Abstract
Dissociative Identity Disorder (DID), commonly known as Multiple Personality Disorder, is often controversial among researchers and misunderstood by the public. Some researchers describe DID as borderline personality disorder or a schizophrenic spectrum disorder while others explain that it is entirely iatrogenic in nature (Brand et al., 2016; Piper & Merskey, 2004). Public conception of the disorder centers upon the portrayals expressed in movies such as Sybil or The Three Faces of Eve. In this paper, I utilize contemporary research supporting the DSM-5 diagnosis of DID and describe: 1) what the disorder is, 2) the etiology that leads to it, and 3) current treatments demonstrating therapeutic efficacy.
Introduction
It is estimated that 1.5% of the population and 5% of psychiatric hospitalized patients meet DSM-5 criteria for Dissociative Identity Disorder or DID, and 12-28% of all dissociative disease disorder spectrum outpatients can be diagnosed with DID (Brand et al, 2016; Gentile, Dillon, & Gillig, 2013; Sar, Dorahy, & Kruger, 2017). It is also estimated that these numbers may be low, resulting from diagnostic difficulties and few practitioners having competence in DID etiology, assessment, and treatment (Brand et al, 2016; Gentile, Dillon, & Gillig, 2013; Van der Hart, Steele, & Nijenhuis, 2017).
There is extensive misinformation about what DID is scientifically and anecdotally. Those who suffer from DID are predominantly survivors of major traumatic episodes during childhood. Dissociation is an effective survival mechanism, protecting the individual from extensive traumatic abuse during childhood by preventing overwhelming emotional flooding; however, dissociation becomes a problematic disorder as the traumatized child enters into adolescence and adulthood. The therapeutic goal of working with DID patients is always integration of the separated ego states (ISSDT, 2011). In this paper, I use contemporary research to define DID, describe its etiology, and present a common treatment path. Further research is clearly needed in biopsychosocial etiology and therapeutic variation and efficacy.
What is Dissociative Identity Disorder?
DID is more commonly known in the mass media and among laypersons as multiple personality disorder. DSM-5 categorizes DID as the end of the dissociative disorders continuum, involving the most severely separated individual (APA, 2013; Van der Hart, Steele, & Nijenhuis, 2017). DSM-5 criteria is based on disruption of identity, involving two or more distinct personality states and involves, “marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning” (APA, 2013, p. 292)
90% of patients with DID experienced chronic physical or sexual trauma when children usually at the hands of an attachment figure through betrayal trauma (APA, 2013; Brand et al., 2016; Sar, 2016; Sar, Dorahy, & Kruger, 2017; Schimmenti & Vincenzo, 2016; Van der Hart, Steele, & Nijenhuis, 2017). When the abuse is occurring, the consciousness of the child enduring the pain separates, or dissociates. This dissociated distinct consciousness is referred to as the alter and remains repressed to protect the self from the harm of the trauma; however, it also prevents the alter from progressing through further applicable developmental stages of normal childhood, (Barrouillet, 2015; Knight, 2017; Schimmenti & Vincenzo, 2016). Essentially, the mind is unable to maintain a unified sense of self across discreet behavioral states and dissociates as a way to escape the traumatic episodes – it is a survival mechanism, which is a common method for handling trauma when there is no means of escape (Dorahy, 2016; Putnam, 2016; Sar, 2016). In childhood, narrative thought processing has not formalized as the amygdala, housing emotional and emotional memory control, develops faster than the prefrontal cortex (Capuzzi & Stauffer, 2016). As a result, it is not cognitively possible for the child to process the trauma with reason and executive logic, so the emotion of the trauma is simply segregated and stored, forming the separate alter state.
Although dissociation is effective in protecting the young child, as the person matures and proceeds through other development stages and into adulthood, the alter, housing the traumatic memory, does not progress – it is not capable of handling “adult” emotions and situations, which can lead to multiple impairments and comorbidities when a stressful event triggers the recall of the alter’s associated emotions and memories(Barrouillet, 2015; Knight, 2017; Sar, Dorahy, & Kruger, 2017; Schimmenti & Vincenzo, 2016; Van der Hart, Steele, & Nijenhuis, 2017). Additionally, with limited developmental, cognitive, and neurobiological capabilities, most children blame themselves for the abuse, believing that it would not occur if they were not at fault (Van der Hart, Steele, & Nijenhuis, 2017). This leads to a lifetime of additional personality disorders and self-destructive behaviors, as often there is one alter whose role is to punish the victim for causing the abuse (Putnam, 2016; Sar, 2016; Sar, Dorahy, & Kruger, 2017).
Separate alters are still a part of the central personality, referred to as the host, sharing the same physiological body, neurobiochemical processes, and external life dynamics. Alters differ from the host and each other in that they are compartmentalized aspects of the self. The alters have separate systems of functioning, including: a unique first person perspective; discreet identities; subjective experiences, memories, emotions, and sense of agency; different names; different ages; and individualized beliefs while simultaneously co-existing within the self (Gentile, Dillon, & Kruger, 2013; Putnam, 2016; Sar, 2016; Sar, Dorahy, & Kruger, 2017; Van der Hart, Steele, & Nijenhuis, 2017).
Frequent comorbidities often make diagnosis of DID difficult, especially considering that the host ego state of most DID patient does not present during dissociated states and separate alters do not reveal themselves for some time – alters exist for protection, so they feel threatened by therapy and do not easily reveal themselves (APA, 2013; Nijenhuis, 2015). The host commonly presents for related symptoms, including: amnesia, depression, panic attacks, post-traumatic stress, personality disorders, eating disorders, sleep disorders, somatic symptom disorders, and obsessive compulsive disorders (APA, 2013; Gentile, Dillon, & Gillig, 2013). Additionally, over 70% of DID patients have attempted suicide (APA, 2013). Although difficult to diagnose, particularly with clinicians without specific training and experience, DID is an empirically robust chronic psychological disorder based on neurobiological, cognitive, and interpersonal non-integration as a response to traumatic stress (Dorahy, 2016; Gentile, Dillon, & Gillig, 2013; Sar, Dorahy, & Kruger, 2017).
There has been considerable controversy in research regarding whether DID is completely iatrogenic, or fantasy based, versus a valid disorder, resulting from a trauma model (Brand et al., 2016). Iatrogenic factors do occur through misguided therapists providing suggestions and patients feigning the disorder; however, proper assessment (which is beyond the scope of this paper) of DID yields high dissociation scores in patients who are accurately diagnosed with DID (APA, 2013; Brand et al, 2016). Additionally, patients who fake DID tend to show “pride” in their disorder, lack the comorbidities common to DID patients, and report stereo-typed symptoms as described in the media (i.e., distinct “bad” and “good” alters in the hopes of making some type of gain such as avoiding criminal charges or consequences of other negative behavior), whereas true DID patients are tremendously ashamed of DID, have often attempted suicide, and include alters that are not stereotyped in character (APA, 2013; Brand et al., 2016). Research has indicated consensus that DID is not post-traumatic stress disorder, bipolar disorder, borderline personality disorder, or schizophrenia (Brand et al., 2016; Laddis, Dell, & Korzekwa, 2017; Sar, 2016; Sar, Dorahy, & Kruger, 2017). As Sar, Dorahy, and Kruger stated, “DID as a diagnostic entity cannot be explained as a phenomenon created by iatrogenic influences, suggestibility, malingering, or social role-taking” (2017). Finally, Brand et al., (2016) stated, “Despite the concerns of fantasy model theorists that DID is iatrogenically created, no study in any clinical population supports the fantasy model of dissociation.”
Etiology of Dissociative Identity Disorder
The etiology of DID is complicated, multi-faceted, and most always stems from chronic traumatic childhood episodes usually at the hands of attachment figures. To describe the etiology of DID, a biopsychosocial model will be used (Fava & Sonino, 2017; Wade & Halligan, 2017).
Biological
Trauma generated neurobiological responses, genetic factors, and epigenetic causes are likely associated with DID; however, they have not been researched adequately (Sar, Dorahy, & Kruger, 2017). DID patients have been found to exhibit disruptions in encoding memories, which impedes memory recall (Sar, Darohy, & Kruger, 2017). Additionally, PET/MRI scans have demonstrated variations in brain activity and activation and inhibition in certain brain regions, especially in the hippocampus with differing personality states and in comparisons with control groups (Capuzzi & Stauffer, 2016; Sar, Dorahy, & Kruger, 2017; Sheehan, Sewall, & Thurber, 2005). Finally, chronic childhood stress from trauma results in permanent structural changes to the brain, which impedes normal processing of memories and emotions (Capuzzi & Stauffer, 2016).
Psychological
Trauma is a factor in 90% of patients with DID, and DID patients exhibit the highest rate of childhood psychological trauma of any other disorder (APA, 2013; Sar, 2011). As previously discussed, alters form when a part of consciousness dissociates to protect the person from the pain of the recurring trauma from an attachment figure. Using a psychodynamic theoretical perspective, this can be construed as a form of repression that blocks the traumatic events from which the child can’t escape (Schimmenti & Vincenzo, 2016). This protects the child, as the memories are no longer available to consciousness. These repressed memories are not lost – they are hidden, and each independent identity has its own unique set of memories that are not accessible to the other alters or even to the host itself (Schimmenti & Vincenzo, 2016).
Sociocultural
Iatrogenic factors are one consideration in DID, which have not been supported in recent research (as previously discussed). DID is more prevalent in women as adults, but as children, it affects boys and girls equally (APA, 2013). As adults, women are more likely to seek treatment and men are more likely to deny alters, leading researchers to believe that the prevalence of DID for men and women is nearly equal at 1.6% for women and 1.4% for men (APA, 2013). Dissociative trance states are used in some cultures and religious practices, but these must be distinguished from a DID diagnosis (APA, 2013). There is a negative societal stigma that DID does not exist – the stigma leads most DID patients to maintain and guard feelings of isolation, loneliness, and alienation, which can be a barrier to seeking treatment and increase suicidal ideation (Sar, Dorahy, & Kruger, 2017). Most troubling is that research has shown most abuse encountered by DID survivors is betrayal trauma, which is trauma perpetrated by someone upon whom the victim depends (Freyd, 1994). These perpetrators present positive, caring, and nurturing sides that unpredictably turn severely abusive. This results in conflicted feelings for the child who is developmentally unable to process such behavior, which provides further traumatization, leading to additional dissociation as part of the self desperately wants to form the attachment with the positive side of the attachment figure (Sar, Dorahy, & Kruger, 2017). The result is a child with compartmentalized traumatic cognitions and feelings too complicated for a child to understand, including: terror, betrayal, love, and shame (Capuzzi & Stauffer, 2016; Nijenhuis, 2015).
Treatment for Dissociative Identity Disorder
The goal of treating DID patients is to enable the alters to integrate (Brand et al., 2012; Brand et al, 2013; Briere & Scott 2015; Myrick et al., 2015; Myrick et al., 2017; Van der Hart, Steele, & Nijenhuis, 2017). Integration can occur in two ways. First, the alters can assimilate, blending together into one sense of self. Second, the alters can resolve to remain separate but work together to create a functional sense of self. Both methods have been found to improve the patient’s life, but it is important for the method of integration to be left to the host and alters to decide together (Brand et al., 2013; Brand et al., 2012; Briere & Scott 2015; Myrick et al., Myrick et al., 2017; 2015; Sar, 2016). Contemporary treatment has been found effective and follows a three step process initially described in a 2012 landmark study of DID therapists’ practices (Brand et al.) and supported by other researchers with a fourth step later added (Briere & Scott 2015; Loyd, 2016; Myrick et al., 2015; Myrick et al., 2017; Nijenhuis, 2015; Putnam, 2016; Sar, 2016; Sar, Dorahy, & Kruger, 2017; Van der Hart, Steele, & Nijenhuis, 2017):
- Stabilize – Ensure the patient is safe from danger from oneself and to others; teach the patient emotional regulation; provide skills training for controlling impulses; and help alters begin developing interpersonal effectiveness.
- Resolve traumatic experiences – Use exposure or abreaction, depending on therapeutic style. It is not necessary or even beneficial to relive traumatic experiences. It is more important for the alters to come to terms with unchecked emotions and phobias related to events that remind the patient of the original trauma.
- Integrate – Assist the host and alters to work together to create one sense of self. This can occur through assimilation or resolution of alters.
- Post-integration – Teach the unified individual how to handle the integrated mind state in life, and work with the individual to develop a life purpose, which provides direction and meaning.
A diverse therapeutic approach, utilizing a trauma model for treating symptoms of DID has been found effective (Briere & Scott 2015; Knight, 2017; Loyd, 2016; Myrick et al., 2017). During these treatments, consensus is that the therapist should engage the different alters when they present, but not seek them out as that could push them further in to reclusion (Brand et al., 2012; Brand et al., 2013). As Gentile, Dillon, and Kruger (2013) stated:
“The focus of the intervention is to listen, empathize, and provide validation and reassurance that the patient is currently safe, particularly when the emerging “alter” represents a person who is much younger than the patient’s current age. In addition, the patient (as the “alter”) must be provided the opportunity to tell her story and be heard and supported.”
There are no medications specifically approved for treating DID and using medications can actually complicate the situation if DID is not recognized or misdiagnosed as another disorder; however, medications can be used to treat comorbid conditions (Briere & Scott 2015; Gentile, Dillon, & Kruger, 2013). The majority of DID patients are suicidal, resulting from depression, and as a result, anti-depressants targeting Serotonin have been found effective in alleviating depressive symptoms in some DID patients as have some anti-psychotics targeting Dopamine (Gentile, Dillon, & Kruger, 2013; Myrick et al., 2015; Myrick et al., 2017). But the most significant improvements are with non-medicinal therapeutic approaches.
In dealing with the early traumatic events, some researchers prefer the psychodynamic approach of abreaction and some advocate for cognitive exposure therapy; however, there does not appear to be a more effective style (Brand et al., 2012; Brand et al., 2016; Knight, 2017; Loyd, 2016). Although more recent reports have indicated that while abreaction allows for a cathartic expressing of emotions, it does not provide a cure in-and-of-itself, and as a result, CBT shows more promising therapeutic results (Schimelpfening, 2018).
The goal of therapy is integration, or synthesis, of the alters, which requires the psychologist to work with the host and alters to resolve the emotions associated with the traumatic events that each alter uniquely and individually compartmentalizes often out of the awareness of the host (Van der Hart, Steele, & Nijenhuis, 2017). It is important to note that this does not mean that the psychologist should have the patient relive all traumatic events – in fact, this can re-traumatize the host and increase the protectionism of the alters, producing a counterproductive effect to a successful therapeutic outcome (Brand et al, 2012; Gentile, Dillon, & Kruger, 2013; Loyd, 2016).
One problem DID patients encounter is that the alters were quite effective in dealing with trauma when it occurred as a child, but as adults, they can’t process stress and emotions of normal adult life due to their developmental stagnation. It is important to provide skills to help DID patients learn to analyze thoughts and behaviors for rationality; control impulsivity; manage stress; mitigate anger (from their protective anger driven alters); take better care of themselves through exercise, nutrition, and sleep; deal with intrapersonal alter conflict; improve interpersonal communication; and gain control over their choices about how they react to events. Techniques from cognitive behavioral therapy, rational emotive behavioral therapy, mindfulness practices, family systems, guided synthesis, EMDR, and Adlerian therapy have been found effective in addressing these issues with flexibility and therapeutic relationship being most essential for stable treatment (Briere & Scott 2015; Loyd, 2016; Myrick et al., 2015; Van der Hart, Steele, & Nijenhuis, 2017).
Finally, it is important to consider cultural, religious, and spiritual factors that could be contributing to the dissociated personalities. DSM-5 considers possession and trance states to be criteria of DID, which are frequently associated with cultural and religious practices (APA, 2013; Loyd, 2016; Sar, 2016; Sar, Dorahy, & Kruger, 2017). This aspect of DID is beyond the scope of this paper.
It is important to note that countertransference is a pressing concern for the therapist to consider, as Van der Hart, Steele, & Nijenhuis stated (2017):
“First, they [psychologists] may develop undue fascination with the content of, and a counter-phobic attitude toward the patient’s traumatic memories. This may result in undue and premature focus on traumatic memories, and on their content, and neglect of the development of essential daily life and emotional skills and the process of therapy. Second, therapists may over-identify with the patient’s lack of realization, colluding to avoid dealing with traumatic memories at all.”
Conclusion
In this paper, I have used recent research to describe what DID is, how it is caused, and how it is most effectively treated. Secondarily, I have tried to dispel the myths and misinformation that are present regarding patients who suffer from DID. These people are survivors of prolonged trauma that occurred from attachment figures at vulnerable cognitive, emotional, and neurobiochemical developmental stages. As a result, they are not able to cope effectively in society with their disorder. Treatments have proven effective in helping patients to integrate their alters and live improved lives. I have only briefly covered the surface of DID and the many facets of the disorder. Additionally, the need for further research into this disorder is apparent, particularly in the areas of psychosocialneurobiological etiology and treatment efficacy.
I find DID to be fascinating clinically but taxing personally, as it is devastating to the people who have suffered with misdiagnosis, ineffective medication treatments, life-long stigma, and accusations of being susceptible to misguided therapists through iatrogenic means. Their condition is well supported in the research and resulted from horrific abuse – DID is a psychosocioneurobiological mechanism that has allowed these people to survive.
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