Dissociative Identity Disorder

Dissociative identity disorder ([DID] formerly called multiple-personality disorder) is a dissociative disorderOpens in new window characterized by the presence of two or more distinct personality states that recurrently take control of behavior.

Gina’s Clinical Case of DID
In December 1965, a woman named Gina Rinaldi sought therapy with Dr. Robert Jeans. Gina, single and 31 years old, lived with another single woman and was working successfully as a writer at a large educational publishing firm. Her friends saw her as efficient, businesslike, and productive, but had observed that she was becoming forgetful and sometimes acted out of character. Gina reported that she had been sleepwalking since her early teens; her present roommate had told her that she sometimes screamed in her sleep. After several sessions with Gina, Dr. Jeans noticed a second personality emerging. Mary Sunshine, as Gina and her therapists Dr. Jeans came to call her, was quite different from Gina. She seemed more childlike, more traditionally feminine, ebullient, and seductive. Gina felt that she walked like a coal miner, but Mary certainly did not. Some concrete incidents indicated Mary’s existence. Sometimes while cleaning her home, Gina found cups that had had hot chocolate in them—neither Gina nor her roommate like hot chocolate. There were large withdrawals from Gina’s bank account that she could not remember making. She even discovered herself ordering a sewing machine on the telephone although she disliked sewing; some weeks later, she arrived at her therapy session wearing a new dress that Mary had sewn. At work, people were finding Gina more pleasant, and her colleagues took to consulting her on how to encourage people to work better with one another. All these phenomena were entirely alien to Gina. Jeans and Gina came to realize that sometimes Gina transformed into Mary.

Gina’s Clinical Case of DID

In December 1965, a woman named Gina Rinaldi sought therapy with Dr. Robert Jeans. Gina, single and 31 years old, lived with another single woman and was working successfully as a writer at a large educational publishing firm. Her friends saw her as efficient, businesslike, and productive, but had observed that she was becoming forgetful and sometimes acted out of character. Gina reported that she had been sleepwalking since her early teens; her present roommate had told her that she sometimes screamed in her sleep.

After several sessions with Gina, Dr. Jeans noticed a second personality emerging. Mary Sunshine, as Gina and her therapists Dr. Jeans came to call her, was quite different from Gina. She seemed more childlike, more traditionally feminine, ebullient, and seductive. Gina felt that she walked like a coal miner, but Mary certainly did not.

Some concrete incidents indicated Mary’s existence. Sometimes while cleaning her home, Gina found cups that had had hot chocolate in them—neither Gina nor her roommate like hot chocolate. There were large withdrawals from Gina’s bank account that she could not remember making. She even discovered herself ordering a sewing machine on the telephone although she disliked sewing; some weeks later, she arrived at her therapy session wearing a new dress that Mary had sewn.

At work, people were finding Gina more pleasant, and her colleagues took to consulting her on how to encourage people to work better with one another. All these phenomena were entirely alien to Gina. Jeans and Gina came to realize that sometimes Gina transformed into Mary.

Consider what it would be like to have dissociative identity disorder (DID), as did Gina, the woman described above. People tell you about things you have done that are out of character and interactions of which you have no memory. How can you explain these events?

The diagnosis of dissociative identity disorder (DID) requires that a person have at least two separate personalities, or alternate personalities (alters), i.e, different modes of being, thinking, feeling, and acting that exist independently of one another and that emerge at different times.

Each alternate personality determines the person’s nature and activities when it is in command. The primary alter may be totally unaware that any other alter exists and may have no memory of what those other alters do and experience when they are in control.

It is believed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to the development of dissociative identity disorder.

DSM-5 Criteria for Dissociative Identity Disorder
Disruption of identity characterized by two or more distinct personality states (alters) or an experience of possession. These disruptions lead to discontinuities in the sense of self or agency, as reflected in altered cogntion, behavior, affect, perceptions, consciousness, memories, or sensory-motor functioning. This disruption may be observed by others or reported by the patient. Recurring gaps in memory for events or important personal information that are beyond ordinary forgetting. Symptoms are not part of a broadly accepted cultural or religious practice. Symptoms are not due to drugs or a medical condition. In children, symptoms are not better explained by an imaginary playmate or by fantasy play.

DSM-5 Criteria for Dissociative Identity Disorder

Disruption of identity characterized by two or more distinct personality states (alters) or an experience of possession. These disruptions lead to discontinuities in the sense of self or agency, as reflected in altered cogntion, behavior, affect, perceptions, consciousness, memories, or sensory-motor functioning. This disruption may be observed by others or reported by the patient.
Recurring gaps in memory for events or important personal information that are beyond ordinary forgetting.
Symptoms are not part of a broadly accepted cultural or religious practice.
Symptoms are not due to drugs or a medical condition.
In children, symptoms are not better explained by an imaginary playmate or by fantasy play.

It is believed that severe sexual, physical or psychological trauma in childhood predisposes a person to the development of dissociative identity disorder.

According to case reports of DID, there is typically one primary personality and this is usually the alter who seeks treatment.

Most commonly, two to four alters are identified when the diagnosis is made, but over the course of treatment others may emerge. Each alter has its own behavior patterns, memories, and relationships. Usually, the personalities of the different alters are quite different from one another, even polar opposites.

Case reports have described alters who have different handedness, like different foods, and have allergies to different substances (Boysen & VanBergen, 2014). The alters are aware of lost periods of time, and the voices of the others may sometimes echo in an alter’s consciousness, even though the alter may not know to whom these voices belong.

In some cultures, people value the experience of spirits who take control of the person’s body (Seligman & Kirmayer, 2008); when experiences of possession are part of a broadly accepted spiritual or cultural practice, the diagnosis of DID is not appropriate.

DID is rarely diagnosed until adulthood, but after their diagnosis, patients often will recall symptoms dating back to childhood. It is more severe and extensive than the other dissociative disordersOpens in new window (Mueller-Pfeiffer, Rufibach, et al., 2012).

DID is much more common in women than in men. Other diagnoses are often present, including posttraumatic stress disorderOpens in new window, major depressive disorderOpens in new window, somatic symptoms disordersOpens in new window, and personality disordersOpens in new window (APA, 2013).

DID is commonly accompanied by other symptoms such as headaches, hallucinationsOpens in new window, suicide attemptsOpens in new window, and self-injurious behavior, as well as by other dissociative symptoms such as amnesiaOpens in new window and depersonalizationOpens in new window.

The inclusion of DID as a diagnosis in DSM is controversial. For example, in a survey of psychiatrists, two-thirds reported reservations about the presence of DID in the DSM (Pope, Oliva, et al., 1999).

Students and the public often ask, “Does DID exist?” Clinicians can describe DID reliably; it “exists” in this sense. As discussed below, controversy swirls about the reasons these symptoms occur.

Etiology of Dissociative Identity Disorder

There are two major theories for the etiology of DID:

The posttraumatic model and
The sociocognitive model.

Both models focus on why some people develop DID. As we will see, considerable debate has arisen between the proponents of these two approaches.

The Posttraumatic Model

It is widely acknowledged that child abuse has profoundly negative effects (Curran, Adamson, et al., 2016).

The posttraumatic model proposes that some people are particularly likely to use dissociation to cope with trauma and that dissociation is the key reason people develop alternate personalities after trauma (Gleaves, 1996).

Research supports two important tenets of this model.

First, children who are abused are at risk for developing dissociative symptoms.
Second, children who dissociate are more likely to develop psychological symptoms after trauma (Ensinck, Berthelot, et al., 2017).

There is debate, though, about whether these childhood experiences shape symptoms in adulthood. On the one hand, most patients in therapy for DID reports severe childhood abuse (Dalenberg et al., 2012).

Patients, though, may be biased in their judgments about whether to describe early childhood experiences as abuse. A few studies have considered whether objective evaluations of childhood abuse (for example, from child protection agencies) predict tendencies to dissociate in adulthood. Those studies have yielded mixed findings about whether childhood abuse predicts tendencies for adults to dissociate (Lynn et al., 2018).

The Sociocognitive Model

According to the sociocognitive model, people who have been abused seek explanations for their symptoms and distress, and their alternate personality states appear in response to suggestions by therapists, exposure to media reports of DID, or other cultural influences (Lillenfeld, Lynn, et al., 1999).

Proponents of this model note that the prevalence of DID surged when media and professionals began to place more emphasis on the diagnosis.

This model, then, implies that DID could be iatrogenic (created within treatment) in that the person often learns to role-play these symptoms within treatment. This does not mean, however, that DID is viewed as conscious deception; the issue is not whether DID is real but how it develops.

Many of the treatment manuals for DID recommend thearapeutic techniques that reinforce clients’ identification of alternate personality states, such as interviewing clients about their identities after administering hypnosis or sodium pentothal (Nathan, 2011).

The reinforcement and suggestive techniques might promote false memories and DID symptoms in vulnerable people (Lilienfeld et al., 1999). The famous case of SybilOpens in new window is now widely cited as an example of how a therapist might elicit and reinforce stories of alternate personalities.

It has been claimed that in Sybil’s caseOpens in new window, the alternate personalities were created by a therapist who gave substance to Sybil’s different emotional states by giving them names, and who helped Sybil elaborate on her early childhood experiences while administering sodium pentothalOpens in new window, a drug that has been shown to contribute to false memories (Borch-Jacobsen, 1997; Nathan, 2011).

As another example of troubling therapeutic techniques, the Clinical case of Elizabeth provides an extreme example of a therapist who unwittingly encouraged her client to adopt a diagnosis of DID when it wasn’t justified by the symptoms. All the symptoms Elizabeth described are common experiences; indeed, none of the symptoms listed are actual diagnostic criteria for DID.

Elizabeth’s Clinical Case: An Example of Unwarranted Diagnosis of DID
The book Creating Hysteria: Women and Multiple Personality Disorder (Acocella, 1999) provides a personal account of a person who received a false diagnosis of DID. Elizabeth Carlson, a 35-year-old married woman, was referred to a psychiatrist after being hospitalized for severe depression. Elizabeth reported that soon after treatment began, her psychiatrist suggested to her that perhaps her problem was the elusive, often undiagnosed condition of multiple personality disorder (MPD, now referred to as DID). Her psychiatrist reviewed … certain telltale signs of MPD. Did Carlson ever “zone out” while driving and arrive at her destination without remembering how she got there? Why yes, Carlson said. Well, that was an alter [an alternate personality] taking over the driving and then vanishing again, leaving her, the “host” personality, to account for the blackout. Did Carlson ever have internal arguments—for example, telling herself, “Turn right” and then “No, turn left”? Yes, Carlson replied, that happened sometimes. Well, that was the alters fighting with each other inside her head. Carlson was amazed and embarrassed. All these years, she had done these things, never realizing that they were symptoms of a severe mental disorder. (Acocella, 1999, p.1)

Elizabeth’s Clinical Case: An Example of Unwarranted Diagnosis of DID

The book Creating Hysteria: Women and Multiple Personality Disorder (Acocella, 1999) provides a personal account of a person who received a false diagnosis of DID. Elizabeth Carlson, a 35-year-old married woman, was referred to a psychiatrist after being hospitalized for severe depression. Elizabeth reported that soon after treatment began, her psychiatrist suggested to her that perhaps her problem was the elusive, often undiagnosed condition of multiple personality disorder (MPD, now referred to as DID). Her psychiatrist reviewed

… certain telltale signs of MPD. Did Carlson ever “zone out” while driving and arrive at her destination without remembering how she got there? Why yes, Carlson said. Well, that was an alter [an alternate personality] taking over the driving and then vanishing again, leaving her, the “host” personality, to account for the blackout. Did Carlson ever have internal arguments—for example, telling herself, “Turn right” and then “No, turn left”? Yes, Carlson replied, that happened sometimes. Well, that was the alters fighting with each other inside her head. Carlson was amazed and embarrassed. All these years, she had done these things, never realizing that they were symptoms of a severe mental disorder. (Acocella, 1999, p.1)

We will never have experimental evidence for the sociocognitive model, since it would be unethical to intentionally reinforce dissociative symptoms. Given this reality, what kinds of evidence have researchers raised in support of the sociocognitive model?

An understanding of the levels and defensive patterns used in response to anxiety is basic to psychiatric-mental health nursing care. This understanding is essential for assessing and planning interventions to lower a patient’s level of anxiety (as well as one’s own) effectively. With practice, you will become skilled at identifying levels of anxiety, understanding the defenses used to alleviate anxiety, and evaluating the possible stressors that contribute to increased levels of anxiety.

DID Symptoms Can Be Role-Played

Across 20 studies, researchers have shown that people can role-play the symptoms of DID (Boysen & VanBergen, 2014).

When instructed to generate a second personality, many participants can even produce responses on personality tests that differ considerably from their initial profile. These findings indicate that people can adeptly role-play DID. This evidence has been criticized though—people can mimic having a broken leg (and many other symptoms), but this does not cast doubt on the reality of broken legs.

Some Therapists Reinforce DID Symptoms in Their Clients

Therapists who diagnose more people with DID tend to use hypnosis, to urge clients to try to unbury unremembered abuse experiences, or to name alternate personality states (Powell & Gee, 2000).

Consistent with the idea that treatments evokes the DID symptoms, most patients are unaware of having alternate personality states until after they begin treatement, and as treatment progresses, they report a rapid increase in the number of personalities they can identify.

Alternate Personalities Share Memories, Even When They Report Amnesia

One of the defining features of DID is the inability to recall information experienced by one personality when a different personality is present. One way to test whether personalities share memory is to use implicit tests of memory (Huntjen, Postma, et al., 2003).

In tests of explicit memory, researchers might ask a person to remember words.
In tests of implicit memory, researchers determine if the word lists have subtler effects on performance. For example, if persons are first shown a word list that included the word lullaby, they might be quicker on a second task to identify lullaby as a word that fills in the puzzle l_l_a_y.

People with DID were taught an initial word list and were then asked to complete the implicit memory test when they returned to the second session in a different personality state.

Twenty-one of the participants diagnosed with DID claimed at the second testing session that they had no memory of the first session. On tests of implicit memory, however, these 21 people performed comparably to people without DID. That is, memories were transferred between personalities.

Many studies replicate this finding (Boysen & VanBergen, 2013). Implicit memory tests also show transfer of autobiographical memories between personality states (Marsh, Dorahy, et al., 2018). People with DID demonstrate more shared memories than they tend to acknowledge.

Treatment of DID

No treatments for the dissociative disorders are well validated. No randomized controlled trials have assessed psychological treatment. Medications have not been shown to relieve the symptoms of dissociative disorders (Lynn et al., 2018).

In the absence of strong evidence, expert clinicians agree on several principles in the treatment of dissociative identity disorder (International Society for the Study of Dissociation, 2011). These include the importance of an empathic and gentle stance.

The goal of treatment should be to convince the person that splitting into different personalities is no longer necessary to deal with traumas. In addition, as DID is conceptualized as a means of escaping from severe stress, therapists can help teach the person more effective ways to cope with stress and to regulate emotions.

Psychoeducation can help a person to understand why dissociation occurs and to begin to identify the triggers for dissociative responses in day-to-day life (Brand, Myrick, et al., 2012). Often, people with DID are hospitalized to help them avoid self-harm and to offer more intensive treatment.

Psychodynamic treatment is probably used more for DID and the other dissociative disorders than for any other psychological disorder. The goal of this treatment is to overcome repressions (MacGregor, 1996), as DID is believed to arise from traumatic events that the person is trying to block from consciousness.

Unfortunately, some psychodynamic practitioners use hypnosis as a means of helping patients diagnosed with dissociative disorders to gain access to repressed material (International Society for the Study of Dissociation, 2011). Typically, the person is hypnotized and encouraged to go back in his or her mind to traumatic events in childhood—a technique called age regression.

The hope is that accessing these traumatic memories will allow the person to realize that childhood threats are no longer present and that adult life need not to be governed by these ghosts from the past (Grinker & Spiegel, 1944). Using hypnosis to promote age regression and recovered memories, though, can exacerbate DID symptoms (Lilienfeld, 1998). Hypnotic techniques have become less popular as the problems have received more attention.