Dissociative identity disorder

Dissociation, the term that underlies dissociative disorder, has been defined as a "compartmentalization of psychological functions such as identity and memory that are usually integrated", with a resulting symptomatic criteria characterized by "unbidden intrusions into awareness and behavior, with accompanying losses of continuity in subjective experience" and/or "inability to access information or control mental functions". proposing to define it instead as an impairment in "meta-consciousness". It is therefore unknown whether there is a commonality among all dissociative experiences, or whether the range of mild to severe symptoms is a result of different etiologies and biological structures. ==Signs and symptoms==

The full presentation of dissociative identity disorder can occur at any age, Amnesia may be asymmetrical between identities; one identity may or may not be aware of what is known by another. The most common presenting complaint of DID is depression (90%) that is often treatment-resistant, with headaches and non-epileptic seizures being common neurologic symptoms. Comorbid disorders include post-traumatic stress disorder (PTSD), substance use disorders, eating disorders, anxiety disorders, personality disorders, and autism spectrum disorder. 30-70% of those diagnosed with DID have history of borderline personality disorder. Presentations of dissociation in people with schizophrenia differ from those with DID as not being rooted in trauma, and this distinction can be effectively tested; the conditions share a high rate of auditory hallucinations in the form of voices. Disturbed and altered sleep has also been suggested as having a role in dissociative disorders in general and specifically in DID. Alterations to environments are also said to affect DID patients. ==Causes==

General There are two competing theories on what causes dissociative identity disorder to develop. The trauma-related model suggests that complex trauma or severe adversity in childhood, also known as developmental trauma, increases the risk of someone developing dissociative identity disorder. The non-trauma related model, also referred to as the sociogenic or fantasy model, suggests that dissociative identity disorder is developed through high fantasy-proneness or suggestibility, roleplaying, or sociocultural influences. Severe sexual, physical, or psychological trauma in childhood has been proposed as an explanation for its development; awareness, memories, and emotions of harmful actions or events caused by the trauma are sequestered away from consciousness, and alternate parts form with differing memories, emotions, beliefs, temperament, and behavior. Dissociative identity disorder is also attributed to extremes of stress and disturbances of attachment to caregivers in early life. What may result in complex post-traumatic stress disorder (C-PTSD) in adults may become dissociative identity disorder when occurring in children, possibly due to their greater use of imagination as a form of coping as well as lack of developmental integration in childhood. Possibly due to developmental changes and a more coherent sense of self past age 6–9 years, the experience of extreme trauma may result in different, though also complex, dissociative symptoms, identity disturbances and trauma-related disorders. Giesbrecht et al. have suggested there is no empirical evidence linking early trauma to dissociation, and instead suggest that problems with neuropsychological functioning, such as increased distractibility in response to certain emotions and contexts, account for dissociative features. A middle position hypothesizes that trauma, in some situations, alters neuronal mechanisms related to memory. Evidence is increasing that dissociative disorders are related both to a trauma history and to "specific neural mechanisms". Referred to as the non-trauma-related model, or the sociocognitive model or fantasy model, it proposes that dissociative identity disorder is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes, While proponents note that dissociative identity disorder is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are skeptical of the trauma-related etiology suggested by proponents of the trauma-related model. They note that a small subset of doctors are responsible for diagnosing the majority of individuals with dissociative identity disorder. Other arguments that therapy can cause dissociative identity disorder include the lack of children diagnosed with DID, the sudden spike in rates of diagnosis after 1980 (although dissociative identity disorder was not a diagnosis until DSM-IV, published in 1994), the absence of evidence of increased rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities (such as those claiming to be animals or mythological creatures) and an increase in the number of alternate identities over time Supporters of therapy as a cause of dissociative identity disorder suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position However, false memory syndrome per se is not regarded by mental health experts as a valid diagnosis, and has been described as "a non-psychological term originated by a private foundation whose stated purpose is to support accused parents," and critics argue that the concept has no empirical support, and further describe the False Memory Syndrome Foundation as an advocacy group that has distorted and misrepresented memory research. A review of recent research into DID found not one empirical study into the sociocognitive model in the 2011-2021 period, identifying the model as "a source of unresolved criticism of the trauma model", not an empirical hypothesis in its own right. Some major skeptics of trauma-related DID have in recent years abandoned single-cause models of the disorder, arguing for an end to the controversy as no such model can provide a "complete or fully satisfactory account" of DID. Children The rarity of DID diagnoses in children is cited as a reason to doubt the validity of the disorder, Proponents of the trauma-related model claim the high correlation of child sexual and physical abuse reported by adults with dissociative identity disorder corroborates the link between trauma and dissociative identity disorder. ==Pathophysiology==

Despite research on DID including structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potentials, and electroencephalography, no convergent neuroimaging findings have been identified regarding DID, with the exception of smaller hippocampal volume in DID patients. In addition, many of the studies that do exist were performed from an explicitly trauma-based position. There is no research to date regarding the neuroimaging and introduction of false memories in DID patients. or support for amnesia between alters. DID patients also appear to show deficiencies in tests of conscious control of attention and memorization (which also showed signs of compartmentalization for implicit memory between alters but no such compartmentalization for verbal memory) and increased and persistent vigilance and startle responses to sound. DID patients may also demonstrate altered neuroanatomy. ==Diagnosis==

General The fifth, revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) diagnoses DID according to the diagnostic criteria found under code 300.14 (dissociative disorders). DID is often initially misdiagnosed because clinicians receive little training about dissociative disorders or DID, and often use standard diagnostic interviews that do not include questions about trauma, dissociation, or post-traumatic symptoms. The diagnosis has been criticized by supporters of therapy as a cause or the sociocognitive hypothesis as they believe it is a culture-bound and often health care-induced condition. Delusions or auditory hallucinations can be mistaken for speech by other personalities. Most individuals who enter an emergency department and are unaware of their names are generally in a psychotic state. Although auditory hallucinations are common in DID, complex visual hallucinations may also occur. Those with DID generally have adequate reality testing. People with DID may have more positive and fewer negative Schneiderian symptoms of schizophrenia. An additional aspect of the controversy of diagnosis is that there are many forms of dissociation and memory lapses, which can be common in both stressful and nonstressful situations and can be attributed to much less controversial diagnoses. A relationship between DID and borderline personality disorder has been posited, with various clinicians noting overlap between symptoms and behaviors and it has been suggested that some cases of DID may arise "from a substrate of borderline traits". Reviews of DID patients and their medical records concluded that 30-70% of those diagnosed with DID have comorbid borderline personality disorder. The DSM-5 elaborates on cultural background as an influence for some presentations of DID. ==Validity disputed==

DID is among the most controversial of the dissociative disorders and among the most controversial disorders found in the DSM-5-TR. The debate between the two positions is characterized by intense disagreement. Psychiatrist Joel Paris asserts that the idea that a personality is capable of splitting into independent alters is an unproven assertion at odds with research in cognitive psychology, According to proponents of the trauma model, the ordinary "host" personality experiences memory gaps for their alter personalities. Research has challenged this idea: Richard McNally (2012) found that although patients reported amnesia between alters, objective tests found their memory function was intact. The iatrogenic model also sometimes states that treatment for DID is harmful. According to Brand, Loewenstein, and Spiegel, "claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID". Their claim is evidenced by the fact that only 5%–10% of people receiving treatment initially worsen in their symptoms. Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation—the fact that people with DID report childhood trauma does not mean trauma causes DID—and point to the rarity of the diagnosis before 1980 as well as a failure to find DID as an outcome in longitudinal studies of traumatized children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as "personality state" and "identities", and question the lack of evidence of childhood abuse (beyond self-reports) in some people with DID, the lack of a defined threshold of abuse sufficient to induce DID, and the extremely small number of cases of children diagnosed with DID despite an average age of three years at the appearance of the first alter. ==Treatment==

Treatment under the sociogenic model Proponents of the sociogenic model dispute that dissociative identity disorder is an organic response to trauma, but believe it is a socially constructed behavior and psychic contagion. Paul R. McHugh says that the disorder is "sustained in large part by the attention that doctors tend to pay to it. This means that it is not a mental condition that derives from nature, such as panic anxiety or major depression. It exists in the world as an artificial product of human devising". McHugh believed that proponents of dissociative identity disorder inadvertently worsen the patient's condition by validating the behavior and providing attention. According to McHugh, at Johns Hopkins Hospital doctors should ignore the displays from "alters", and instead focus on treatment for other psychiatric problems patients present with. This method of treatment is reportedly successful: According to a 2014 review, such views are based on anecdotal or non-peer-reviewed findings. In controlled studies, non-specialised treatment that did not address dissociative self-states did not substantially improve DID symptoms, though there may be improvement in patients' other conditions. Hypnosis should be carefully considered when choosing both treatment and provider practitioners because of its dangers. For example, hypnosis can sometimes lead to false memories and false accusations of abuse by family, loved ones, friends, providers, and community members. Those who suffer from dissociative identity disorder have commonly been subject to actual abuse (sexual, physical, emotional, financial) by therapists, family, friends, loved ones, and community members. Brief treatment due to managed care may be difficult, as individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic alliance. Regular contact (at least weekly) is recommended, and treatment generally lasts years, not weeks or months. Sleep hygiene has been suggested as a treatment option, but has not been tested. In general, there are very few clinical trials on the treatment of DID, none of which were randomized controlled trials. Therapy for DID is generally phase-oriented. Different alters may appear based on their greater ability to deal with specific situational stresses or threats. While some patients may initially present with a large number of alters, this number may reduce during treatment, though it is considered important for the therapist to become familiar with at least the more prominent personality states, as the "host" personality may not be the "true" identity of the patient. Specific alters may react negatively to therapy, fearing that the therapist's goal is to eliminate the alter (particularly those associated with illegal or violent activities). A more realistic and appropriate goal of treatment is to integrate adaptive responses to abuse, injury, or other threats into the overall personality structure. The first phase of therapy focuses on symptoms and relieving the distressing aspects of the condition, ensuring the safety of the individual, improving the patient's capacity to form and maintain healthy relationships, and improving general daily life functioning. Comorbid disorders such as substance use disorder and eating disorders are addressed in this phase of treatment. The second phase focuses on stepwise exposure to traumatic memories and prevention of re-dissociation. The final phase focuses on reconnecting the identities of disparate alters into a single functioning identity with all its memories and experiences intact. Prognosis Little is known about prognosis of untreated DID. Symptoms commonly wax and wane over time. Patients with mainly dissociative and post-traumatic symptoms face a better prognosis than those with comorbid disorders or those still in contact with abusers, and the latter groups often face a lengthier and more difficult treatment course. Suicidal ideation, suicide attempts, and self-harm are common in the DID population. Duration of treatment can vary depending on patient goals, which can range from merely improving inter-alter communication and cooperation, to reducing inter-alter amnesia, to integration and fusion of all alters, but this last goal generally takes years, with trained and experienced psychotherapists. ==Epidemiology==

General According to the American Psychiatric Association, the 12-month prevalence of DID among adults in the US is 1.5%, with similar prevalence between women and men. Population prevalence estimates have been described to widely vary, with some estimates of DID in inpatient settings suggesting 1–9.6%." As of 2012, DID was diagnosed 5 to 9 times more commonly in women than men during young adulthood, although this may have been due to selection bias, as men meeting DID diagnostic criteria were suspected to end up in the criminal justice system rather than hospitals. DID occurs more commonly in young adults and declines in prevalence with age. There is a poor awareness of DID in the clinical settings and the general public. Poor clinical education (or lack thereof) for DID and other dissociative disorders has been described in literature: "most clinicians have been taught (or assume) that DID is a rare disorder with a florid, dramatic presentation." There is a significant overlap of symptoms between borderline personality disorder and DID. Historical prevalence Rates of diagnosed DID were increasing in the late 20th century, reaching a peak of diagnoses at approximately 40,000 cases by the end of the 20th century, up from less than 200 diagnoses before 1970. • The result of therapist suggestions to suggestible people, much as Charcot's hysterics acted per his expectations. • Psychiatrists' past failure to recognize dissociation is being redressed by new training and knowledge. • Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: "hysteria". Dissociative disorders were excluded from the Epidemiological Catchment Area Project. North America DID continues to be considered a controversial diagnosis; it was once regarded as a phenomenon confined to North America, though studies have since been published from DID populations across 6 continents. and the condition has been described in non-English speaking nations and non-Western cultures, these reports all occur in English-language journals authored by international researchers who cite Western scientific literature. ==History==

published in Variations de la personnalité by Henri Bourru and Prosper Ferdinand Burot Early references In the 19th century, dédoublement, or "double consciousness", the historical precursor to DID, was frequently described as a state of sleepwalking, with scholars hypothesizing that the patients were switching between a normal consciousness and a "somnambulistic state". An intense interest in spiritualism, parapsychology and hypnosis continued throughout the 19th and early 20th centuries, running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings. Hypnosis, which was pioneered in the late 18th century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist. By the late 19th century, there was a general acceptance that emotionally traumatic experiences could cause long-term disorders that might display a variety of symptoms. These conversion disorders were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivet (1863–?), who had a traumatic experience as a 17-year-old when he encountered a viper. Vivet was the subject of countless medical papers and became the most studied case of dissociation in the 19th century. Between 1880 and 1920, various international medical conferences devoted time to sessions on dissociation. It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation. One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality. 20th century In the early 20th century, interest in dissociation and multiple personalities waned for several reasons. After Charcot died in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet's association with Charcot tarnished his theories of dissociation. Whereas Kraepelin's natural disease entity was anchored in the metaphor of progressive deterioration and mental weakness and defect, Bleuler offered a reinterpretation based on dissociation or "splitting" (Spaltung) and widely broadened the inclusion criteria for the diagnosis. A review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States. The rise of the broad diagnostic category of dementia praecox has also been posited in the disappearance of "hysteria" (the usual diagnostic designation for cases of multiple personalities) by 1910. Several factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon. The cause of the sudden increase of cases is indefinite, but it may be attributed to the increased awareness, which revealed previously undiagnosed cases or new cases may have been induced by the influence of the media on the behavior of individuals and the judgement of therapists. it presented a detailed discussion of the problems of treatment of "Sybil Isabel Dorsett", a pseudonym for Shirley Ardell Mason. Though the book and subsequent films helped popularize the diagnosis and trigger an epidemic of the diagnosis, later analysis of the case suggested different interpretations, ranging from Mason's problems having been caused by the therapeutic methods and sodium pentathol injections used by her psychiatrist, C. B. Wilbur, or an inadvertent hoax due in part to the lucrative publishing rights, David Spiegel, a Stanford psychiatrist whose father treated Shirley Ardell Mason on occasion, says that his father described Mason as "a brilliant hysteric. He felt that Wilbur tended to pressure her to exaggerate on the dissociation she already had." As media attention on DID increased, so too did the controversy surrounding the diagnosis. History in the DSM The DSM-II used the term hysterical neurosis, dissociative type. It described the possible occurrence of alterations in the patient's state of consciousness or identity, and included the symptoms of "amnesia, somnambulism, fugue, and multiple personality". The DSM-IV-TR criteria for DID have been criticized for failing to capture the clinical complexity of DID, lacking usefulness in diagnosing individuals with DID (for instance, by focusing on the two least frequent and most subtle symptoms of DID) producing a high rate of false negatives and an excessive number of DDNOS diagnoses, for excluding possession (seen as a cross-cultural form of DID), and for including only two "core" symptoms of DID (amnesia and self-alteration) while failing to discuss hallucinations, trance-like states, somatoform, depersonalization, and derealization symptoms. Arguments have been made for allowing diagnosis through the presence of some, but not all of the characteristics of DID rather than the current exclusive focus on the two least common and noticeable features. for being tautological, using imprecise and undefined language and for the use of instruments that give a false sense of validity and empirical certainty to the diagnosis. The DSM-5 updated the definition of DID in 2013, summarizing the changes as: Between 1968 and 1980, the term that was used for dissociative identity disorder was "Hysterical neurosis, dissociative type". The APA wrote in the second edition of the DSM: "In the dissociative type, alterations may occur in the patient's state of consciousness or in his identity, to produce such symptoms as amnesia, somnambulism, fugue, and multiple personality." The number of cases sharply increased in the late 1970s and throughout the 80s, and the first scholarly monographs on the topic appeared in 1986. and also added Post-traumatic Stress Disorder in Anxiety Disorders section. In the opinion of McGill University psychiatrist Joel Paris, this inadvertently legitimized them by forcing textbooks, which mimicked the structure of the DSM, to include a separate chapter on them, and increased the diagnosis of dissociative conditions. Once a rarely occurring spontaneous phenomenon (research in 1944 showed only 76 cases), the diagnosis became "an artifact of bad (or naïve) psychotherapy" as patients capable of dissociating were accidentally encouraged to express their symptoms by "overly fascinated" therapists. "Interpersonality amnesia" was removed as a diagnostic feature from the DSM-III in 1987, which may have contributed to the increasing frequency of the diagnosis. Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995. Scientific publications regarding DID peaked in the mid-1990s, rapidly declined, The ICD-10 classified DID as a "Dissociative [conversion] disorder" and used the name "multiple personality disorder" with the classification number of F44.81. 21st century A 2006 study compared scholarly research and publications on DID and dissociative amnesia to other mental health conditions, such as anorexia nervosa, alcohol use disorder, and schizophrenia from 1984 to 2003. The results were found to be unusually distributed, with a very low level of publications in the 1980s followed by a significant rise that peaked in the mid-1990s and subsequently rapidly declined in the decade following. Compared to 25 other diagnoses, the mid-1990s "bubble" of publications regarding DID was unique. In the opinion of the authors of the review, the publication results suggest a period of "fashion" that waned, and that the two diagnoses "presently do not command widespread scientific acceptance." A 2024 review found "steady" continued research after 2011, with 160 academic studies located in the 2011-2021 period, an increase of 60% over the previous decade. Authors previously skeptical of DID have adopted a "trans-theoretical" approach where trauma and social factors are simply two of many potential factors, indicating that "the heat of past DID controversies has diminished some with the rise of multidimensional models of psychopathology". ==Society and culture==

Legal issues People with dissociative identity disorder may be involved in legal cases as a witness, defendant, or the victim/injured party. Claims of DID have been used only rarely to argue criminal insanity in court. In the United States, dissociative identity disorder has previously been found to meet the Frye test as a generally accepted medical condition, and the newer Daubert standard. Within legal circles, DID has been described as one of the most disputed psychiatric diagnoses and forensic assessments are needed. In DID, evidence about the altered states of consciousness, actions of alter identities and episodes of amnesia may be excluded from a court if they are not considered relevant, although different countries and regions have different laws. A not guilty by reason of insanity plea was first used successfully in an American court in 1978, in the State of Ohio v. Milligan case. In popular culture The public's long fascination with DID has led to a number of different books and films, Movies about DID have been also criticized for poor representation of both DID and its treatment, including "greatly overrepresenting" the role of hypnosis in therapy, showing a significantly smaller number of personalities than many people with DID have, Some movies are parodies and ridicule DID, for instance, Me, Myself & Irene, which also incorrectly states that DID is schizophrenia. In some stories, DID is used as a plot device, e.g. in Fight Club, and in whodunnit stories like Secret Window. A number of people with DID have publicly spoken about their experiences, including comedian and talk show host Roseanne Barr, who interviewed Truddi Chase, author of When Rabbit Howls; Chris Costner Sizemore, the subject of The Three Faces of Eve, Cameron West, author of First Person Plural: My life as a multiple, and NFL player Herschel Walker, author of Breaking Free: My life with dissociative identity disorder. In The Three Faces of Eve (1957) hypnosis is used to identify a childhood trauma which then allows her to fuse from three identities into just one. Sizemore re-entered therapy and by 1974 had achieved a lasting recovery. In popular culture dissociative identity disorder is often confused with schizophrenia, as was true of the 1958 episode "The Case of the Deadly Double" of the Perry Mason TV series, where a woman shown as having two very distinct personas is described as being schizophrenic On the other hand, some movies advertised as representing dissociative identity disorder may be more representative of psychosis or schizophrenia, for example Psycho (1960). In the USA Network television production Mr. Robot, the protagonist Elliot Alderson was created using anecdotal experiences of DID of the show's creator's friends. Sam Esmail said he consulted with a psychologist who "concretized" the character's mental health conditions, especially his plurality. In M. Night Shyamalan's Unbreakable superhero film series (specifically, the films Split and Glass), Kevin Wendell Crumb is diagnosed with DID, and that some of the personalities have super-human powers. Experts and advocates say the films are a negative portrayal of DID, and the films promote the stigmatization of the disorder. In the 1993 Indian psychological horror film Manichithrathazhu, the central character Ganga exhibits symptoms depicted as DID, where an alternate personality, Nagavalli, expresses suppressed emotions. While lauded for popularizing mental health discussions, the film's dramatic, ritualistic "cure" is considered an oversimplification of DID's complex treatment. Nevertheless, it remains a culturally significant portrayal. In the 1997 Japanese role-playing game Final Fantasy VII, the protagonist Cloud Strife is shown to have an identity disorder involving false memories as a result of post-traumatic stress disorder (PTSD). Sharon Packer has identified Cloud as having DID. In Marvel Comics, the character of Moon Knight is shown to have DID. In the TV series Moon Knight based on the comic book character, protagonist Marc Spector is depicted with DID; the website for the National Alliance on Mental Illness appears in the series' end credits. Online subculture A community of self-identifying "plurals" exists on social media, including YouTube, Reddit, Discord, and TikTok with an associated experience called multiplicity. In some cases, members of the community have claimed to have DID diagnoses or sought them out, but several high-profile members of this community have been criticized for allegedly faking their condition for views, or for portraying the disorder lightheartedly. Lately, the plural community has been divided between those who argue that anyone without DID diagnosis is likely fabricating their experience with others rejecting the DID diagnosis entirely and instead arguing against pathologizing the plural identity at all. Advocacy Some advocates consider recognizing 'positive plurality' and also the use of plural pronouns such as "we" and "our". Advocates also challenge the necessity of integration. Timothy Baynes argues that forcing people to undergo it as a treatment is "seriously immoral". A DID Awareness Day takes place on March 5 annually, participants displaying a multicolored awareness ribbon, based on the idea of a "crazy quilt." ==References==