress Disorder (PTSD) Here

5. Therapy-Induced Causes

An extension of the fantasy-related model, the socio-cognitive model (SCM) [mfn] Dell P. F. (2013). The weakness of the sociocognitive model of dissociative identity disorder. The Journal of nervous and mental disease, 201(5), 438. https://doi.org/10.1097/NMD.0b013e31828e10e8 [/mfn] states that therapists accidentally create DID symptoms in people, using psychotherapy techniques. People with certain traits (like fantasization or suggestibility) then, consciously or unconsciously, adopt behaviors or additional identities promoted by cultural stereotypes portrayed in the media.

However, as a 1996 study [mfn] Gleaves D. H. (1996). The sociocognitive model of dissociative identity disorder: a reexamination of the evidence. Psychological bulletin, 120(1), 42–59. https://doi.org/10.1037/0033-2909.120.1.42 [/mfn] puts it, “Treatment recommendations [of DID] that follow from the sociocognitive model may be harmful because they involve ignoring the posttraumatic symptomatology of persons with DID.”

6. Environmental Causes

Studies [mfn] Dorahy, M. J., Brand, B. L., Şar, V., Krüger, C., Stavropoulos, P., Martínez-Taboas, A., Lewis-Fernández, R., & Middleton, W. (2014). Dissociative identity disorder: An empirical overview. Australian & New Zealand Journal of Psychiatry, 48(5), 402–417. https://doi.org/10.1177/0004867414527523 [/mfn] show that DID can also be caused by a number of factors, such as:

• Stressful lifestyle
• Lack of sleep
• Unable to adjust to family settings
• Attachment issues
• Rigid parenting styles

How Is Dissociative Identity Disorder Diagnosed?

Even after decades of research and practice in clinical setups, DID still remains to be understood. Medical literature has elaborately described the early signs of dissociative identity disorder, but most of the time, it is “misdiagnosed and often requires multiple assessments for an accurate diagnosis.”

The dissociative identity disorder diagnosis consists of the following phases:

1. Physical Examination

In this phase, to determine if any physical injury is causing DID-like symptoms, the patient undergoes several examinations of his/her physical health like:

• Electroencephalograms
• Lumbar punctures
• Brain imaging

If physical health conditions are ruled out, the patient is referred to a mental health practitioner for a diagnosis.

2. Psychiatric Examination

While diagnosing DID, medical practitioners review patient’s individual symptoms and personal histories often related to trauma experiences, social setting, lifestyle, and health conditions. They also take into account collateral histories and the acquired information is verified by several physical examinations and psychiatric scales.

They then tally the person’s conditions with the criteria for dissociative identity disorder diagnosis outlined in DSM-5. For a person to be diagnosed, she/he must:

• Have two or more distinct personality states
• Have an experience of amnesia about personal information, self-identity, etc.
• Have trouble functioning in personal, social, or occupational areas in life
• Not face disturbances created by cultural or religious practices
• Not have physiological symptoms from other health conditions like alcoholism, substance abuse, blackouts, seizures, etc.

Psychiatrists often use diagnostic scales to ensure the severity of the DID symptoms in a patient and for differential diagnosis from other disorders with similar symptoms of dissociation. These include:

• Dissociative Experiences Scale (DES) [mfn] Carlson, E. B., Putnam, F. W., Ross, C. A., Torem, M., Coons, P., Dill, D. L., Loewenstein, R. J., & Braun, B. G. (1993). Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: a multicenter study. The American journal of psychiatry, 150(7), 1030–1036. https://doi.org/10.1176/ajp.150.7.1030 [/mfn]
• Dissociation Questionnaire
• Structured Clinical Interview for DSM Disorders (SCID)
• Structured Interview for DSM-III-R Personality Disorders (SIDP-R)
• Dissociative Disorder Interview Schedule (DDIS)
• Shipley Institute of Living Scales Tellegen Absorption Scale
• Rorschach test [mfn] Scroppo, J. C., Drob, S. L., Weinberger, J. L., & Eagle, P. (1998). Identifying dissociative identity disorder: a self-report and projective study. Journal of abnormal psychology, 107(2), 272–284. https://doi.org/10.1037//0021-843x.107.2.272 [/mfn]

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How Can Dissociative Identity Disorder Be Treated?

According to a 2021 study, the treatment plan for dissociative identity disorder usually follows a three-pronged approach.

• In the first step, the doctors should assess the risk the patient poses to himself/herself, such as contemplating suicide or self-harm. Such symptoms are addressed with interventions and medicines.
• In the second step, using therapy, they should focus on the trauma-induced mindset of the patient, including “tolerating, processing, and integrating past trauma”. They can access and modify the traumatic memories of alternate personalities and allow the patient to reassess personal experiences and their impact on his/her life.
• In the third step of dissociative identity disorder treatment, the doctors help the patient reassess his/her relationship with oneself and the rest of the world.

Read More About Self-Harm Here

The following therapies and medications are used to treat people with DID:

1. Therapies

Dissociative identity disorder do not have specific therapeutic treatment, but people with DID can avail the large number of therapies that are already available to treat cognitive disorders, such as:

1. Psychotherapy

The cornerstone of DID therapies, psychotherapy helps to address “the patient’s unconscious conflicts which may be a cause of maladaptive functioning”.

In most cases, other forms [mfn] van Minnen, A., & Tibben, M. (2021). A brief cognitive-behavioral treatment approach for PTSD and Dissociative Identity Disorder, a case report. Journal of behavior therapy and experimental psychiatry, 72, 101655. https://doi.org/10.1016/j.jbtep.2021.101655 [/mfn] of psychotherapy (such as cognitive behavioral therapy [CBT], dialectical behavioral therapy [DBT], or hypnotherapy) are used “to reduce dissociation and integrate the functioning of the mind” of the DID patient. These also treat the symptoms of other comorbidities existing with DID, such as anxiety, depression, etc. But, the effectiveness of psychotherapies in treatment for dissociative identity disorder remains contested.

Read More About Cognitive Behavioral Therapy (CBT) Here

2. Eye Movement Desensitization And Reprocessing (EMDR)

Studies [mfn] Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., & Ghildiyal, R. (2020). Psychological Interventions for Dissociative disorders. Indian journal of psychiatry, 62(Suppl 2), S280–S289. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_777_19 [/mfn] show that EMDR, though prescribed for treatment of general trauma and stress disorders, worsens [mfn] Papanikolopoulos, P., & Prattos-Spongalides, T. A. (2017). E.M.D.R therapy and the theory of structural dissociation of the personality in severe interpersonal trauma of young adolescents. European Journal of Psychotraumatology, 8(sup4), 1351207. https://doi.org/10.1080/20008198.2017.1351207 [/mfn] dissociative identity disorder symptoms. But it can be used in adjunctive treatment or integrative treatment. A 2021 study actually recommends EMDR processing to recovered patients who are “generally stable and [have] adequate coping skills”.

3. Schema Therapy

Schema therapy [ST] is used to resolve attachment-related dysfunction [mfn] Huntjens, R., Rijkeboer, M. M., & Arntz, A. (2020). Schematherapy in DID: treatment length and related studies on dissociative amnesia. European journal of psychotraumatology, 11(1), 1711638. https://doi.org/10.1080/20008198.2020.1711638 [/mfn] in DID patients in phases, by “blending traditional cognitive-behavioral treatment with experiential and interpersonal elements”. ST is thought to be cost-effective and more successful in treating severe DID cases.

4. Phase-Oriented Trauma Treatment (POTT)

According to a 2020 study [mfn] Otani A. (2020). The Mindfulness-Based Phase-Oriented Trauma Therapy (MB-POTT): Hypnosis-informed mindfulness approach to trauma. The American journal of clinical hypnosis, 63(2), 95–111. https://doi.org/10.1080/00029157.2020.1765726 [/mfn], POTT treats people with dissociative identity disorder in different stages:

• Therapeutic alliance building and symptom stabilization
• Formation of a narrative about the trauma
• Re-creation of the meaning of life after trauma
• Future symptom management

Research [mfn] Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis. European journal of psychotraumatology, 11(1), 1729633. https://doi.org/10.1080/20008198.2020.1729633 [/mfn] shows that POTT boosts mindfulness and positive feelings like love, kindness, etc. in patients availing treatment.

5. Group Therapy

Research shows that patients with DID often find it difficult to participate in generic group therapies and develop more severe symptoms. But, one 2020 study suggests that “select groups focused on psycho-education, problem solving and specific skills development can be a valuable adjunct to individual psychotherapy” for treating dissociative identity disorders.

Read More About Group Therapy Here

2. Medication

There are no prescribed medications for dissociative identity disorder treatment, because of which medicines for treating similar symptoms [mfn] Gentile, J. P., Dillon, K. S., & Gillig, P. M. (2013). Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innovations in clinical neuroscience, 10(2), 22–29. [/mfn] in other disorders (such as hyperarousal, mood changes, nightmares, etc.) are also used for DID, such as:

• Antidepressants/anxiolytics (such as selective serotonin reuptake inhibitors, nonselective reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, etc.)
• Benzodiazepines
• Clonidine
• Atypical (second generation) antipsychotics
• Prazosin
• Carbamazepine and other mood stabilizers
• Naltrexone

Takeaway

Dissociative identity disorder (DID) is a rare and complex disorder, which remains misunderstood and under-diagnosed most of the time. If untreated, it interferes with a person’s quality of life and personal and professional reputations. However, it can be effectively managed by timely diagnosis, therapy, medication, and psychoeducation.

Dissociative Identity Disorder At A Glance

1. In dissociative identity disorder (DID), a person develops several personality states with their own distinctive identities, thoughts, and actions.
2. It is a rare and complex psychiatric disorder.
3. It causes chronic memory loss, hallucinations, and behavioral changes.
4. DID has its origins in childhood abuse and trauma.
5. DID is often misdiagnosed, remaining untreated for life.
6. Patients with DID cannot be completely cured.
7. But, they can effectively manage to live a normal life with therapy, medication, and psychoeducation.

Frequently Asked Questions (FAQs)