What Is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is perhaps one of the most debated and controversial psychiatric disorders due to dissensus amongst mental health professionals regarding diagnosis and treatment.¹  DID is a rare psychiatric disorder which, up until 1994, was previously known as Multiple Personality Disorder.² To be diagnosed with DID, an individual must possess at least two different personalities which have significant control over the individual’s behaviour.  

This article will outline DID, its causes, symptoms, and how the disorder can be treated and managed. The key points of the article are:

• DID is a type of dissociation disorder
• Individuals with DID have two or more distinct identities/personalities that have significant control over the individual’s behaviour
• DID is perhaps one of the most controversial psychiatric disorders
• DID often co-exists alongside other psychiatric disorders
• Multiple different factors could lead to the development of DID
• The primary factor in the development of DID is thought to be childhood abuse and/or neglect
• Psychotherapy is the most common form of treatment for DID

Overview

DID is part of a broader group of psychiatric disorders called Dissociative disorders (DDs). These  consist of severe psychiatric symptoms that significantly impact an individual’s quality of life. Furthermore, DDs have a huge impact on the mental health system in terms of cost and use of resources.  DDs are often mis/underdiagnosed. Additionally, there are some mental health professionals who even doubt their existence, probably due to a lack of understanding of their origin and pathology. The linking characteristic of DDs is dissociation which can be deduced as a defence mechanism to protect oneself from trauma.³

Dissociation affects the normal working of consciousness, memory, perception, emotion, and identity with dissociation symptoms spanning from everyday experiences like being absorbed in a book, to dysfunctional symptoms such as not recognising yourself in a mirror.⁴ If an individual starts using dissociation as a trauma response, they may start applying this response to other situations which aren’t traumatic, consequently becoming maladaptive.³ Dissociation is thought of as the ultimate form of adaptive response to developmental trauma, as patients with DDs are more likely to have a history of childhood abuse and/or neglect compared to other psychiatric disorders.⁵ The main types of DDs include:

• Dissociative Identity Disorder
• Dissociative amnesia
• Depersonalisation-derealisation disorder

DID is perhaps the most challenging and complex DD, which can be defined by an individual possessing dissociative symptoms as well as the presence of two or more distinct identities/personalities which control the sufferer’s behaviour.¹ Each personality differs in consciousness, behaviour, memory, and perception of the world.² The prevalence of DID in the general population ranges from about 1-5% and affects significantly more females than males. 

There is a high percentage of individuals diagnosed with DID who are also diagnosed with post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD). Furthermore, it is also common for DID patients to have a previous diagnosis of schizophrenia; however, this may be because DID is often misdiagnosed as both disorders may present similar symptoms.¹ DID also coexists with some other psychiatric disorders, including:¹

• Substance use disorder
• Eating disorders
• Somatoform disorders
• Anxiety/mood disorder
• Personality disorders
• Psychotic disorders

As mentioned previously, DID is an extremely controversial psychiatric disorder due to disagreement on its validity, prevalence, and cause. One of the major challenges surrounding DID is cultural issues due to differences in the clinical manifestation of DID and its diagnostic classifications. Additionally, there are variations in how identity is perceived across different cultures - Western ideas around identity are very autonomous compared to the ‘self’ being perceived as more relational in other cultures.⁶ Another controversy surrounding DID is the prospect of criminals using a DID diagnosis as their defence, leading to a potential mistrust in the judicial system.⁷

Causes of dissociative identity disorder

It is thought that a multitude of factors lead to the development of DID. Most commonly it is thought that DID is a chronic post-traumatic developmental disorder that arises during childhood due to a child’s failure to develop a cohesive sense of self across distinct behavioural states. DID is significantly linked to the basic mechanisms underpinning PTSD, however, the discrete identities which are characteristic of DID are not present in PTSD. Studies have shown that DID is caused by chronic childhood abuse, particularly by an attachment figure e.g. a parent or carer. In most of these studies, childhood abuse/neglect has been reported in 90-100% of patients.

It has also been proposed that DID may develop due to a child having a disorganised attachment style - a theory coined by Bowlby. This concept suggests that a child experiencing insufficient care from their caregiver may develop several internal representations of self. Subsequently, children may implement this dysfunctional attachment style in contexts of abuse to protect themselves. As dysfunctional attachment style is significantly associated with childhood abuse/neglect, it may represent a foundation for the development of DID.⁵

One of the hallmarks of DID is a disruption in an individual’s cognitive processes, which includes memory and the construction of self-identity. It has been proposed that personality is made up of ‘modes’ - for example, a woman may have a ‘mother’ mode which influences how she feels and behaves when caring for a child. Generally, these modes, which make up personality, are all connected and contribute to one’s sense of self. Therefore, from a cognitive perspective, it is thought that DID may develop due to these modes becoming disconnected, consequently leading to multiple conscious control systems and a disjointed sense of self.⁵

Additionally, imaging studies of the brains of people with DID have shown biological differences when compared to ‘healthy’ individuals.⁶ This suggests that there may also be a biological cause for the development of DID. However, studies on potential genetic factors for DID have had mixed findings.¹

Signs and symptoms of dissociative identity disorder

There are a range of signs and symptoms that people with dissociative identity disorder may exhibit. As mentioned previously, to be diagnosed with DID, patients must present with dissociation, which includes: ⁸

• Disconnection from yourself and the surrounding world
• Forgetting personal information and events (amnesia)
• Uncertainty about sense of self
• Feeling little or no physical pain

For a diagnosis of DID, dissociative symptoms also must present alongside diagnostic characteristics of DID: ³

• Two or more distinct identities/personality states
• At least two of these identities/personality states must have significant control over one’s behaviour
• These clinical symptoms must not be due to the effects of drugs or alcohol
• Regarding children, the symptoms must not be due to harmless childhood fantasies/imagination

It is also common for individuals with DID to have psychotic symptoms, which should not be confused with Schizophrenia. Additionally, most people with DID present with suicidal ideation and self-harm behaviours.²

Management and treatment for dissociative identity disorder

DID is diagnosed by a mental health professional, with treatment following a similar structure to personality disorder treatment. Firstly, the risk of suicide/self-harm needs to be managed so that treatment can focus on treating the root cause of DID. Common treatment approaches for DID include:²

• Psychotherapy: the preferred treatment approach for DID which aims to stabilise/reduce symptoms, work through traumatic memories and integrate identities
• Hypnosis: DID patients are more easily influenced by hypnosis than the general population and therefore it has been shown as an effective form of treatment
• Eye Movement Desensitisation and Reprocessing (EMDR): recommended treatment when the patient does not have a severe form of DID and good coping skills

Using medication to treat DID is not the preferred treatment option and may only be used to treat certain symptoms. Prescribed medication is generally  for mood/psychotic disorders or PTSD. It is not the ideal form of treatment because a person with DID may have different identities/personality types which present with different symptoms. Therefore, some of the distinct identities may meet the requirements for treatment, whereas others may not.²

FAQs

How is dissociative identity disorder diagnosed?

Dissociative identity disorder is diagnosed by a mental health professional. The individual must present with dissociative symptoms as well as two or more distinct identities/personality types that have significant control over the individual’s behaviour.

Can dissociative identity disorder be prevented?

As there are a multitude of causes for dissociative identity disorder, not much is known about how it can be directly prevented. However, in general, children who have a good stable upbringing, and a healthy attachment type are less likely to develop DID.

Who is at risk of dissociative identity disorder?

Individuals who are subjected to childhood abuse and/or neglect, particularly by their caregiver, are significantly more likely to develop DID. Additionally, DID is much more likely to occur in women than men.

How common is dissociative identity disorder?

The prevalence of dissociative identity disorder in the general population is about 1-5%.

When should I see a doctor?

If you are experiencing the symptoms highlighted in this article, it is important to see a doctor, especially if it is affecting your quality of life and is causing you significant distress.

Summary

DID is a chronic psychiatric disorder that affects approximately 1-5% of the general population, with women being predominantly diagnosed. It is part of the group of Dissociative disorders and is perhaps one of the most controversial psychiatric disorders, due to a lack of consensus among mental health professionals on its origin and validity. An individual with DID will present with dissociative symptoms as well as two or more distinct identities/personality types which have significant control over one’s behaviour. DID commonly co-exists alongside other psychiatric disorders, particularly PTSD and borderline personality disorder. It is thought that multiple factors can lead to the development of DID, but childhood abuse and/or neglect is acknowledged as the primary factor. DID is mainly treated through psychotherapy but can also be treated by hypnosis and EMDR. Medication is not routinely prescribed to treat DID as the distinct identities that an individual with DID possesses may present with different symptoms, so medication may not be appropriate.