Dissociative identity disorder (DID) is a psychiatric diagnosis characterised by two key symptoms: memory gaps and fragmented, multiple identities.
Dissociative identity disorder (DID) is a rare condition, diagnosed more often in women than in men. It is hard to be absolutely certain how common DID is, as accurate diagnosis can be difficult. Also, individuals with DID symptoms may choose not to see a psychiatrist for diagnosis. However, it is now becoming more frequently diagnosed.
What are the symptoms of dissociative identity disorder?
The two essential symptoms which distinguish dissociative identity disorder (DID) from other diagnoses are:
- Memory gaps
- Disruption of identity
For a person to be diagnosed with DID, these two symptoms must be present. However, perhaps because of their traumatic pasts, people with DID complain of a wide range of distressing symptoms. In fact, people with DID who see their doctor for diagnosis often complain of other symptoms; for example, depression, anxiety, self-harm, drug or alcohol addiction, eating disorders.
Only on closer questioning do they describe the two essential symptoms. As a consequence, accurate diagnosis can be a challenge and it may be that DID is more common than we think. A common feeling in DID is shame. Shame colours much of the affected person's experience.
Along with shame, there is often a desire for privacy and secrecy. The combination of shame and secrecy can leave DID hidden, sometimes even from close family, for many years. It only becomes obvious when it gets too much to maintain the appearance of a normal life. It is not always the case that DID creates the unusual symptoms with which it has been associated in the past. In fact, it can remain hidden and undetected, with people who have the condition often able to maintain the appearance of a normal life, despite DID.
What is disruption of identity?
Identity means a sense of who we are: our age, gender, sexuality, temperament, personality. It has memories and experiences of its own and an understanding of itself. Whilst everyone can feel and behave differently depending on what they are doing, they always have a sense of a constant self, regardless of who they are with and what they are doing.
This is not the case in dissociative identity disorder (DID). In DID, individuals have several different identities, each one being different from the rest. They can switch between identities instantly, even without intending to. They might have no awareness of switching, although it can be apparent to the people around them. Particularly when under stress, their identity can switch to one which might be very different. It might even have a different age or gender. It might have its own set of memories - memories which are not shared by the other identities within the person.
The person with DID can have no recollection of switching identity. This is because the identity switch comes with dissociation, meaning the person is not consciously aware of the identity change. They may not be aware of anything that happens whilst in a different identity. Minutes or hours may pass without their knowing; occasionally even longer. The person with DID might only aware of 'coming to' when no longer in the dissociated identity. They may find evidence of their actions whilst functioning in a dissociated identity, like new clothes they have no memory of buying, for example.
This can be confusing and embarrassing for the person with DID. There can be several different identities within one person, but these are not complete and fully formed extra personalities, as was once thought. In fact, in DID, it is as if the person's identity has been broken up into several different identity fragments, each having a different role in helping the person function.
As well as episodes of full dissociation with memory gaps and identity changes, people with DID can experience many other symptoms too. These other symptoms are often a result of the trauma endured during their childhoods and the difficult attachments to the people in their lives. They can cause a wide variety of distressing symptoms - for example, flashbacks, physical pain, fearfulness, depression, self-harm, eating disorders, addictions and relationship problems. Individuals may also hear voices or see images which are not there. These experiences can be very intrusive. They can be disorientating and distressing to the person with DID. They can happen frequently, too, interfering with a person's ability to live a normal life.
What are memory gaps?
When in a fully dissociated state, an individual's thoughts, feelings and behaviours are beyond their conscious awareness. In dissociative identity disorder (DID), these dissociations are coupled with a change in identity. When functioning from one of the fragmented identities, whilst being fully alert and able to complete complex tasks, this functioning is pinched off from the individual's consciousness. Time can pass without the individual being aware of it. This apparent loss of time is experienced by the person with DID as memory gaps.
It is these memory gaps which are typical and diagnostic of DID. This loss of time and memory is often highly distressing to the person with DID. They may be presented with evidence of actions carried out whilst in a dissociated identity. They may be aware of 'coming to' with no recall of what happened.
What is dissociation?
We know that, when someone is faced with trauma, the distress it causes can become too much for the person's mind to take in. Rather than being overwhelmed, the mind can automatically switch into a different way of thinking and feeling. This is called dissociation. Dissociation is a way of managing extreme feelings. It can happen automatically, without a person meaning to dissociate.
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What causes dissociative identity disorder?
Whilst it is not certain what causes dissociative identity disorder (DID), many people believe that it is a response to repeated childhood trauma. The trauma affects how the child's mind develops, causing DID symptoms in adulthood.
What is trauma?
Trauma occurs when an overwhelming event leaves a person feeling helpless. The event can be physical, sexual or emotional in nature. The traumatic feelings are too great for the mind to take in and to process. What the mind cannot process is relived time after time as if happening all over again. It is possible for any person to experience trauma; there is no personality type which is immune to it; no race or gender. If a person is overwhelmed by an experience and feels helpless, trauma occurs.
Trauma can manifest in many ways: flashbacks, nightmares, avoidance of people, places and situations, fearfulness and panic. It can cause relationship difficulties, self-harm, depression and even suicide. It can result in post-traumatic stress disorder. It can also trigger dissociation.
Dissociation is a strategy used by the mind to cope with trauma. It is an altered way of thinking and feeling. It creates a psychological distance from the overwhelming feelings. Dissociation can be experienced in many ways, some of which are normal, everyday experiences. Others accompany more significant, psychological trauma. Examples of dissociation are:
- Depersonalisation - feeling as if you are not yourself.
- Derealisation - feeling as if your surroundings are unreal.
- Losing time.
- Blanking out.
- A sense of time going more slowly - for example, when feeling afraid.
What role do trauma and dissociation have in dissociative identity disorder?
Not everyone who experiences trauma and dissociation goes on to develop dissociative identity disorder (DID). People who experience DID have often had early lives where they have felt unsafe and frightened by the people who were meant to keep them safe. They have experienced repeated trauma throughout their childhood.
This may have been at the hands of a caregiver, or it may have involved the caregiver because he/she did not prevent the traumas from occurring. Faced with repeated traumas, the child's mind uses dissociation to cope. Dissociations during childhood, when a young person's mind is still developing, can affect how the personality forms. Instead of one complete personality, during times of dissociation, fragments of identity are created.
These identity fragments remain separate and dissociated - cut off from the rest of the person's mind. They can resurface at times of distress. Whilst DID stems from childhood trauma, its symptoms show themselves in adulthood, often long after the traumas have stopped. The DID mind continues to cope with stress by using its dissociated identities. What was a brilliant survival strategy for the child, causes problems for the adult who is no longer in danger.
Anyone can experience trauma and dissociation, so DID can be thought of as a developmental response, rather than a 'mental illness'. It could happen to anyone who has survived repeated childhood trauma.
Not everyone thinks that DID is a result of trauma. Because some people with DID are easily hypnotised, some professionals have wondered whether DID might be induced in susceptible people by hypnosis and suggestion. This might also be at the hands of inexperienced therapists, or by therapists who are actively looking for signs of DID. Rather than it being a response to trauma, some people think that the identity fragments are embellished at the suggestion of the professional trying to diagnose and treat them. This is known as the 'iatrogenic model'. DID symptoms are also influenced by the person's environments, by media and by culture. This effect on symptoms is called the 'sociocognitive model'. People continue to debate the cause of DID.
DID used to be known as 'multiple personality disorder'. It has been renamed because the personalities in DID are fragments of one, unintegrated personality. They are not multiple, fully formed personalities residing within one mind.
Dissociation and DID
It is thought that dissociation is the root of DID. As well as switching off from distress, people who have the condition develop fragments of different identities during times of dissociation. As the traumas keep happening, so the identities keep developing. It can be thought of as a survival strategy which helps the person cope with severe trauma again and again. Once the mind has learned to cope by using dissociated identities, it keeps on doing so, even into adulthood when the traumas have stopped.
Along with dissociation, some people have speculated that DID can be induced or worsened in susceptible people by hypnosis and suggestion. This may even be at the hands of an inexperienced psychotherapist. Many people who do not have symptoms of DID can have a feeling that they have lots of different parts to their personalities; for example a critical, parental part or a timid little child part. Unlike DID, these are still felt as if they are part of the same self - the same identity. It has been speculated that DID could be induced in susceptible clients by a therapist's suggestion that there are separate identities present.
What are the treatment options for dissociative identity disorder?
In order to plan the right treatment, it is vital to get an accurate diagnosis, as getting the wrong diagnosis could mean getting the wrong treatment. Because dissociative identity disorder (DID) can come with many different symptoms, it can be mistaken for other psychiatric conditions. Added to its many symptoms, its shame and secrecy can keep it hidden. This can get in the way of an accurate diagnosis. If you wonder whether you or someone you know might have DID, consider talking about this with your doctor. They will be able to help and advise you.
Treatment for DID is with psychotherapy. Psychotherapy sessions typically take place weekly and last for around one hour. Therapy for DID is often long-term - sometimes over several years. In the UK, because of the long-term nature of therapy for DID, NHS therapy is not always available. For this reason, people sometimes turn to private therapists. When choosing a private therapist, it is important to find someone who is familiar with DID and knows how to work with it. Not all therapists have the right kind of experience. The therapist must also have a supervisor who understands DID and is happy to oversee the work. If you are looking for a therapist, it is OK to check with them that they have everything in place to work long-term with DID.
What is psychotherapy?
Sometimes, people talk about dissociative identity disorder (DID) psychotherapy as being divided up into three phases. These are:
- Establishing safety, stabilisation and symptom reduction.
- Working through and integrating traumatic memories.
- Integration and rehabilitation.
The first phase in therapy is to establish a strong and trusting relationship between the client and therapist - a relationship which feels safe enough to explore traumatic experiences. For someone who has grown up with abuse, this can be an unsettling prospect. For this reason, it is crucial that the fit between the therapist and the client is a good one. If the therapy relationship is strong, the chances of recovery are greater. It can take time to develop a secure and trusting relationship, particularly when clients have been hurt by people they have trusted in the past; it doesn't happen straightaway.
Once the right therapist has been found and a safe relationship has been established, the next task is to work through traumatic memories. This allows the client to process trauma in ways that they have not been able to do before. Talking through trauma in a therapy relationship actually helps make sense of the past and to move forward, instead of reliving it over and over again.
In DID, dealing with trauma often means dealing with dissociated identities. Working with these identities requires some finesse on the part of the therapist. The aim of therapy is to build relational bridges between the identities, allowing the client's personality to become more integrated. It is important that the therapist does not encourage greater autonomy for the dissociated identities. This can result in more separation rather than integration of identities. With a skilled therapist and a committed client, personality integration is possible, through gentle and careful unpicking of traumatic experiences.
The final phase of therapy - that of integration and rehabilitation - prepares the client for the end of therapy. This too can take some time. After working closely with a therapist, saying goodbye and moving forward need preparation. It can feel daunting. Whilst therapy can be thought of as consisting of three phases, it is rarely a smooth progression through them, as dealing with trauma can feel unsettling. Working through difficult memories requires frequent returns back to the first phase of therapy: establishing safety.
What about medication?
There are no medications which have been shown to work for dissociative identity disorder (DID). However, medication can help with some of the consequences of living with DID. It can sometimes help with anxiety and depression, or help with sleep problems.
Medications can be used alongside therapy work and can help, during difficult times, to complement the therapy work. Your doctor might consider using antidepressants, anti-anxiety medication, antipsychotics or medication for sleep. There is a wide range of medication to choose from. Your doctor will be able to talk you through your medication choices and advise you about which is best for you.
What is the outlook in dissociative identity disorder?
Research has been carried out, looking at the progress of people with dissociative identity disorder (DID) in long-term therapy. The findings of the research have been encouraging.
Research evidence suggests that appropriate, one-to-one, long-term therapy has a positive effect on DID symptoms. It suggests that after two years of therapy, clients with DID report:
- Fewer mood and anxiety symptoms.
- Fewer dissociative episodes.
- Fewer distressing trauma symptoms.
There is evidence too of fewer hospitalisations, reduced use of psychiatric medication and fewer episodes of self-harm.
Despite fears to the contrary, evidence suggests that working sensitively with dissociated identities can be beneficial. It can increase the integration of personality parts and decrease the frequency of dissociative episodes. In the past, it had been thought that working directly with dissociated identities could make DID worse. Some believed that it could increase the characteristics of the dissociated identities, worsening DID symptoms. Evidence seems to suggest that this is not that case. If fact, working in the right way with identities can help to reduce distressing symptoms.
Treatment for DID can be challenging and time-consuming. However, over time, integration of identities and symptom improvement are possible. With the right therapy, the right support and good motivation, evidence shows us that change is possible.
Further reading and references
International Society for the Study of Trauma and Dissociation (2011); Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, Journal of Trauma & Dissociation, 12:2, 115-187
Brand BL, Sar V, Stavropoulos P, et al; Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder. Harv Rev Psychiatry. 2016 Jul-Aug24(4):257-70. doi: 10.1097/HRP.0000000000000100.
Reinders AA, Willemsen AT, Vos HP, et al; Fact or factitious? A psychobiological study of authentic and simulated dissociative identity states. PLoS One. 20127(6):e39279. doi: 10.1371/journal.pone.0039279. Epub 2012 Jun 29.
Brand, B. L., Myrick, A. C et al. A Survey of Practices and RecommendedTreatment Interventions Among Expert Therapists Treating Patients With Dissociative Identity Disorder and Dissociative Disorder Not Otherwise Specified. Psychological Trauma:Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0026487 (2011)
Cronin E, Brand BL, Mattanah JF; The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. Eur J Psychotraumatol. 2014 Mar 65. doi: 10.3402/ejpt.v5.22676. eCollection 2014.