Dissociative Identity Disorder (DID) - Does it really exist?
Is Dissociative Identity Disorder (DID) a real disorder?
Dissociative Identity Disorder (DID) has been fraught with debate since it was first included in the Diagnostics & Statistical Manual of Mental Disorders (DSM-III) in 1980. The condition shot into the awareness of the general population with the release of the popular non-fiction book Sybil by Flora Rheta Schreiber in 1973 and a TV miniseries with the same name in 1976 depicting a woman diagnosed with what was then referred to as Multiple Personality Disorder (MPD). The sharp increase in cases of MPD following the popularity of the film caused many mental health professionals to question the validity of the diagnosis.
More recently in 2020, the controversy was brought into focus again when a popular YouTuber created a channel (called DissocaiDID) to bring awareness to the mental health challenges of individuals with DID and began posting videos of their disparate identities (Harris, 2020). A community of individuals with similar experiences formed around DissociateDID and even developed its own jargon for the DID experience using terms like “alter” to refer to their differing personality states and “system” to refer to their network for coexisting personality states. The growth of the online community led to accusations of members faking the disorder and brought even more skepticism upon the validity of the DID.
According to the DSM-5, DID is characterized by “two or more distinct identities or personality states that coincide, with fluctuating consciousness and changing access to autobiographical memory” (Reinders, 2020). While it appears the DID was in fact over-diagnosed following its dramatic insurgence into the awareness of the general public in the 1980s, recent psychobiological research suggests that DID is a real psychological disorder with distinct neurobiological underpinnings that results as a post-traumatic stress response.
What Causes Dissociative Identity Disorder (DID)
Given the dramatic increase in DID diagnoses following the popularity of Sybil in the 1980s, it is understandable that many psychologists would push back against sensationalism and question the validity of DID as a legitimate psychological disorder. Many skeptics view DID as an “unscientific fad of the 1980s” (Loewenstein, 2018). But the argument against the validity of DID goes further to include three theories of the etiology (cause) of dissociative symptoms; the Iatrogenic Model (IM), the Sociocognitive Model (SCM), and the Fantasy Model (FM).
Iatrogenic means that an illness was caused by medical examination or treatment. Those who support the IM theory of DID etiology posit that psychotherapy practices have been harmful to highly suggestible patients and that clinicians who believe that hypnotherapy can be used to recover repressed memories have actually implanted false memories in patients with DID (Loewenstein, 2018). The theory suggests that following psychotherapy fantasy-prone individuals could suffer “cognitive slippage” that leaves them unable to differentiate between internal and external experience; a psychological situation referred to as False-Memory Syndrome (Loewenstein, 2018).
The SCM highlights the impact of media reports of repressed memories and DID on highly suggestible patients. Of course, it would be hard to argue that the increased public awareness of the disorder would have no impact on the prevalence of the disorder. Awareness of treatment options for individuals with DID and de-stigmatization may well have caused some to seek treatment options that they were previously unaware existed. However, the SCM asserts that the increase in public awareness causes DID; that impressionable individuals would develop the symptoms because of the sudden popularity of the condition. Finally, the FM puts the blame on imaginative individuals themselves and “conceptualizes dissociation as a cognitive trait that leads to fantasies/confabulations of traumatic experiences” (Loewenstein, 2018).
Arguments against the validity of DID as a diagnosis are more than just a scholarly debate. They extend to the treatment of distressed individuals. If a mental health practitioner is in the camp of DID skeptics, they may choose to ignore the symptoms of the disorder and patients may not receive the care needed to find relief from their troubling symptoms.
The Trauma Model & The DSM-5
On the other hand, most clinicians who support the validity of DID subscribe to the Trauma Model (TM) of DID etiology. According to the TM, “dissociation is a psychobiological state or trait that functions as a protective response to traumatic or overwhelming experiences” (Loewenstein, 2018). While a mild form of dissociation is part of normal functioning, pathological dissociation (of which DID is a subset) results from traumatic experiences; often of a violent or sexual nature that occurred during childhood (Facco et al, 2019). According to the article Dissociation Debates: Everything You Know is Wrong by Richard J. Loewenstein MD, “the TM posits that dissociation mitigates the impact of trauma by psychobiologically sequestering information about trauma through protective activation of altered states of consciousness. Subsequently, dissociation segregates from ordinary awareness the full meaning and impact of traumatic events for the person” (Lowenstein, 2018).
Since the 1980s significant effort has been given to creating a self-report diagnostic inventory to assess the disorder in patients diagnosed with DID. Studies of the data retrieved from these self-report inventories from an international sample of patients show that dissociative disorders are “strongly linked to scute and/or chronic traumatic experiences (Loewenstein, 2018). Reporting on these findings, Loewenstein et al states that “epidemiological studies do not fit the IM/SCM/FM paradigms. Few subjects had previously been recognized as having DD or were in specialized DD psychotherapy” (Loewenstein, 2018).
In sum, the findings did not suggest that DID had been caused by therapeutic or social suggestion or the patient’s proneness to fantastical thinking.
In sum, the findings did not suggest that DID had been caused by therapeutic or social suggestion or the patient’s proneness to fantastical thinking. The placement of DID in the DSM-V is based on this evidence-based TM theory of DID etiology. The diagnostic manual includes a dissociative subtype of Post-Traumatic Stress Disorder (PTSD) called PTSD-DS within the diagnostic criteria for PTSD.
Adding significant weight to the psychobiological and TM model for the etiology of DID comes from neurobiological evidence for this argument. In 2003 a neuroimaging study of neural processes for storing memory was taken of individuals with DID. The study showed that the neural processes of subjects when recalling trauma-related memories was personality-state-dependent (Reinders et al, 2020). The bran imaging did not support that the theory that individuals were simulating a hypnotic state or creating identities. The brain was using different neurological processes when recalling traumatic events from the subjective vantage point of an individual’s alternative personalities. Later, a study in 2012, showed that “individuals with DID can be distinguished from DID-simulating healthy controls with high and low levels of fantasy proneness”. This provides considerable evidence for DID as a valid psychobiological condition resulting from a traumatic experience.
Personal Experience
I have had the personal experience of conversing with two individuals who had been diagnosed with DID in a crisis intervention setting. In the short discussion, it was impossible for me to determine whether the disordered state was caused iatrogenically, given my limited knowledge of their treatment history and trauma. However, it appeared that the alternate personalities were not affected in an effort to gain attention or impress.
In the first experience, an individual was speaking in depth about sexual trauma when, at the most horrendous moment in the narrative, their speech suspended. There were 30 seconds of silence followed by a continuing of the conversation with an altered person-state with a completely different style of speech who appeared confused and oblivious about the context of the conversation. After several more minutes of banter, the individual became silent again and reverted to the self-presentation style from the beginning of the call. The switch appeared to have a sort of cathartic effect on the individual who promptly thanked me for my time and ended the discussion.
In another instance, a completely lucid individual was relating to me the names of the altered personalities that communicated with her and at times assumed a dominant role in her self-presentation. She gave her description of these alternative personas soberly and when met with my lack of surprise, showed no disappointment in my lack of shock or surprise. The individual expressed comments of horrendous sexual trauma and did not appear to be faking an altered state disorder.
An Optimistic Future for DID
From the above clinical and neurobiological evidence, it can be stated confidently that DID is a valid diagnosis. Accepting the validity of this disorder is important for mental health practitioners and laypeople alike so that those who suffer can receive the treatment that they need. When seen from the TM perspective, DID can be understood as the extreme reaction of the mind to overwhelmingly traumatic events. Empathy for such ones requires that adequate consideration be given to the psychological symptoms rather than a dismissive stance of disbelief.
However, the SCM presents some confounding factors. The popularity of the DID YouTube community is a prime example. While DID is a legitimate diagnosis based on clinical and neurobiological evidence, there is the danger that individuals cling to diagnostic nomenclature as part of their post-trauma self-concept. When a diagnosis is used as a self-identifier, social infrastructures can develop not in support of psychiatric or psychotherapeutic treatment, but to provide a sense of comradery between fellow sufferers. Fellow sufferers may then be subject to the effects of social polarization; causing them to reinforce their diagnosis instead of embracing the therapeutic and cognitive effort required to recover from a disordered state.
For example, if one makes their means of living from a YouTube page highlighting their DID, then it is unlikely that such an individual would seek the sort of therapy that would result in the further integration of altered states into a comprehensive self and beyond; to the equanimous state of egolessness. This same weakness of psychological diagnostic nomenclature can be seen in online forums in support of sufferers of many troublesome diagnoses such as depression, anxiety, PTSD, Complex Post-Traumatic Stress Disorder (CPTSD).
Surely, humanitarian interests would require that each individual not only feel supported through psychological suffering but also as they heal from such a disorder to the point that it no longer afflicts them; to the point that it would no longer be considered a clinical diagnosis. It must be our fervent desire that individuals diagnosed with depression, anxiety, PTSD, or CPTSD be treated to the point that they can consider themselves individuals who were at one time diagnosed with depression, anxiety, PTSD, or CPTSD. If, as Facco et all suggest in Dissociative Identity as a Continuum from Healthy Mind to Psychiatric Disorders: Epistemological and Neurophenomenological Implications Approached Through Hypnosis, dissociation is an extreme version of a healthy cognitive state (Facco et al, 2019), then perhaps those diagnosed with DID can with treatment eventually identify themselves as individuals who have recovered from DID.
As the argument for the SCM and the social polarization of social media groups of individuals of common diagnoses show, the manifestation of DID may always be influenced by social factors. While diagnostic nomenclature helps clinicians treat patients effectively, psychological and sociological danger exists that a patient incorporates their diagnosis into their personal self-concept with a rigidity that is detrimental to their future well-being.
Psychological disorders are often framed with the biopsychosocial approach. Based on this framework, psychological disorders have a biological component, a psychological (or cognitive) component, and a social component. While the neurobiological imaging studies mention in this paper provides evidence to the validity of DID, perhaps when appropriate attention is given to cognitive dangers (absorbing DID into the self-concept) and social dangers (relying on one’s diagnosis for comradery or income), and as more patients with DID access evidence-based treatments, we will continue to see a reduction in those who suffer harmful dysfunction as a result of DID.
References:
Blihar, D., Crisafio, A., Delgado, E., Buryak, M., Gonzalez, M., & Waechter, R. (2021). A Meta-Analysis of Hippocampal and Amygdala Volumes in Patients Diagnosed With Dissociative Identity Disorder. Journal of Trauma & Dissociation, 1-13.
Facco, E., Mendozzi, L., Bona, A., Motta, A., Garegnani, M., Costantini, I., ... & Lipari, S. (2019). Dissociative identity as a continuum from healthy mind to psychiatric disorders: Epistemological and neurophenomenological implications approached through hypnosis. Medical hypotheses, 130, 109274.
Harris, M., Dodgson, L., (2020) A thriving YouTube community of people with multiple personality states went viral. Then controversies fractured it down the middle. Insider. Retrieved from: https://www.insider.com/did-dissociative-identity-disorder-youtube-multiple-personalities-community-real-fake-2020-8
Loewenstein, R. J. (2018). Dissociation debates: Everything you know is wrong. Dialogues in clinical neuroscience, 20(3), 229.
Reinders, A. A., & Veltman, D. J. (2020). Dissociative identity disorder: out of the shadows at last?. The British Journal of Psychiatry, 1-2.
Paris, J. (2019). Dissociative identity disorder: validity and use in the criminal justice system. BJPsych Advances, 25(5), 287-293.
Rutkofsky, I. H., Kahn, A. S., Sahito, S., Aqeel, N., & Tohid, H. (2017). The neuropsychiatry of dissociative identity disorder: why split personality patients switch personalities intermittently. J Cell Sci Ther, 8(2), 1-8.
