Dissociative identity disorder

Template:Redirect2 Template:Short description Template:Cs1 config Template:Infobox medical condition (new) Dissociative identity disorder (DID), previously known as multiple personality disorder (MPD), is characterized by the presence of at least two personality states or "alters". The diagnosis is extremely controversial, largely due to two opposing models of the disorder.<ref name=":0">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="pmid15503730" /><ref name="pmid15560314" /> 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 (fantasy) model of DID as a societal construct and learned behavior used to express underlying distress; developed through iatrogenesis in therapy, cultural beliefs about the disorder, and exposure to the concept in media or online forums. The disorder was popularized in purportedly true books and films in the 20th century; Sybil became the basis for many elements of the diagnosis, but it was later found to be fictionalized.<ref name=":0" />

The disorder is accompanied by memory gaps more severe than could be explained by ordinary forgetfulness.<ref name="DSM5">Template:Cite book</ref><ref name="Hersen2014">Template:Cite book</ref> These are total memory gaps, meaning they include gaps in consciousness, basic bodily functions, perception, and all behaviors.<ref name="DSM5" /> Some clinicians view it as a form of hysteria.<ref name=":0" /> After a sharp decline in publications in the early 2000s from the initial peak in the 90s, some authors claimed the disorder to be an academic fad.<ref name = Pope/> A subsequent review in 2024 found that research in the field increased 60% afterwards, reaching steady levels with somewhat reduced controversy.<ref name=boysen2024 />

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.<ref name="American-Psychiatric-Association-2022">Template:Cite book</ref>Template:Rp<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> 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.<ref name="American-Psychiatric-Association-2022" />Template:Rp Other traumatic childhood experiences that have been reported include painful medical and surgical procedures,<ref name="American-Psychiatric-Association-2022" />Template:Rp<ref name="Dissociative-Identity-Disorder">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> war,<ref name="American-Psychiatric-Association-2022" />Template:Rp terrorism,<ref name="American-Psychiatric-Association-2022" />Template:Rp attachment disturbance,<ref name="American-Psychiatric-Association-2022" />Template:Rp natural disaster, cult and occult abuse, loss of a loved one or loved ones,<ref name="Dissociative-Identity-Disorder" /> human trafficking,<ref name="American-Psychiatric-Association-2022" />Template:Rp and dysfunctional family dynamics.<ref name="American-Psychiatric-Association-2022" />Template:Rp<ref name="Vedat">Template:Cite journal</ref>

There is no medication to treat DID directly, but medications can be used for comorbid disorders or targeted symptom relief—for example, antidepressants for anxiety and depression or sedative-hypnotics to improve sleep.<ref name="Guidelines2011">Template:Cite journal</ref><ref name="MacDonald" /> Treatment generally involves supportive care and psychotherapy.<ref name="Mer2019Pro">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The condition generally does not remit without treatment, and many patients have a lifelong course.<ref name="Mer2019Pro" /><ref name="Brand2014">Template:Cite journal</ref>

Lifetime prevalence was found to be 1.1–1.5% of the general population (based on multiple epidemiological studies) and 3.9% of those admitted to psychiatric hospitals in Europe and North America.<ref name="DSM5" /><ref name="American-Psychiatric-Association-2022" />Template:Rp<ref name="Guidelines2011" /> DID is diagnosed 6–9 times more often in women than in men.<ref name="Hersen2014" />

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.<ref name="Hersen2014" /> 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.<ref name="DSM5" /><ref name="American-Psychiatric-Association-2022" />Template:Rp

Definitions

Dissociation, the term that underlies dissociative disorder, has been defined as a "compartmentalization of psychological functions such as identity and memory that are usually integrated",<ref name=boysen2024/><ref name="Nijenhuis-2011">Template:Cite journal</ref> 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".<ref name=DSM5 /> Critics have argued that the term lacks a precise, empirical, and generally agreed upon definition,<ref name = Hersen2012>Template:Cite book</ref> proposing to define it instead as an impairment in "meta-consciousness".<ref name=lynn2022/>

Many diverse experiences have been termed dissociative, ranging from normal failures in attention to the breakdowns in memory processes characterized by the dissociative disorders.<ref name="Nijenhuis-2011" /><ref name="Wiley-2008">Template:Cite book</ref>Template:Rp 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.<ref name=Hersen2012/> Other terms used in the literature, including personality, personality state, identity, ego state, and amnesia, also lack agreed upon definitions.<ref name=Kihlstrom/><ref name=pmid15560314/> Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones.<ref name=Kihlstrom/>

Due to the lack of consensus about terminology in the study of DID, several terms have been proposed. One is ego state (behaviors and experiences possessing permeable boundaries with other such states but united by a common sense of self). Another is alters (each of which may have a separate autobiographical memory, independent initiative and a sense of ownership over individual behavior).<ref name = Gillig/><ref name="Rieger">Template:Cite bookTemplate:Page needed</ref>

Signs and symptoms

The full presentation of dissociative identity disorder can onset at any age,<ref name="American-Psychiatric-Association-2022" /> although symptoms typically begin by ages 5–10.<ref name="Gillig" /> DID is generally a disorder that develops in childhood. According to the fifth edition [text revision] of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), symptoms of DID include "the presence of two or more distinct personality states" accompanied by the inability to recall personal information beyond what is expected through normal memory issues. Other DSM-5 symptoms include a loss of identity as related to individual distinct personality states, loss of one's subjective experience of the passage of time, and degradation of a sense of self and consciousness.<ref name = dsm/> In each individual, the clinical presentation varies and the level of functioning can change from severe impairment to minimal impairment.<ref name="Cardena">Template:Cite book</ref><ref name = Mer2019Pro /> The symptoms of dissociative amnesia are subsumed under a DID diagnosis, and thus should not be diagnosed separately if DID criteria are met.<ref name=DSM5 /> Individuals with DID may experience distress from both the symptoms of DID (hearing voices, intrusive thoughts/emotions/impulses) and the consequences of the accompanying symptoms (inability to remember specific information or periods of time).<ref name = Spiegel/> The large majority of patients with DID report repeated childhood sexual and/or physical abuse, usually by caregivers as well as organized abuse.<ref name = APA2008>Template:Cite book</ref><ref>Template:Cite journal</ref> Amnesia between identities may be asymmetrical; identities may or may not be aware of what is known by another.<ref name=Mer2019Pro/> Individuals with DID may be reluctant to discuss symptoms due to associations with abuse, shame, and fear.<ref name = APA2008/>

Around half of people with DID have fewer than 10 identities and most have fewer than 100; although as many as 4,500 have been reported by Richard Kluft in 1988.<ref name = Hersen2012/>Template:Rp The average number of identities has increased over the past few decades, from two or three to now 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.<ref name = Hersen2012/>Template:Failed verification

Comorbid disorders

The psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures.<ref name=webmd>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The most common presenting complaint of DID is depression (90%) that is often treatment-resistant, with headaches and non-epileptic seizures being common neurologic symptoms. Comorbid disorders include post-traumatic stress disorder (PTSD), substance use disorders, eating disorders, anxiety disorders, personality disorders, and autism spectrum disorder.<ref name="Dorahy2014">Template:Cite journal</ref><ref>Template:Cite book</ref> 30-70% of those diagnosed with DID have history of borderline personality disorder.<ref name="Shadows">Template:Cite journal</ref> 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, although both conditions share a high rate of auditory hallucinations in the form of voices.<ref>Template:Cite journal</ref> Disturbed and altered sleep has also been suggested as having a role in dissociative disorders in general and specifically in DID, alterations in environments also largely affecting the DID patient.<ref name="Kloet2012" /> Individuals diagnosed with DID demonstrate the highest hypnotizability of any clinical population.Template:Citation needed

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.<ref name="Blihar">Template:Cite journal</ref><ref name="Dalenberg-2012">Template:Cite journal</ref><ref name="Vissia-2016">Template:Cite journal</ref> 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.<ref name="Blihar" /><ref name="Dalenberg-2012" /><ref name="Vissia-2016" />

The DSM-5-TR states that "early life trauma (e.g., neglect and physical, sexual, and emotional abuse, usually before ages 5-6 years) represents a major risk factor for dissociative identity disorder."<ref name="American-Psychiatric-Association-2022" />Template:Rp Other risk factors reported include painful medical procedures, experiences of war, witnessing terrorism, or being trafficked in childhood.<ref name="American-Psychiatric-Association-2022" />Template:Rp 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.<ref name="American-Psychiatric-Association-2022" />Template:Rp

Traumagenic model

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Dissociative identity disorder is often conceptualized as "the most severe form of a childhood-onset post-traumatic stress disorder."<ref name="Blihar" /> According to many researchers, the etiology of dissociative identity is multifactorial, involving a complex interaction between developmental trauma, sociocultural influences, and biological factors.<ref name="Dorahy">Template:Cite journal</ref><ref name="Blihar" /><ref name="Vedat" />

People diagnosed with dissociative identity disorder often report that they have experienced physical or sexual abuse during childhood<ref name="Mer2019Pro" /> (although the accuracy of these reports has been disputed<ref name="dsm" />); others report overwhelming stress, serious medical illness, or other traumatic events during childhood.<ref name="Mer2019Pro" /> They also report more historical psychological trauma than those diagnosed with any other mental illness.<ref name="Sar2011">Template:Cite journal See also §5.3, Childhood Psychological Trauma, p. 5.</ref>Template:Efn

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.<ref>Template:Cite book</ref> 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 (C-PTSD) 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.<ref name=Spiegel>Template:Cite journal</ref>

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.<ref name = Spiegel/> Relationships between childhood abuse, disorganized attachment, and lack of social support are thought to be common risk factors leading to dissociative identity disorder.<ref name = Gillig/> Although the role of a child's biological capacity to dissociate remains unclear, some evidence indicates a neurobiological impact of developmental stress. Moreover, the 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.<ref name="Vedat"/>

Delinking early trauma from the etiology of dissociation has been explicitly rejected by those supporting the early trauma model. However, a 2012 review article supports 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.<ref name="pmid22423434">Template:Cite journal</ref> Giesbrecht et al. have suggested there is no actual 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.<ref name="pmid18729565">Template:Cite journal</ref> 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".<ref name = Spiegel/> 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.<ref name = Lynn2012/>

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.<ref name = Paris2012/>

Sociogenic model

Symptoms of dissociative identity disorder may be created by therapists using techniques to "recover" memories (such as the use of hypnosis to "access" alter identities, facilitate age regression or retrieve memories) on suggestible individuals.<ref name="pmid15503730" /><ref name="pmid15560314"/><ref name =Cardena/><ref name = Boysen/><ref name="Blackwell">Template:Cite book</ref> Referred to as the non-trauma-related model, or the sociocognitive model or fantasy model, it proposes that dissociative identity disorder is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes,<ref name = Boysen/> with unwitting therapists providing cues through improper therapeutic techniques. This model posits that behavior is enhanced by media portrayals of dissociative identity disorder.<ref name = Lynn2012/>

Proponents of the non-trauma-related model note that the dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of dissociative identity disorder who, through the process of eliciting, conversing with, and identifying alters, shape or possibly create the diagnosis.<ref>Template:Cite book</ref> While proponents note that dissociative identity disorder is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are skeptical of the trauma-related etiology suggested by proponents of the trauma-related model.<ref name = McNally2005/> Proponents of non-trauma-related dissociative identity disorder are concerned about the possibility of hypnotizability, suggestibility, frequent fantasization and mental absorption predisposing individuals to dissociation.<ref name="MacDonald">Template:Cite journal</ref> They note that a small subset of doctors are responsible for diagnosing the majority of individuals with dissociative identity disorder.<ref name="Blackwell neurology">Template:Cite book</ref><ref name="pmid15560314"/><ref name = Paris2012/>

Psychologist Nicholas Spanos and others have suggested that, besides cases caused by therapy, dissociative identity disorder might result from role-playing. However, others disagree, arguing that there is no strong incentive for people to fabricate or maintain separate identities. They also cite reported histories of abuse as evidence.<ref>Template:Cite book</ref> Other arguments that therapy can cause dissociative identity disorder include the lack of children diagnosed with DID, the sudden spike in rates of diagnosis after 1980 (although dissociative identity disorder was not a diagnosis until DSM-IV, published in 1994), the absence of evidence of increased rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities (such as those claiming to be animals or mythological creatures) and an increase in the number of alternate identities over time<ref name="Lynn2012" /><ref name="pmid15560314" /> (as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy<ref name="Lynn2012" />). These various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably borderline personality disorder, which is commonly comorbid with dissociative identity disorder.<ref name="Lynn2012" /> In addition, presentations can vary across cultures, such as Indian patients who only switch alters after a period of sleep – which is commonly how dissociative identity disorder is presented by the media within that country.<ref name="Lynn2012" />

Proponents of non-trauma-related dissociative identity disorder state that the disorder is strongly linked to (possibly suggestive) psychotherapy, often involving recovered memories (memories that the person previously had amnesia for) or false memories, and that such therapy could cause additional identities. Such memories could be used to make an allegation of child sexual abuse. There is little agreement between those who see therapy as a cause and trauma as a cause.<ref name="Rein2008">Template:Cite journal</ref> Supporters of therapy as a cause of dissociative identity disorder suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position<ref name="Boysen" /> though it has also been claimed that higher rates of diagnosis in specific countries like the United States may be due to greater awareness of DID. Lower rates in other countries may be due to artificially low recognition of the diagnosis.<ref name="Cardena" /> However, false memory syndrome per se is not regarded by mental health experts as a valid diagnosis,<ref>Template:Cite book</ref> and has been described as "a non-psychological term originated by a private foundation whose stated purpose is to support accused parents,"<ref name="Carstensen1993">Template:Cite journal</ref> and critics argue that the concept has no empirical support, and further describe the False Memory Syndrome Foundation as an advocacy group that has distorted and misrepresented memory research.<ref name="Dallam">Template:Cite journal</ref><ref name="olio">Template:Cite book</ref>

A review of recent research into DID found not one empirical study into the sociocognitive model in the 2011-2021 period, identifying the model as "a source of unresolved criticism of the trauma model", not an empirical hypothesis in its own right. Some major skeptics of trauma-related DID have in recent years abandoned single-cause models of the disorder, arguing for an end to the controversy as no such model can provide a "complete or fully satisfactory account" of DID.<ref name=boysen2024/> As part of their "trans-theoretical" model Lynn et al. suggested that trauma may be more important than sociocognitive factors in clinical cases.<ref name=lynn2022>Template:Cite journal</ref>

Children

The rarity of DID diagnoses in children is cited as a reason to doubt the validity of the disorder,<ref name="pmid15560314"/><ref name=Boysen/> and proponents of both etiologies believe that the discovery of dissociative identity disorder in a child who had never undergone treatment would critically undermine the non-trauma related model. Conversely, if children are found to develop dissociative identity disorder only after undergoing treatment it would challenge the trauma-related model.<ref name=Boysen/> Template:As of, approximately 250 cases of dissociative identity disorder in children have been identified, though the data does not offer unequivocal support for either theory. While children have been diagnosed with dissociative identity disorder before therapy, several were presented to clinicians by parents who were themselves diagnosed with dissociative identity disorder; others were influenced by the appearance of dissociative identity disorder in popular culture or due to a diagnosis of psychosis due to hearing voices – a symptom also found in dissociative identity disorder. No studies have looked for children with dissociative identity disorder in the general population, and the single study that attempted to look for children with dissociative identity disorder not already in therapy did so by examining siblings of those already in therapy for dissociative identity disorder. An analysis of diagnosis of children reported in scientific publications, 44 case studies of single patients were found to be evenly distributed (i.e., each case study was reported by a different author) but in articles regarding groups of patients, four researchers were responsible for the majority of the reports.<ref name=Boysen/>

The initial theoretical description of dissociative identity disorder was that dissociative symptoms were a means of coping with extreme stress (particularly childhood sexual and physical abuse), but this belief has been challenged by the data of multiple research studies.<ref name=Lynn2012>Template:Cite journal</ref> Proponents of the trauma-related model claim the high correlation of child sexual and physical abuse reported by adults with dissociative identity disorder corroborates the link between trauma and dissociative identity disorder.<ref name=Hersen2012/><ref name=Lynn2012/> However, the link between dissociative identity disorder and maltreatment has been questioned for several reasons. The studies reporting the links often rely on self-report rather than independent corroborations, and these results may be worsened by selection and referral bias.<ref name=Hersen2012/><ref name=Lynn2012/> Most studies of trauma and dissociation are cross-sectional rather than longitudinal, which means researchers can not attribute causation, and studies avoiding recall bias have failed to corroborate such a causal link.<ref name=Hersen2012/><ref name=Lynn2012/> In addition, studies rarely control for the many disorders comorbid with dissociative identity disorder, or family maladjustment (which is itself highly correlated with dissociative identity disorder).<ref name=Hersen2012/><ref name=Lynn2012/> The popular association of dissociative identity disorder with childhood abuse is relatively recent, occurring only after the publication of Sybil in 1973. Most previous examples of "multiples" such as Chris Costner Sizemore, whose life was depicted in the book and film The Three Faces of Eve, reported no memory of childhood trauma.<ref name=McNally2005>Template:Cite book</ref>

Pathophysiology

Despite research on DID including structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potentials, and electroencephalography, no convergent neuroimaging findings have been identified regarding DID, with the exception of smaller hippocampal volume in DID patients. In addition, many of the studies that do exist were performed from an explicitly trauma-based position. There is no research to date regarding the neuroimaging and introduction of false memories in DID patients.<ref name = Rein2008/> or support for amnesia between alters.<ref name = Rein2008/><ref name = Kihlstrom/> DID patients also appear to show deficiencies in tests of conscious control of attention and memorization (which also showed signs of compartmentalization for implicit memory between alters but no such compartmentalization for verbal memory) and increased and persistent vigilance and startle responses to sound. DID patients may also demonstrate altered neuroanatomy.<ref name = Gillig/>

Diagnosis

General

The fifth, revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) diagnoses DID according to the diagnostic criteria found under code 300.14 (dissociative disorders). DID is often initially misdiagnosed because clinicians receive little training about dissociative disorders or DID, and often use standard diagnostic interviews that do not include questions about trauma, dissociation, or post-traumatic symptoms.<ref name=Guidelines2011 />Template:Rp This contributes to difficulties diagnosing the disorder, and to clinician bias.<ref name=Guidelines2011 />

DID is rarely diagnosed in children.<ref name="pmid15560314"/> The criteria require that an individual be recurrently controlled by two or more discrete identities or personality states, accompanied by memory lapses for important information that is not caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures.<ref name="DSM5" /> In children, the symptoms must not be better explained by "imaginary playmates or other fantasy play".<ref name="DSM5" /> Diagnosis is normally performed by a clinically trained mental health professional such as a psychiatrist or psychologist through clinical evaluation, interviews with family and friends, and consideration of other ancillary material. Specially designed interviews (such as the SCID-D) and personality assessment tools may be used in the evaluation as well.<ref name="webmd"/> Since most of the symptoms depend on self-report and are not concrete and observable, there is a degree of subjectivity in making the diagnosis.<ref name = Kihlstrom/> People are often disinclined to seek treatment, especially since their symptoms may not be taken seriously; thus dissociative disorders have been referred to as "diseases of hiddenness".<ref name="MacDonald"/><ref name="Recognizing Traumatic Dissociation">Template:Cite journal</ref>

The diagnosis has been criticized by supporters of therapy as a cause or the sociocognitive hypothesis as they believe it is a culture-bound and often health care induced condition.<ref name = Hersen2012/><ref name="pmid15560314">Template:Cite journal</ref><ref name="pmid15503730" /> The social cues involved in diagnosis may be instrumental in shaping patient behavior or attribution, such that symptoms within one context may be linked to DID, while in another time or place the diagnosis could have been something other than DID.<ref name = Paris2012/> Other researchers disagree and argue that the existence of the condition and its inclusion in the DSM is supported by multiple lines of reliable evidence, with diagnostic criteria allowing it to be clearly discriminated from conditions it is often mistaken for (schizophrenia, borderline personality disorder, and seizure disorder).<ref name = Cardena/> That a large proportion of cases are diagnosed by specific health care providers, and that symptoms have been created in nonclinical research subjects given appropriate cueing has been suggested as evidence that a small number of clinicians who specialize in DID are responsible for the creation of alters through therapy.<ref name = Hersen2012/>

Differential diagnoses

Patients with DID are diagnosed with 5-7 comorbid disorders on average – higher than other mental conditions. Misdiagnoses (e.g. schizophrenia, bipolar disorder) are very common among patients with DID.<ref name=Gillig/>

Due to overlapping symptoms, the differential diagnosis includes schizophrenia, normal and rapid-cycling bipolar disorder, epilepsy, borderline personality disorder, and autism spectrum disorder.<ref name=Shibayama>Template:Cite journal</ref> Delusions or auditory hallucinations can be mistaken for speech by other personalities.<ref name=Spiegel/> Persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotizability and reports from family members or other associates indicating a history of such changes can help distinguish DID from other conditions. A diagnosis of DID takes precedence over any other dissociative disorders. Distinguishing DID from malingering is a concern when financial or legal gains are an issue, and factitious disorder may also be considered if the person has a history of help or attention-seeking. Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with dissociative disorder not otherwise specified rather than DID due to the lack of identities or personality states.<ref name = dsm>Template:Cite book</ref> Most individuals who enter an emergency department and are unaware of their names are generally in a psychotic state. Although auditory hallucinations are common in DID, complex visual hallucinations may also occur.<ref name=Gillig>Template:Cite journal</ref> Those with DID generally have adequate reality testing. People with DID may have more positive and less negative Schneiderian symptoms of schizophrenia.<ref name=Cardena2/> The DID persona perceives any voices heard as coming from inside their heads whereas the schizophrenia persona perceives voices as external.<ref name=Hersen2012/> In addition, individuals with psychosis are much less susceptible to hypnosis than those with DID.<ref name=Spiegel/> Difficulties in differential diagnosis are increased in children.<ref name=Boysen/>

DID must be distinguished from, or determined if comorbid with, a variety of disorders including mood disorders, psychosis, anxiety disorders, PTSD, personality disorders, cognitive disorders, neurological disorders, epilepsy, somatoform disorder, factitious disorder, malingering, other dissociative disorders, and trance states.<ref name=Sad2007>Template:Cite book</ref> An additional aspect of the controversy of diagnosis is that there are many forms of dissociation and memory lapses, which can be common in both stressful and nonstressful situations and can be attributed to much less controversial diagnoses.<ref name = Paris2012/>

A relationship between DID and borderline personality disorder has been posited, with various clinicians noting overlap between symptoms and behaviors and it has been suggested that some cases of DID may arise "from a substrate of borderline traits". Reviews of DID patients and their medical records concluded that 30-70% of those diagnosed with DID have comorbid borderline personality disorder.<ref name=Gillig/>

The DSM-5 elaborates on cultural background as an influence for some presentations of DID.<ref name=DSM5/>Template:Rp

Many features of dissociative identity disorder can be influenced by the individual's cultural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the characteristics of other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and their surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion.{{#if:|{{#if:|}}

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Controversy and criticism of validity

DID is among the most controversial of the dissociative disorders and among the most controversial disorders found in the DSM-5-TR.<ref name=Stern>Template:Cite book</ref><ref name=Hersen2012/><ref name="Blihar"/> The primary dispute is between those who believe DID is caused by traumatic stresses that split the mind into multiple identities, each with a separate set of memories,<ref name= Howell/><ref name=Kihlstrom/> and those who believe that the symptoms of DID are produced artificially by certain psychotherapeutic practices or patients playing a role they believe appropriate for a person with DID.<ref name=Blackwell/><ref name="pmid15503730"/><ref name="MacDonald" /><ref name="Weiten">Template:Cite book</ref><ref name=Cardena2>Template:Cite book</ref> The debate between the two positions is characterized by intense disagreement.<ref name=Rein2008/><ref name=Blackwell/><ref name="pmid15560314"/><ref name="pmid15503730"/><ref name =Weiten/><ref name=Cardena2/> Research has been characterized by poor methodology.<ref name="Howell">Template:Cite book</ref> Psychiatrist Joel Paris asserts that the idea that a personality is capable of splitting into independent alters is an unproven assertion at odds with research in cognitive psychology,<ref name = Paris2012/> while David Gleaves argues that recognition of DID was in fact prompted by developments in that field, including theories of parallel-distributed processing.<ref>Template:Cite journal</ref>

Some people, such as Russell A. Powell and Travis L. Gee, believe that DID is caused by health care, i.e. symptoms of DID are created by therapists themselves via hypnosis. This implies that those with DID are especially susceptible to manipulation by hypnosis and suggestion.<ref>Template:Cite journal</ref> The iatrogenic model also sometimes states that treatment for DID is harmful. According to Brand, Loewenstein, and Spiegel, "claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID". Their claim is evidenced by the fact that only 5%–10% of people receiving treatment initially worsen in their symptoms.<ref name=Brand2014 />

Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation—that people with DID report childhood trauma does not mean trauma causes DID—and point to the rarity of the diagnosis before 1980 as well as a failure to find DID as an outcome in longitudinal studies of traumatized children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as "personality state" and "identities", and question the evidence for childhood abuse beyond self-reports, the lack of a defined threshold of abuse sufficient to induce DID, and the extremely small number of cases of children diagnosed with DID despite an average age of appearance of the first alter of three years.<ref name="pmid15560314"/> Psychiatrist Colin Ross disagrees with Piper and Merskey's conclusion that DID cannot be accurately diagnosed, pointing to internal consistency between different structured dissociative disorder interviews (including the Dissociative Experiences Scale, Dissociative Disorders Interview Schedule, and Structured Clinical Interview for Dissociative Disorders)<ref name=Kihlstrom/> in the internal validity range of widely accepted mental illnesses such as schizophrenia and major depressive disorder. In his opinion, Piper and Merskey set the standard of proof higher than it is for other diagnoses. He also asserts that Piper and Merskey have cherry-picked data and not incorporated all relevant scientific literature, such as independent corroborating evidence of trauma.<ref name=Ross2009>Template:Cite journal</ref>

Treatment

Treatment under the sociogenic model

Proponents of the sociogenic model dispute that dissociative identity disorder is an organic response to trauma, but believe it is a socially constructed behavior and psychic contagion. Paul R. McHugh says that the disorder is "sustained in large part by the attention that doctors tend to pay to it. This means that it is not a mental condition that derives from nature, such as panic anxiety or major depression. It exists in the world as an artificial product of human devising". McHugh believed that proponents of dissociative identity disorder inadvertently worsen patient condition by validating the behavior and providing attention.<ref>Template:Cite book</ref>

According to McHugh, at Johns Hopkins Hospital doctors should ignore the displays from "alters", and instead focus on treatment for other psychiatric problems patients present with. This method of treatment is reportedly successful:Template:Sfn

According to a 2014 review, such views are based on anecdotal or non-peer-reviewed findings. In controlled studies, non-specialised treatment that did not address dissociative self-states did not substantially improve DID symptoms, though there may be improvement in patients' other conditions.<ref name="Brand2014" />

Treatments under the trauma model

The International Society for the Study of Trauma and Dissociation, proponents of the trauma model, have published guidelines for phase-oriented treatment in adults as well as children and adolescents that are widely used successfully in the field of DID treatment.<ref name="Dorahy2014" /><ref name="Guidelines2011" /> The guidelines state that "a desirable treatment outcome is a workable form of integration or harmony among alternate identities". Some experts in treating people with DID use the techniques recommended in the 2011 treatment guidelines.<ref name="Dorahy2014" /> The empirical research includes the longitudinal TOP DD treatment study, which found that patients showed "statistically significant reductions in dissociation, PTSD, distress, depression, hospitalisations, suicide attempts, self-harm, dangerous behaviours, drug use, and physical pain" and improved overall functioning.<ref name="Dorahy2014" /> Treatment effects have been studied for over thirty years, with some studies having a follow-up of ten years.<ref name="Dorahy2014" /> Adult and child treatment guidelines exist that suggest a three-phased approach.<ref name="Guidelines2011" />

Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive behavioral therapy (CBT),<ref name="Guidelines2011" /><ref name="Gillig" /> insight-oriented therapy,<ref name="Kihlstrom" /> dialectical behavioral therapy (DBT), hypnotherapy, and eye movement desensitization and reprocessing (EMDR).<ref>Template:Cite journal</ref>

Hypnosis should be carefully considered when choosing both treatment and provider practitioners because of its dangers. For example, hypnosis can sometimes lead to false memories and false accusations of abuse by family, loved ones, friends, providers, and community members. Those who suffer from dissociative identity disorder have commonly been subject to actual abuse (sexual, physical, emotional, financial) by therapists, family, friends, loved ones, and community members.<ref>Template:Cite journal</ref>

Brief treatment due to managed care may be difficult, as individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic alliance.<ref name="Guidelines2011" /> Regular contact (at least weekly) is recommended, and treatment generally lasts years – not weeks or months.<ref name="Gillig" /> Sleep hygiene has been suggested as a treatment option, but has not been tested. In general there are very few clinical trials on the treatment of DID, none of which were randomized controlled trials.<ref name="Lynn2012" />

Therapy for DID is generally phase oriented.<ref name="Dorahy2014" /> Different alters may appear based on their greater ability to deal with specific situational stresses or threats. While some patients may initially present with a large number of alters, this number may reduce during treatment – though it is considered important for the therapist to become familiar with at least the more prominent personality states as the "host" personality may not be the "true" identity of the patient. Specific alters may react negatively to therapy, fearing the therapist's goal is to eliminate the alter (particularly those associated with illegal or violent activities). A more realistic and appropriate goal of treatment is to integrate adaptive responses to abuse, injury, or other threats into the overall personality structure.<ref name="Gillig" />

The first phase of therapy focuses on symptoms and relieving the distressing aspects of the condition, ensuring the safety of the individual, improving the patient's capacity to form and maintain healthy relationships, and improving general daily life functioning. Comorbid disorders such as substance use disorder and eating disorders are addressed in this phase of treatment.<ref name="Guidelines2011" /> The second phase focuses on stepwise exposure to traumatic memories and prevention of re-dissociation. The final phase focuses on reconnecting the identities of disparate alters into a single functioning identity with all its memories and experiences intact.<ref name="Guidelines2011" />

Prognosis

Little is known about prognosis of untreated DID.<ref name = Sad2007/> Symptoms commonly wax and wane over time.<ref name = Mer2019Pro/> Patients with mainly dissociative and post-traumatic symptoms face a better prognosis than those with comorbid disorders or those still in contact with abusers, and the latter groups often face a lengthier and more difficult treatment course. Suicidal ideation, suicide attempts, and self-harm are common in the DID population.<ref name = Mer2019Pro/> Duration of treatment can vary depending on patient goals, which can range from merely improving inter-alter communication and cooperation, to reducing inter-alter amnesia, to integration and fusion of all alters, but this last goal generally takes years, with trained and experienced psychotherapists.<ref name = Mer2019Pro/>

Epidemiology

General

According to the American Psychiatric Association, the 12-month prevalence of DID among adults in the US is 1.5%, with similar prevalence between women and men.<ref name="Reategui-2019">Template:Cite journal</ref> Population prevalence estimates have been described to widely vary, with some estimates of DID in inpatient settings suggesting 1-9.6%."<ref name = Hersen2012/> Reported rates in the community vary from 1% to 3% with higher rates among psychiatric patients.<ref name = Guidelines2011/><ref name = Cardena/> As of 2017, evidence suggested a prevalence of DID of 2–5% among psychiatric inpatients, 2–3% among outpatients, and 1% in the general population.<ref name="Vedat"/>

As of 2012, DID was diagnosed 5 to 9 times more common in women than men during young adulthood, although this may have been due to selection bias as men meeting DID diagnostic criteria were suspected to end up in the criminal justice system rather than hospitals.<ref name = Hersen2012/> DID diagnoses are extremely rare in children; much of the research on childhood DID occurred in the 1980s and 1990s and does not address ongoing controversies surrounding the diagnosis.<ref name="Boysen">Template:Cite journal</ref> DID occurs more commonly in young adults<ref name="Sadockconcise">Template:Cite book</ref> and declines in prevalence with age.<ref>Template:Cite book</ref>

There is a poor awareness of DID in the clinical settings and the general public. Poor clinical education (or lack thereof) for DID and other dissociative disorders has been described in literature: "most clinicians have been taught (or assume) that DID is a rare disorder with a florid, dramatic presentation."<ref name="Guidelines2011" /><ref name="Stern" /> Symptoms in patients are often not easily visible, which complicates diagnosis.<ref name="Guidelines2011" /> DID has a high correlation with, and has been described as a form of, complex post-traumatic stress disorder.<ref>Template:Cite journal</ref> There is a significant overlap of symptoms between borderline personality disorder and DID.<ref>Template:Cite journal</ref>

Historical prevalence

Rates of diagnosed DID were increasing in the late 20th century, reaching a peak of diagnoses at approximately 40,000 cases by the end of the 20th century, up from less than 200 diagnoses before 1970.<ref name = APA2008/><ref name = Hersen2012/> Initially DID along with the rest of the dissociative disorders were considered the rarest of psychological conditions, diagnosed in less than 100 by 1944, with only one further case reported in the next two decades.<ref name =Kihlstrom/> In the late 1970s and '80s, the number of diagnoses rose sharply.<ref name =Kihlstrom/> An estimate from the 1980s placed the incidence at 0.01%.<ref name = APA2008/> Accompanying this rise was an increase in the number of alters, rising from only the primary and one alter personality in most cases, to an average of 13 in the mid-1980s (the increase in both number of cases and number of alters within each case are both factors in professional skepticism regarding the diagnosis).<ref name = Kihlstrom/> Others explain the increase as being due to the use of inappropriate therapeutic techniques in highly suggestible individuals, though this is itself controversial<ref name = Blackwell/><ref name = Weiten/> while proponents of DID claim the increase in incidence is due to increased recognition of and ability to recognize the disorder.<ref name = Hersen2012/>

A 1996 essay suggested three possible causes for the sudden increase of DID diagnoses, among which the author suspects the first being most likely:<ref name="Paris J 1996">Template:Cite journal</ref>

1. The result of therapist suggestions to suggestible people, much as Charcot's hysterics acted in accordance with his expectations.
2. Psychiatrists' past failure to recognize dissociation being redressed by new training and knowledge.
3. Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: "hysteria".

Dissociative disorders were excluded from the Epidemiological Catchment Area Project.<ref>Template:Cite book</ref>

North America

DID continues to be considered a controversial diagnosis; it was once regarded as a phenomenon confined to North America, though studies have since been published from DID populations across 6 continents.<ref name="pmid15503730">Template:Cite journal</ref><ref name="pmid7794202" /> Although research has appeared discussing the appearance of DID in other countries and cultures<ref>Template:Cite book</ref> and the condition has been described in non-English speaking nations and non-Western cultures, these reports all occur in English-language journals authored by international researchers who cite Western scientific literature.<ref name="Boysen" />

Social media

A paper published in 2022 in the journal Comprehensive Psychiatry described how prolonged social media use, especially on video-sharing platforms including TikTok, has exposed young people, largely adolescent females, a core user group of TikTok, to a growing number of content creators making videos about their self-diagnosed disorders. "An increasing number of reports from the US, UK, Germany, Canada, and Australia have noted an increase in functional tic-like behaviors prior to and during the COVID-19 pandemic, coinciding with an increase in social media content related to[...]dissociative identity disorder." Authors noted that such cases of self-diagnosed DID (amongst other conditions) often differ from clinically defined symptoms of the disorder, creating the possibility of malingering, and potential negative impacts on those with clinically diagnosed DID seeking integrative therapy. The paper concluded that there "is an urgent need for focused empirical research investigation into this concerning phenomenon that is related to the broader research and discourse examining social media influences on mental health".<ref>Template:Cite news</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="pmid37271332">Template:Cite journal</ref>

History

File:Vivé.jpg

One of ten photogravure portraits of Louis Vivet published in Variations de la personnalité by Henri Bourru and Prosper Ferdinand Burot

Early references

In the 19th century, dédoublement, or "double consciousness", the historical precursor to DID, was frequently described as a state of sleepwalking, with scholars hypothesizing that the patients were switching between a normal consciousness and a "somnambulistic state".<ref name = Kloet2012>Template:Cite journal</ref>

An intense interest in spiritualism, parapsychology and hypnosis continued throughout the 19th and early 20th centuries,<ref name="pmid7794202">Template:Cite journal</ref> running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings.<ref name="pmid12094818">Template:Cite journal</ref> Hypnosis, which was pioneered in the late 18th century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.<ref name="pmid7794202" />

File:Plaque Pierre Janet, 54 rue de Varenne, Paris 7.jpg

The plaque on the former house of Pierre Marie Félix Janet (1859–1947), the philosopher and psychologist who first alleged a connection between events in the subject's past and present mental health, also coining the words "dissociation" and "subconscious"

In the 19th century, there were a number of reported cases of multiple personalities which Rieber<ref name="pmid12094818"/> estimated would be close to 100. Epilepsy was seen as a factor in some cases,<ref name="pmid12094818" /> and discussion of this connection continues into the present era.<ref name="pmid6427406">Template:Cite journal</ref><ref name="pmid2725878">Template:Cite journal</ref>

By the late 19th century, there was a general acceptance that emotionally traumatic experiences could cause long-term disorders which might display a variety of symptoms.<ref name="Borch-Jacobsen M 2000">Template:Cite journal</ref> These conversion disorders were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivet (1863–?), who had a traumatic experience as a 17-year-old when he encountered a viper. Vivet was the subject of countless medical papers and became the most studied case of dissociation in the 19th century.

Between 1880 and 1920, various international medical conferences devoted time to sessions on dissociation.<ref name="putnam">Template:Cite book</ref> It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation.<ref name="pmid2686473">Template:Cite journal</ref> One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality.<ref name="pmid2686473"/><ref>Template:Cite book</ref>

20th century

In the early 20th century, interest in dissociation and multiple personalities waned for several reasons. After Charcot's death in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet's association with Charcot tarnished his theories of dissociation.<ref name="pmid7794202" /> Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.<ref name="pmid7794202" />

In 1908, Eugen Bleuler introduced the term "schizophrenia" to represent a revised disease concept for Emil Kraepelin's dementia praecox.<ref name="Noll 2011">Template:Cite book</ref> Whereas Kraepelin's natural disease entity was anchored in the metaphor of progressive deterioration and mental weakness and defect, Bleuler offered a reinterpretation based on dissociation or "splitting" (Spaltung) and widely broadened the inclusion criteria for the diagnosis. A review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States.<ref name="pmid7004385">Template:Cite journal</ref> The rise of the broad diagnostic category of dementia praecox has also been posited in the disappearance of "hysteria" (the usual diagnostic designation for cases of multiple personalities) by 1910.<ref>Template:Cite journal</ref> A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.<ref name="putnam"/>

Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports.<ref name="putnam"/> With the rise of a uniquely American reframing of dementia praecox/schizophrenia as a functional disorder or "reaction" to psychobiological stressors – a theory first put forth by Adolf Meyer in 1906—many trauma-induced conditions associated with dissociation, including "shell shock" or "war neuroses" during World War I, were subsumed under these diagnoses.<ref name="Noll 2011"/> It was argued in the 1980s that DID patients were often misdiagnosed with schizophrenia.<ref name=putnam/>

The public, however, was exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe had a formidable impact.<ref name=pmid12094818/>

The Three Faces of Eve

In 1957, with the publication of the bestselling book The Three Faces of Eve by psychiatrists Corbett H. Thigpen and Hervey M. Cleckley, based on a case study of their patient Chris Costner Sizemore, and the subsequent popular movie of the same name, the American public's interest in multiple personality was revived. More cases of dissociative identity disorder were diagnosed in the following years.<ref name="Schacter, D. L. 2011">Template:Cite book</ref> The cause of the sudden increase of cases is indefinite, but it may be attributed to the increased awareness, which revealed previously undiagnosed cases or new cases may have been induced by the influence of the media on the behavior of individuals and the judgement of therapists.<ref name="Schacter, D. L. 2011"/> During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.<ref name="putnam"/>

History in the DSM

The DSM-II used the term hysterical neurosis, dissociative type. It described the possible occurrence of alterations in the patient's state of consciousness or identity, and included the symptoms of "amnesia, somnambulism, fugue, and multiple personality".<ref name=dsmii/> The DSM-III grouped the diagnosis with the other four major dissociative disorders using the term "multiple personality disorder". The DSM-IV made more changes to DID than any other dissociative disorder,<ref name = Cardena/> and renamed it DID.<ref name=dsm/> The name was changed for two reasons: First, the change emphasizes the main problem is not a multitude of personalities, but rather a lack of a single, unified identity<ref name = Cardena/> and an emphasis on "the identities as centers of information processing".<ref name = Spiegel/> Second, the term "personality" is used to refer to "characteristic patterns of thoughts, feelings, moods, and behaviors of the whole individual", while for a patient with DID, the switches between identities and behavior patterns is the personality.<ref name = Cardena/> It is, for this reason, the DSM-IV-TR referred to "distinct identities or personality states" instead of personalities. The diagnostic criteria also changed to indicate that while the patient may name and personalize alters, they lack independent, objective existence.<ref name = Cardena/> The changes also included the addition of amnesia as a symptom, which was not included in the DSM-III-R because despite being a core symptom of the condition, patients may experience "amnesia for the amnesia" and fail to report it.<ref name = Spiegel/> Amnesia was replaced when it became clear that the risk of false negative diagnoses was low because amnesia was central to DID.<ref name = Cardena/>

The ICD-10 places the diagnosis in the category of "dissociative disorders", within the subcategory of "other dissociative (conversion) disorders", but continues to list the condition as multiple personality disorder.<ref name="ICD10">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

The DSM-IV-TR criteria for DID have been criticized for failing to capture the clinical complexity of DID, lacking usefulness in diagnosing individuals with DID (for instance, by focusing on the two least frequent and most subtle symptoms of DID) producing a high rate of false negatives and an excessive number of DDNOS diagnoses, for excluding possession (seen as a cross-cultural form of DID), and for including only two "core" symptoms of DID (amnesia and self-alteration) while failing to discuss hallucinations, trance-like states, somatoform, depersonalization, and derealization symptoms. Arguments have been made for allowing diagnosis through the presence of some, but not all of the characteristics of DID rather than the current exclusive focus on the two least common and noticeable features.<ref name = Spiegel/> The DSM-IV-TR criteria have also been criticized<ref>Template:Cite journal</ref> for being tautological, using imprecise and undefined language and for the use of instruments that give a false sense of validity and empirical certainty to the diagnosis.

The DSM-5 updated the definition of DID in 2013, summarizing the changes as:<ref name=highlights>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Several changes to the criteria for dissociative identity disorder have been made in DSM-5. First, Criterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. Second, Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions.{{#if:|{{#if:|}}

— {{#if:|, in }}Template:Comma separated entries

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{{#invoke:Check for unknown parameters|check|unknown=Template:Main other|preview=Page using Template:Blockquote with unknown parameter "_VALUE_"|ignoreblank=y| 1 | 2 | 3 | 4 | 5 | author | by | char | character | cite | class | content | multiline | personquoted | publication | quote | quotesource | quotetext | sign | source | style | text | title | ts }}

Between 1968 and 1980, the term that was used for dissociative identity disorder was "Hysterical neurosis, dissociative type". The APA wrote in the second edition of the DSM: "In the dissociative type, alterations may occur in the patient's state of consciousness or in his identity, to produce such symptoms as amnesia, somnambulism, fugue, and multiple personality."<ref name=dsmii>Template:Cite book</ref> The number of cases sharply increased in the late 1970s and throughout the 80s, and the first scholarly monographs on the topic appeared in 1986.<ref name = Kihlstrom/>

Book and film Sybil

In 1974, the highly influential book Sybil was published, and later made into a miniseries in 1976 and again in 2007. Describing what Robert Rieber called "the third most famous of multiple personality cases,"<ref name = Rieber>Template:Cite journal</ref> it presented a detailed discussion of the problems of treatment of "Sybil Isabel Dorsett", a pseudonym for Shirley Ardell Mason.

Though the book and subsequent films helped popularize the diagnosis and trigger an epidemic of the diagnosis,<ref name = Paris2012>Template:Cite journal</ref> later analysis of the case suggested different interpretations, ranging from Mason's problems having been caused by the therapeutic methods and sodium pentathol injections used by her psychiatrist, C. B. Wilbur, or an inadvertent hoax due in part to the lucrative publishing rights,<ref name = Rieber/><ref>Template:Cite book</ref> though this conclusion has itself been challenged.<ref>Template:Cite journal</ref>

David Spiegel, a Stanford psychiatrist whose father treated Shirley Ardell Mason on occasion, says that his father described Mason as "a brilliant hysteric. He felt that Wilbur tended to pressure her to exaggerate on the dissociation she already had."<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Template:Better source needed As media attention on DID increased, so too did the controversy surrounding the diagnosis.<ref name="Farrell">Template:Cite journal</ref>

Re-classifications

The DSM-III intentionally omitted the terms "hysteria" and "neurosis", naming those as Dissociative Disorders, which included Multiple Personality Disorder,<ref>Template:Cite book</ref> and also added Post-traumatic Stress Disorder in Anxiety Disorders section.

In the opinion of McGill University psychiatrist Joel Paris, this inadvertently legitimized them by forcing textbooks, which mimicked the structure of the DSM, to include a separate chapter on them and resulted in an increase in diagnosis of dissociative conditions. Once a rarely occurring spontaneous phenomenon (research in 1944 showed only 76 cases),<ref>Template:Cite news</ref> the diagnosis became "an artifact of bad (or naïve) psychotherapy" as patients capable of dissociating were accidentally encouraged to express their symptoms by "overly fascinated" therapists.<ref name=Paris2008>Template:Cite book</ref>

"Interpersonality amnesia" was removed as a diagnostic feature from the DSM III in 1987, which may have contributed to the increasing frequency of the diagnosis.<ref name = Kihlstrom/> There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990.<ref name="pmid7788115">Template:Cite journal</ref> Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.<ref name="Accocella">Template:Cite book</ref> Scientific publications regarding DID peaked in the mid-1990s, rapidly declined,<ref name = Pope/> then has continued on a steady increasing trend since.<ref name=boysen2024/>

In 1994, the fourth edition of the DSM replaced the criteria again and changed the name of the condition from "multiple personality disorder" to the current "dissociative identity disorder" to emphasize the importance of changes to consciousness and identity rather than personality. The inclusion of interpersonality amnesia helped to distinguish DID from dissociative disorder not otherwise specified (DDNOS), but the condition retains an inherent subjectivity due to difficulty in defining terms such as personality, identity, ego-state, and even amnesia.<ref name = Kihlstrom>Template:Cite journal</ref> The ICD-10 classified DID as a "Dissociative [conversion] disorder" and used the name "multiple personality disorder" with the classification number of F44.81.<ref name = ICD10/> In the ICD-11, the World Health Organization have classified DID under the name "dissociative identity disorder" (code 6B64), and most cases formerly diagnosed as DDNOS are classified as "partial dissociative identity disorder" (code 6B65).<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

21st century

A 2006 study compared scholarly research and publications on DID and dissociative amnesia to other mental health conditions, such as anorexia nervosa, alcohol use disorder, and schizophrenia from 1984 to 2003. The results were found to be unusually distributed, with a very low level of publications in the 1980s followed by a significant rise that peaked in the mid-1990s and subsequently rapidly declined in the decade following. Compared to 25 other diagnosis, the mid-1990s "bubble" of publications regarding DID was unique. In the opinion of the authors of the review, the publication results suggest a period of "fashion" that waned, and that the two diagnoses "presently do not command widespread scientific acceptance."<ref name = Pope>Template:Cite journal</ref> A 2024 review found "steady" continued research after 2011, with 160 academic studies located in the 2011-2021 period, an increase of 60% over the previous decade. Authors previously skeptical of DID have adopted a "trans-theoretical" approach where trauma and social factors are simply two of many potential factors, indicating that "the heat of past DID controversies has diminished some with the rise of multidimensional models of psychopathology".<ref name="boysen2024">Template:Cite journal</ref>

Society and culture

Legal issues

People with dissociative identity disorder may be involved in legal cases as a witness, defendant, or as the victim/injured party. Claims of DID have been used only rarely to argue criminal insanity in court.<ref name="Farrell" /><ref name="Farrell2011">Template:Cite journal</ref> In the United States, dissociative identity disorder has previously been found to meet the Frye test as a generally accepted medical condition, and the newer Daubert standard.<ref name="FrankelCrime">Template:Cite journal</ref><ref name="Crego2020">Template:Cite journal</ref> Within legal circles, DID has been described as one of the most disputed psychiatric diagnoses and forensic assessments are needed.<ref name="Rein2008" /> For defendants whose defense states they have a diagnosis of DID, courts must distinguish between those who genuinely have DID and those who are malingering to avoid responsibility.<ref name="FrankelCrime" /><ref name="Rein2008" /> Expert witnesses are typically used to assess defendants in such cases,<ref name="Farrell" /> although some of the standard assessments like the MMPI-2 were not developed for people with a trauma history and the validity scales may incorrectly suggest malingering.<ref name="BrownDetect">Template:Cite book</ref> In DID, evidence about the altered states of consciousness, actions of alter identities and episodes of amnesia may be excluded from a court if they are not considered relevant, although different countries and regions have different laws.<ref name="Farrell" /> A diagnosis of DID may be used to claim a defense of not guilty by reason of insanity, but this very rarely succeeds, or of diminished capacity, which may reduce the length of a sentence.<ref name="Farrell2011" /><ref name="Crego2020" /> DID may also affect competency to stand trial.<ref>Template:Cite book</ref> A not guilty by reason of insanity plea was first used successfully in an American court in 1978, in the State of Ohio v. Milligan case.<ref name="Farrell2011" /> However, a DID diagnosis is not automatically considered a justification for an insanity verdict, and since Milligan the few cases claiming insanity have largely been unsuccessful.<ref name="Farrell2011" />

Bennett G. Braun was an American psychiatrist known for his promotion of the concept of multiple personality disorder (now called "dissociative identity disorder") and involvement in promoting the "Satanic Panic", a moral panic around a discredited conspiracy theory that led to thousands of people being wrongfully medically treated or investigated for nonexistent crimes.<ref name="Risen-2024">Template:Cite news</ref><ref name="Hanson-1998">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

In popular culture

The public's long fascination with DID has led to a number of different books and films,<ref name="Guidelines2011" />Template:Rp with many representations described as increasing stigma by perpetuating the myth that people with mental illness are usually dangerous.<ref name="Cinema">Template:Cite book</ref> Movies about DID have been also criticized for poor representation of both DID and its treatment, including "greatly overrepresenting" the role of hypnosis in therapy,<ref name="Gabbard">Template:Cite book</ref> showing a significantly smaller number of personalities than many people with DID have,<ref name="DoalMedia" /><ref name="Gabbard" /><ref name="seattleobituary" /> and misrepresenting people with DID as having theatrical and blatant switches between very conspicuous and different alters.<ref name="Hunterbook">Template:Cite book</ref> Some movies are parodies and ridicule DID, for instance, Me, Myself & Irene, which also incorrectly states that DID is schizophrenia.<ref name="ButlerDidIt">Template:Cite journal</ref> In some stories, DID is used as a plot device, e.g. in Fight Club, and in whodunnit stories like Secret Window.<ref name="WeddingMovies" /><ref name="ButlerDidIt" />

United States of Tara was reported to be the first US television series with DID as its focus, and a professional commentary on each episode was published by the International Society for the Study of Trauma and Dissociation.<ref name="isstd-Tara">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="Halter2017">Template:Cite book</ref>

A number of people with DID have publicly spoken about their experiences, including comedian and talk show host Roseanne Barr, who interviewed Truddi Chase, author of When Rabbit Howls; Chris Costner Sizemore, the subject of The Three Faces of Eve, Cameron West, author of First Person Plural: My life as a multiple, and NFL player Herschel Walker, author of Breaking Free: My life with dissociative identity disorder.<ref name="DoalMedia">Template:Cite journal</ref><ref>Template:Cite book</ref>

In The Three Faces of Eve (1957) hypnosis is used to identify a childhood trauma which then allows her to fuse from three identities into just one.<ref name="Gabbard" /> However, Sizemore's own books I'm Eve and A Mind of My Own revealed that this did not last; she later attempted suicide, sought further treatment, and actually had twenty-two personalities rather than three.<ref name="Gabbard" /><ref name="seattleobituary">Template:Cite news</ref> Sizemore re-entered therapy and by 1974 had achieved a lasting recovery.<ref name="Gabbard" /> Voices Within: The Lives of Truddi Chase portrays many of the 92 personalities Chase described in her book When Rabbit Howls, and is unusual in breaking away from the typical ending of integrating into one.<ref name="Hunterbook" /><ref name="ButlerDidIt" /> Frankie & Alice (2010), starring Halle Berry was based on a real person with DID.<ref name="WeddingMovies">Template:Cite book</ref> In popular culture dissociative identity disorder is often confused with schizophrenia,<ref name="EncyclopediaTrauma">Template:Cite book</ref> as was true of the 1958 episode "The Case of the Deadly Double" of the Perry Mason TV series, where a woman shown as having two very distinct personas is described as being schizophrenic <ref>"S1 E24: The Case of the Deadly Double" Paramount +</ref> On the other hand, some movies advertised as representing dissociative identity disorder may be more representative of psychosis or schizophrenia, for example Psycho (1960).<ref name="Cinema" /><ref name="WeddingMovies" />

In his book The C.I.A. Doctors: Human Rights Violations by American Psychiatrists, psychiatrist Colin A. Ross states that based on documents obtained through freedom of information legislation, a psychiatrist linked to Project MKULTRA reported being able to deliberately induce dissociative identity disorder using a variety of highly aversive and abusive techniques, creating a Manchurian Candidate for military purposes.<ref name="Vogt2019">Template:Cite book</ref><ref name="Ross2006">Template:Cite book</ref>

In the USA Network television production Mr. Robot, the protagonist Elliot Alderson was created using anecdotal experiences of DID of the show's creator's friends. Sam Esmail said he consulted with a psychologist who "concretized" the character's mental health conditions, especially his plurality.<ref>Template:Cite magazine</ref>

In M. Night Shyamalan's Unbreakable superhero film series (specifically, the films Split and Glass), Kevin Wendell Crumb is diagnosed with DID, and that some of the personalities have super-human powers. Experts and advocates say the films are a negative portrayal of DID and the films promote the stigmatization of the disorder.<ref>Template:Cite news</ref>

In the 1997 Japanese role-playing game Final Fantasy VII, the protagonist Cloud Strife is shown to have an identity disorder involving false memories as a result of post-traumatic stress disorder (PTSD). Sharon Packer has identified Cloud as having DID.<ref>Template:Cite book</ref>

In Marvel Comics, the character of Moon Knight is shown to have DID. In the TV series Moon Knight based on the comic book character, protagonist Marc Spector is depicted with DID; the website for the National Alliance on Mental Illness appears in the series' end credits.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Online subculture

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A DID community exists on social media, including YouTube, Reddit, Discord, and TikTok. In those contexts, the experience of dissociative identities has been called multiplicity.<ref name="Lucas-2021">Template:Cite news</ref> High-profile members of this community have been criticized for faking their condition for views, or for portraying the disorder lightheartedly.<ref name="Lucas-2021" /> Psychologist Naomi Torres-Mackie, head of research at The Mental Health Coalition, has stated "All of a sudden, all of my adolescent patients think that they have this, and they don't ... Folks start attaching clinical meaning and feeling like, 'I should be diagnosed with this. I need medication for this', when actually a lot of these experiences are normative and don't need to be pathologized or treated."<ref name="Teen-Vogue-2022">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Advocacy

Some advocates consider DID to be a form of neurodiversity, leading to advocacy in recognizing 'positive plurality' and the use of plural pronouns such as "we" and "our".<ref name="DoalMedia" /><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Advocates also challenge the necessity of integration.<ref>Template:Cite news</ref><ref>Template:Cite news</ref> Timothy Baynes argues that forcing people to undergo it as a therapeutic treatment is "seriously immoral".<ref>Template:Cite journal</ref>

A DID Awareness Day takes place on March 5 annually, participants displaying a multicolored awareness ribbon, based on the idea of a "crazy quilt."<ref name="McHugh2019">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

References

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External links

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