What is dissociative identity disorder (DID)? Dissociative identity disorder (DID) is the disorder that was previously recognized as multiple personality disorder. It’s characterized by the presence of two or more dissociated self-states, known as alters, that have the ability to take executive control and are associated with some degree of inter-identity amnesia. DID is caused by chronic childhood trauma and is highly associated with posttraumatic stress disorder.
DID in the DSM-5-TR
The DSM-5-TR gives the following criteria for a diagnosis of dissociative identity disorder:
A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or other medical condition (e.g., complex partial seizures) (American Psychiatric Association, 2022). DID in the DSM-5 | DID-Research.org
“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on … It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
Criterion A refers to the presence of at least one alter (distinct personality state) in addition to the main, or host, personality. The alter(s) may sometimes be mistaken for spirits and the experience of dissociation for one of possession. Alters may each have their own perception of themself as a unique individual or entity, or they may demonstrate sharp discontinuities that go beyond what would be expected from normal state shifting in an integrated individual. Alters can have different degrees of emotional expressiveness, behave in different ways, experience consciousness in different ways, have different memories, perceive themselves and the world around them in different ways, think in different ways and have different cognitive skills, and have different skills and abilities related to sensory-motor functioning. A small number of alters even identify or present as animals or mythical figures, particularly in cultural contexts in which alters may be interpreted as spirits or other external entities. Other people may have noticed these differences (for example, the individual might switch during a diagnostic interview or friends and family of the individual might have told them about their alters’ behaviors) or the individual might have noticed changes due to finding evidence of their alters’ activities or due to the ability to remain co-conscious with their alters. For example, the individual might report sudden experiences of feeling like they are a different gender, are multiple ages at once, or don’t fit in their body. They may or may not associate these experiences with distinct internal parts, and they may be hesitant to disclose anything about the existence of parts that they are aware of. Attempts to conceal symptoms are typical.
It must be noted that the majority of individuals with DID are covert (i.e., not easily recognizable as having DID) the majority of the time. DID may be more visible when it presents as an experience of possession or when the individual is going through a period of extreme stress. Even clinicians may not immediately recognize the presence of alternate identities. More readily noticeable may be sharp discontinuities of opinion and memory without any parts announcing themself as such. It must also be noted that some DID systems have no alters that are distinct enough to have their own names, let alone drastically different presentations. Very few individuals with DID have parts that wear noticeably different clothing, style their hair in very different ways, have extremely different accents, or other highly overt changes associated with media portrayals of DID. That said, in some cases, identities may have drastic and immediately obvious differences, such as speaking a different language (e.g., a bilingual individual with DID having an alter that only speaks the language not shared by others in the individual’s current location) or presenting as a possessing spirit. More common are individuals presenting with subtle alterations in identity accompanied by reports of depersonalization; periods of feeling like an observer or passenger in their body; internal voices; imposed or ego-dystonic thoughts, emotions, urges, or actions; the abrupt vanishing or inhibition of thoughts, emotions, urges, or actions; and confusing shifts in opinion, ability, self-concept, and temperament.
Criterion B refers to the inability of one or more alters to remember things that one or more other alters have experienced. This specific type of dissociative amnesia is most commonly associated with amnesia for everyday events in which an alter other than the current alter was present. This is what leads to some dissociative individuals finding evidence of their time loss in the form of clothing or other items that they apparently own but don’t recognize, journal entries or sticky notes in their handwriting that they don’t remember writing, or insistent strangers calling them a name that isn’t theirs. It is not uncommon for individuals to have fugue episodes, in which they suddenly become aware that they’re in a new location (e.g., a different city, their place of work, their closet) with no memory of how they got there. This criterion can also be fulfilled by alters being unable to recall pertinent personal information such as the body’s age, current residence, or spouse. The individual may report lacking memory for highly personally relevant experiences such as their wedding or the birth of their child, and they may intermittently lose access to well-rehearsed skills such as driving or performing their job. However, this criterion is generally not considered fulfilled just because the host or other alters are unable to recall traumatic experiences. That alone would not point to inter-identity amnesia and so would result in a diagnosis of other specified dissociative disorder subtype 1. This criterion also cannot be fulfilled by incidents that can be explained by ordinary forgetting. Notably, the individual with DID may attempt to downplay or rationalize their episodes of amnesia, which may be more apparent to observers (e.g., the individual may try to make excuses for not remembering having dinner with their parents the week before, but their spouse reports this is highly unusual because many important discussions happened that night which the individual no longer shows any awareness of). The individual may be “amnesiac to their amnesia” and display no awareness of sudden discontinuities in their memory.
Criterion C refers to the fact that DID is a disorder. If a condition doesn’t cause distress or impairment, it is not a disorder and does not belong in the DSM-5. This criterion is present in the criteria of over half of all DSM-5 diagnoses in order to reduce the rate of false positive diagnoses given for non-clinically significant symptoms.
Criterion D excludes presentations that mimic DID due to culture or religion (such as a spiritual leader acting as a medium as part of cultural ceremonies) or due to imaginary play. It is important to reiterate that possession experiences can be culturally normative and require no diagnosis or can be involuntary, distressing, dysfunctional, and culturally atypical in a way that suggests DID is an appropriate diagnosis. DID that presents as possession is more common in rural areas in low- and middle-income countries and among certain religious groups.
Criterion E excludes presentations and symptoms that are due to organic, physiological, or situational causes. For example, blacking out while drunk is not an example of amnesia that meets Criterion B, and feeling like a different person while experiencing an altered consciousness due to a seizure is not an example of Criterion A.
As discussed elsewhere on this website, individuals with DID often have comorbid posttraumatic stress disorder (PTSD), depression, anxiety, or other mental health conditions. Functional neurological (conversion) symptoms are also common; in non-Western settings, this often presents as non-epileptic seizures, and in Western settings, this may present as headaches, seizures, or symptoms suggestive of disorders such as multiple sclerosis. Reactive dissociative psychosis is also possible, especially for individuals in highly violent, chaotic, or oppressive environments with prolonged absence of appropriate treatment or support. Avoidant personality features are common, and borderline features (e.g., highly unstable mood or self-injury) may become prominent in times of extreme stress. Obsessive traits are also common. A minority of people with DID present with histrionic, antisocial, or narcissistic features. Risky or self-destructive behaviors such as substance misuse, self-injury, and suicide attempts are common; over 70% of outpatients with DID have attempted suicide. Despite this, functional impairments range from minimal to profound.
DID is often confused for other disorders. Although it often co-occurs with or involves depersonalization/derealization, dissociative amnesia, conversion symptoms, posttraumatic stress, and depressed mood, its full clinical picture is more complex than any of these disorders alone. Alters may be confused for mood cycling in bipolar disorder, hallucinatory voices in schizophrenia spectrum disorders, or identity confusion and variable relational styles in borderline personality disorder, but the actual presentation and phenomenology differs significantly. In short, DID is unique for its requirement of personality / identity states with alterations in self and agency (alters) as well as inter-identity dissociative amnesia.
American Psychiatric Association. (2022). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., Text Revision).
DID Symptoms
Dissociative identity disorder (DID) is best known for alters, dissociated parts of the personality that the individual with DID experiences as separate from themself. However, prior to diagnosis, many individuals with DID are aware of the effects of having alters but not necessarily of their actual alters. Individuals with DID have dissociative amnesia for both their traumatic past and for many of their alters’ activities (inter-identity amnesia), and they often experience other memory problems as well (Dell, 2006)1. They might find evidence of amnesia such as possessions that they do not remember obtaining, art or writing that they do not recognize having done, being called an unknown name by strangers who act in a familiar manner towards them, or being confronted about their supposed actions that they cannot remember. Sometimes, they might experience dissociative fugue and suddenly find themself in a different location with no explanation of how they got there. There might be periods of their life that they can’t recall. Conversely, they might experience flashbacks of traumatic events and then find themself unable to recall what they just remembered (American Psychiatric Association (APA), 2013)2.
Individuals with DID might experience more direct evidence of their alters as well. They might hear “voices” that they do not at first understand are originating from their alters. They might experience intruding emotions, sensations, thoughts, and urges that make no sense to them and do not feel like their own. They often find themselves doing or saying things that they didn’t plan to do or say, and they might sometimes feel like they’re watching their body do things that they can neither predict nor control. Their skills and abilities might fluctuate, as might their knowledge. Their preferences, perceptions, and memories shift between sets (Dell, 2006)1.
DID includes a range of other dissociative symptoms as well. Identity alteration accounts for the existence of alters, but DID also involves high levels of identity confusion (being unsure who one is), depersonalization (feeling disconnected from aspects of oneself, including one’s emotions, thoughts, memories, physical sensations, body or parts of one’s body, or identity), and derealization (feeling disconnected from one’s environment or feeling like nothing is real). This can manifest as the individual: feeling like their body is foreign and not really theirs; feeling like they’ve morphed to a different age, gender, or build; not recognizing themself in a mirror; feeling like an imposter who’s taken over someone else’s life; or feeling like everything that’s happened to them is just a script for a movie. Individuals with DID can also experience: trance states, in which they show minimal awareness of or ability to respond to their surroundings; perceptual disturbances, such as feeling as if sounds are coming from far away; and somatic symptoms, such as stomachaches, headaches, or joint pain in response to emotional stress (Dell, 2006)1. DID is so strongly associated with dissociative symptoms that a diagnosis of DID renders any other dissociative disorder diagnoses unnecessary.
Because DID is the result of trauma, it’s highly comorbid with posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (C-PTSD), and flashbacks, emotional numbing, nightmares, emotional dysregulation, and pessimism about the future are common. Individuals with DID often have other comorbid disorders as well, including mood disorders (such as major depressive disorder), anxiety disorders (such as social anxiety disorder), personality disorders (such as borderline personality disorder (BPD)), eating disorders (such as anorexia nervosa), or conversion disorder (APA, 2013)2. Occasionally, individuals with DID might experience dissociative psychosis, a type of reactive psychosis triggered by extreme stress and associated with dissociative symptoms (Dell, 2006)1.
Presentation
Dissociative identity disorder (DID) is often covert and difficult to notice, with only 5-6% of individuals with DID having a more florid presentation. Switching between alters is rarely accompanied by dramatic shifts in personality that are highlighted by changes in clothing, preferences, and accent. In contrast, systems often go to great lengths to hide their condition and will deny and downplay their symptoms as much as possible once diagnosed. Alters frequently manifest through passive influence instead of completely taking executive control, and many individuals with DID are amnesiac for their own amnesia and do not notice even when a full switch has occurred.
According to the DSM-5, individuals who are diagnosed with DID often first present to clinicians with comorbid posttraumatic stress disorder, depressive disorders, anxiety disorders, personality disorders such as borderline personality disorder or avoidant personality disorder, conversion disorder, somatic symptom disorder, feeding and eating disorders, substance-related disorders, obsessive compulsive disorder, sleep disorders, self injury, or psychogenic non-epileptic seizures (PNES) (American Psychiatric Association, 2013).1
Their symptoms might be mistaken for mood disorders (such as bipolar disorders or major depressive disorder), personality disorders (such as borderline personality disorder), psychotic disorders (such as schizophrenia), other dissociative disorders (such as other specified dissociative disorder or dissociative amnesia), posttraumatic stress disorder alone, conversion disorder, seizure disorders, obsessive-compulsive disorder, paranoia, or cognitive disorders. DID often becomes more visible with age or when the disordered individual is removed from the traumatic situation, when the individual has children reach the age at which the individual was traumatized, or when the individual’s abuser(s) die(s) or contract(s) a terminal illness (American Psychiatric Association, 2013).1
The DSM-5 warns that over 70% of outpatients with DID have attempted suicide. That some but not other alters may self harm or have suicidal thoughts or urges complicates treatment (American Psychiatric Association, 2013).1
Systems and Subsystems
A system is a collection of alters within one body. The entirety of a dissociative identity disorder (DID) system includes all of the alters within one body. Research suggests that males average 12 alters and females average 15 alters. However, systems can range in size from 2 alters to 100s of alters, although in very large systems it is unlikely that all alters will front frequently. Instead, alters in large systems are likely to become active mostly when needed or triggered, and they often present in pairs or small groups.
Subsystems are systems within systems. There are two main types of subsystems. The first refers to separate internal groups within one larger system. In this case, two or more groups of alters might have developed separately, and they may or may not be aware of the other group(s). While groups may have good communication and co-consciousness among themselves, they may lose time when alters from other subsystems front, making communication through notes or sympathetic outsiders necessary. Different subsystems may reside in different locations in an internal world or may have non-overlapping internal worlds. They may exist to deal with different types of trauma and may not be aware of what other subsystems have experienced. Some subsystems might be entirely trauma locked; for example, someone with DID might have a group of alters who experience themselves as permanently trapped in an abusive environment, can only rarely communicate with the main group of alters, and cannot understand that the body is no longer trapped and hurting.
The second type of subsystem deals with alters who have their own alters (yes, it is like “alterception!”). These alters may or may not use the same internal presentation. That is to say, if Alter A has their own alters A1, A2, and A3, the other alters might experience all of the A alters as being different individuals who are only recognizable as Alter A because they all claim the same or a similar name and are never around at the same time. On the other hand, it is also possible that the other alters might experience all of the A alters as having to share one internal “body” and voice as outsiders experience the overall system as doing. Alters from this type of subsystem may or may not be aware of each other and may or may not have good communication. They may be very similar and differ mainly in regards to their age, function, or traits such as gender, or they may be complete alters in their own right.
Systems can also be affectionately referred to as collectives, internal families, clans, or crews.
Validity
One major support for DID as a traumagenic disorder is the strong association between DID and childhood trauma. DID patients have smaller hippocampal and amygdalar glands, something seen in those who were abused as children and have posttraumatic stress disorder (PTSD) (Vermetten, Schmahl, Linder, Loewenstein, & Bremme, 2006).1 As well, one study confirmed childhood abuse in eight out of nine cases of DID and all twelve cases of DDNOS (OSDD-1) examined (Coons, 1994).2 At least 79% of those with DID meet the criteria for PTSD (Ellason, Ross, & Fuchs, 1996)3, though other studies place the number at 89% (Brand et al., 2009).4 Another study found that 98.1% of individuals with DID experienced child abuse (Ellason & Ross, 1997).5 Despite these findings, DID cannot be said to be the same as PTSD. Individuals with DID and co-morbid PTSD have larger putamen and pallidum volumes compared to individuals with only PTSD with these volumes being positively correlated with severity of dissociative symptoms. Severity of dissociative symptoms is also negatively correlated with volume of the inferior parietal cortex (Chalavi et al., 2015).6
Another important point is the difference between trauma-oriented and non-trauma-oriented alters. The current theory for the formation of DID, the theory of structural dissociation, relies on the existence of both trauma oriented emotional parts (EP) and daily life oriented apparently normal parts (ANP), and various studies reinforce that these parts are distinct. It’s been shown that ANP (also called neutral identity states, or NIS) and EP (also called trauma-related identity states, or TIS) have different neural resting state activity, with EP being more likely to activate brain regions involved in self-referencing and sensorimotor actions (Schlumpf et al., 2014).7 When exposed to trauma scripts, NIS activate areas in the cerebral cortex while TIS activate subcortical areas. NIS brain network activation patterns are similar to those displayed by healthy individuals who are emotionally suppressing unwanted memories. In contrast, TIS brain network activation patterns indicate unsuppressed memory retrieval associated with acute stress. This supports that TIS but not NIS relate traumatic autobiographical memories to themselves (Reinders, Willemsen, Vos, Boer, & Nijenhuis, 2012).8 Similarly, EP compared to ANP are over-reactive towards angry and neutral preconsciously perceived faces and in response demonstrate more activation of the right parahippocampal gyrus, an area of the brain associated with recall of autobiographical memories and with re-experiencing symptoms for individuals with PTSD (Schlumpf et al., 2013).9
In none of these studies are individuals without DID able to match the differences between trauma oriented and non-trauma oriented parts even if the control individuals are highly fantasy prone. In fact, the low fantasy prone individuals studied better imitate the neural reactions of NIS versus TIS to trauma scripts. The same study finds that individuals with DID are not more fantasy prone than the general population, a finding that refutes the idea that DID is caused by fantasy proneness or suggestibility (Reinders, Willemsen, Vos, Boer, & Nijenhuis, 2012).8
1 Vermetten, E., Schmahl, C., Lindner, S., Loewenstein, R., & Bremner, J. (2006). Hippocampal and amygdalar volumes in Dissociative Identity Disorder. American Journal of Psychiatry, 163(4), 630-636. doi: 10.1176/appi.ajp.163.4.630
2 Coons, P. (1994). Confirmation of childhood abuse in child and adolescent cases of multiple personality disorder and dissociative disorder not otherwise specified [Abstract]. The Journal of Nervous and Mental Disease, 182(8), 461-4. doi: 10.1097/00005053-199408000-00007
3 Ellason, J., Ross, C., & Fuchs, D. (1996). Lifetime Axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry: Interpersonal and Biological Processes, 59(3), 255-266.
4 Brand, B., Classen, C., Lanins, R., Loewenstein, R., McNary, S., Pain, C., Putnam, F. (2009). A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specific patients treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 153-171. doi: 10.1037/a0016210
5 Ellason, J., & Ross, C. (1997). Two-year follow-up of inpatients with Dissociative Identity Disorder. American Journal of Psychiatry, 154(6), 832-839. Retrieved from http://www.rossinst.com/treatment_outcome.html
6 Chalavi, S., Vissia, E. M., Giesen, M. E., Nijenhuis, E. R., Draijer, N., Barker, G. J., . . . Reinders, A. A. (2015). Similar cortical but not subcortical gray matter abnormalities in women with posttraumatic stress disorder with versus without dissociative identity disorder. Psychiatry Research: Neuroimaging, 231(3), 308-319. doi:10.1016/j.pscychresns.2015.01.014
7 Schlumpf, Y. R., Reinders, A. A., Nijenhuis, E. R., Luechinger, R., Osch, M. J., & Jäncke, L. (2014). Dissociative part-dependent resting-state activity in dissociative identity disorder: A controlled fMRI perfusion study. PLoS ONE, 9(6). doi:10.1371/journal.pone.0098795
8 Reinders, A. A., Willemsen, A. T., Vos, H. P., Boer, J. A., & Nijenhuis, E. R. (2012). Fact or factitious? A psychobiological study of authentic and simulated dissociative identity states. PLoS ONE, 7(6). doi:10.1371/journal.pone.0039279
9 Schlumpf, Y. R., Nijenhuis, E. R., Chalavi, S., Weder, E. V., Zimmermann, E., Luechinger, R., . . . Jäncke, L. (2013). Dissociative part-dependent biopsychosocial reactions to backward masked angry and neutral faces: An fMRI study of dissociative identity disorder. NeuroImage: Clinical, 3, 54-64. doi:10.1016/j.nicl.2013.07.002
Traumatized Viridimere 