Dissociative identity disorder
Dissociative identity disorder, previously known as multiple personality disorder, is a dissociative disorder characterized by the presence of at least two personality states or "alters". The diagnosis is controversial and remains disputed. Proponents of DID support the trauma model, viewing the disorder as an organic response to severe childhood trauma. Critics of the trauma model support the sociogenic ''model of DID as a societal construct and learned behavior used to express distress; developed through iatrogenesis in therapy, cultural beliefs, and exposure to the behavior in media or online.
Public perceptions of the disorder were popularized by alleged true stories in the 20th century; Sybil'' influenced many elements of the diagnosis, but was later found to be fraudulent. After multiple personality disorder was recognized as a diagnosis in DSM-III in 1975, an epidemic of the disorder spread across North America, closely tied to the satanic panic. Therapists began using hypnosis on patients, believing they were discovering alters and recovering forgotten memories of satanic ritual abuse. Psychologists familiar with the malleability of memory argued they were constructing false memories. Diagnoses reached 50,000 by the 1990s, but the FBI failed to validate allegations made against caregivers. Skepticism increased when MPD patients recovered from the behavior, retracted their false memories, and brought successful lawsuits against therapists. A sharp decline in cases followed, and the disorder was reclassified as "dissociative identity disorder" in DSM-IV. In the 2020s, an uptick in DID cases followed the spread of viral videos about the disorder on TikTok and YouTube.
According to the DSM, the disorder is accompanied by memory gaps more severe than could be explained by ordinary forgetfulness, including gaps in consciousness, basic bodily functions, and perception. Research has challenged this premise; McNally found that although patients reported amnesia between alters, objective tests found their memory function was intact. Some clinicians view it as a form of hysteria. After a sharp decline in publications in the early 2000s from the peak in the 90s, Pope et al. described the disorder as an academic fad. Boysen et al. described research as steady, but lacking in convincing evidence.
According to the DSM-5-TR, early childhood trauma, typically starting before 5–6 years of age, places someone at risk of developing dissociative identity disorder. Across diverse geographic regions, 90% of people diagnosed with dissociative identity disorder report experiencing multiple forms of childhood abuse, such as rape, violence, neglect, or severe bullying. Other traumatic childhood experiences that have been reported include painful medical and surgical procedures, war, terrorism, attachment disturbance, natural disaster, cult and occult abuse, loss of a loved one or loved ones, human trafficking, and dysfunctional family dynamics.
Treatment generally involves supportive care and psychotherapy. Medications can be used for comorbid disorders or targeted symptom relief. Lifetime prevalence, according to two epidemiological studies in the US and Turkey, is between 1.1–1.5% of the general population and 3.9% of those admitted to psychiatric hospitals in Europe and North America, though these figures have been argued to be both overestimates and underestimates. Comorbidity with other psychiatric conditions is high. DID is diagnosed 6–9 times more often in women than in men.
The number of recorded cases increased significantly in the latter half of the 20th century, along with the number of identities reported by those affected, but it is unclear whether increased rates of diagnosis are due to better recognition or to sociocultural factors such as mass media portrayals. The typical presenting symptoms in different regions of the world may also vary depending on culture, such as alter identities taking the form of possessing spirits, deities, ghosts, or mythical creatures in cultures where possession states are normative.
Definitions
, 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". Critics have argued that the term lacks a precise, empirical, and generally agreed upon definition, proposing to define it instead as an impairment in "meta-consciousness".Many diverse experiences have been termed dissociative, ranging from normal failures in attention to the breakdowns in memory processes characterized by the dissociative disorders. 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. Other terms used in the literature, including personality, personality state, identity, ego state, and amnesia, also lack agreed upon definitions. Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones.
Due to the lack of consensus about terminology in the study of DID, several terms have been proposed. One is ego state. Another is alters.
Signs and symptoms
The full presentation of dissociative identity disorder can occur at any age, but symptoms typically begin by ages 5–10. DID generally develops in childhood. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, symptoms of DID include "the presence of two or more distinct personality states" accompanied by the inability to recall personal information. Other DSM-5 symptoms include a loss of identity as related to individual distinct personality states, loss of subjective experience of the passage of time, and degradation of a sense of self and consciousness. In each individual, the clinical presentation varies, and the level of functioning can change from severe impairment to minimal impairment. The symptoms of dissociative amnesia are subsumed under a DID diagnosis; dissociative amnesia should not be diagnosed separately if DID criteria are met. Individuals with DID may experience distress from both the symptoms of DID and the consequences of the accompanying symptoms. The large majority of patients with DID report repeated childhood sexual and/or physical abuse, usually by caregivers, as well as organized abuse. Amnesia may be asymmetrical between identities; one identity may or may not be aware of what is known by another. Individuals with DID may be reluctant to discuss symptoms due to associations with abuse, shame, and fear.Around half of the people with DID have fewer than 10 identities, and most have fewer than 100; a person with as many as 4,500 identities was reported by Richard Kluft in 1988. The average number of identities has increased over time, from two or three to an average of approximately 16. However, it is unclear whether this is due to an actual increase in identities or simply that the psychiatric community has become more accepting of a high number of compartmentalized memory components.
Comorbid disorders
The person's psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures. The most common presenting complaint of DID is depression that is often treatment-resistant, with headaches and non-epileptic seizures being common neurologic symptoms. Comorbid disorders include post-traumatic stress disorder, 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. Individuals diagnosed with DID demonstrate the highest hypnotizability of any clinical population.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.The DSM-5-TR states that "early life trauma represents a major risk factor for dissociative identity disorder." Other risk factors reported include painful medical procedures, experiences of war, witnessing terrorism, or being trafficked in childhood. Dissociative disorders frequently occur after trauma, and the DSM-5-TR places them after the chapter on trauma- and stressor-related disorders to reflect this close relationship between complex trauma and dissociation.
Traumagenic model
Dissociative identity disorder is often conceptualized as "the most severe form of a childhood-onset post-traumatic stress disorder." According to many researchers, the etiology of dissociative identity is multifactorial, involving a complex interaction between developmental trauma, sociocultural influences, and biological factors.People diagnosed with dissociative identity disorder often report that they have experienced physical or sexual abuse during childhood ; others report overwhelming stress, serious medical illness, or other traumatic events during childhood. They also report more historical psychological trauma than those diagnosed with any other mental illness.
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 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. Relationships between childhood abuse, disorganized attachment, and lack of social support are thought to be common risk factors leading to dissociative identity disorder. Although the role of a child's biological capacity to dissociate remains unclear, some evidence indicates a neurobiological impact of developmental stress. Moreover, in a review study done Vedat, it was proposed that personalities of children are universally born unintegrated, and the various aspects of a child's undeveloped personality gradually integrate as the child's brain grows and develops.
Delinking early trauma from the etiology of dissociation has been explicitly rejected by those supporting the early trauma model. A 2012 review article argues the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states. 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". It has also been suggested that there may be a genuine but more modest link between trauma and dissociative identity disorder, with early trauma causing increased fantasy-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of dissociative identity disorder.
Joel Paris states that the trauma model of dissociative identity disorder increased the appeal of the diagnosis among health care providers, patients and the public as it validated the idea that child abuse had lifelong, serious effects. Paris asserts that there is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption.