Dissociative Identity Disorder

Dissociative Identity Disorder, formerly Multiple Personality Disorder, is a psychological diagnosis listed in the dissociative disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and also in the International Statistical Classification of Diseases and Related Health Problems (ICD-10). It has had a highly controversial history, falling into and out of popularity amongst psychologists. An internet culture, formed from people experiencing plurality, has a very different take on the diagnosis, and on related conditions.

It is similar to tulpamancy, in that it is an experience of plurality. These persons experience alters, which are like other personalities, that can take over the body. The original idea is that all persons experiencing this condition must have had advanced trauma at some time in the past, causing it, but this is controversial.

Health and Safety
This page covers a clinical diagnosis of a mental disorder. As a matter of a person's health, it is important to handle this topic carefully. You might believe that you should redirect anyone who appears to be suffering from this to seek professional help. This presupposes that the person is ill, and that they need help. You are not a doctor. Don't do this.

Similarly, if a person comes to you claiming to have DID, treat them with respect. You are not a doctor, and you don't know what the label means. However, anyone diagnosed with DID has a lot more going on than multiple personalities. According to all professional standards, having multiple personalities is not sufficient reason to apply any diagnosis whatsoever in and of itself. Respect that they may have additional concerns and needs.

Diagnosis
The DSM is the de facto standard for the diagnosis of this condition. However, in practise, diagnostics often diverge from the standards.

The DSM, revision 5, has five criteria for DID, all of which must be met. Several other dissociative disorders use the same criteria, but need fewer of them to be met.


 * 1) Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession.  The disruption in identity 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. These signs and symptoms may be observed by others or reported by the individual.
 * 2) Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
 * 3) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
 * 4) The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
 * 5) The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

The DSM goes on to clarify some of these points briefly.


 * "When alternate personality states are not directly observed, the disorder can be identified by two clusters of symptoms: 1) sudden alterations or discontinuities in sense of self and sense οί agency (Criterion A), and 2) recurrent dissociative amnesias (Criterion B)."


 * "Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their "own" speech and actions, which they may feel powerless to stop (sense of self). Such individuals may also report perceptions of voices (e.g., a child's voice; crying; the voice of a spiritual being). In some cases, voices are experienced as multiple, perplexing, independent thought streams over which the individual experiences no control. Strong emotions, impulses, and even speech or other actions may suddenly emerge, without a sense of personal ownership or control (sense of agency)."


 * "Although most Criterion A symptoms are subjective, many of these sudden discontinuities in speech, affect, and behavior can be witnessed by family, friends, or the clinician."


 * "The dissociative amnesia of individuals with dissociative identity disorder manifests in three primary ways: as 1) gaps in remote memory of personal life events (e.g., periods of childhood or adolescence; some important life events, such as the death of a grandparent, getting married, giving birth); 2) lapses in dependable memory (e.g., of what happened today, of well-learned skills such as how to do their job, use a computer, read, drive); and 3) discovery of evidence of their everyday actions and tasks that they do not recollect doing (e.g., finding unexplained objects in their shopping bags or among their possessions; finding perplexing writings or drawings that they must have created; discovering injuries; "coming to" in the midst of doing something)."


 * "Possession-form identities in dissociative identity disorder typically manifest as behaviors that appear as if a "spirit," supernatural being, or outside person has taken control, such that the individual begins speaking or acting in a distinctly different manner. For example, an individual's behavior may give the appearance that her identity has been replaced by the "ghost" of a girl who committed suicide in the same community years before, speaking and acting as though she were still alive. Or an individual may be "taken over" by a demon or deity, resulting in profound impairment, and demanding that the individual or a relative be punished for a past act, followed by more subtle periods of identity alteration. However, the majority of possession states around the world are normal, usually part of spiritual practice, and do not meet criteria for dissociative identity disorder."


 * "Many features of dissociative identity disorder can be influenced by the individual's cultural background."

The DID further discusses comorbidity, showing that depression, anxiety, substance abuse, self-injury and non-epileptic seizures all correlate with DID. It suggests that those with DID are often unaware, or conceal their symptoms at first. It says that disorienting flashbacks can occur. The DSM discusses the reporting of maltreatment and other trauma, but it's not part of the diagnostic criteria. The DSM lists higher than average hypnotizability and dissociativity, and transient psychotic events as also correlating with DID. Attempted suicide is ridiculously common, with 70% having attempted it.

Prevalence is estimated, roughly, at 1.5% of the population, based on the study of a U.S. town.

Differential Diagnosis
Other Specified Dissociative Disorder: The division of identity (aka plurality) is shared with one variant of OSDD. OSDD does not require amnesia symptoms, and it can be supported by dissociative symptoms not strong enough to meet the first criteria of DID.

Major Depressive Disorder: Most people with DID are also depressed, and this can disguise symptoms of DID.

Bipolar: Personality changes can easily be misinterpreted as mood swings.

Post Traumatic Stress Disorder: Has heavy overlap of symptoms with DID. This can mean the presence of PTSD can hide further evidence of DID. Dissociation unrelated to trauma is a sign it's not just PTSD.

Psychotic disorders: Personified voices can be mistaken for hallucinations, one of the criteria for various psychotic disorders. Furthermore, possession events can be confused for formal thought disorder, thought insertion, and thought withdrawal, other symptoms. People with DID may also experience trauma related hallucinations. However, people with DID do not have delusional explanations for their symptoms.

Alters
A large number of misconceptions surround alters. Alters are the official label used for the other personalities in those diagnosed with DID or a similar condition. However, what this means, is highly ambiguous. The diagnosis has changed and morphed over time. And plurality in general does not fit the diagnosis. To be a DID alter is different than to be a OSDD alter. There is also great difficulty in defining the concepts of personality, identity, and personhood, all of which the definition of alters depends upon.

The official definition of of alters is that they are "distinct personality states". Due to the looseness of this definition, it is even possible that some people with DID don't experience plurality as a tulpamancer would recognise it, though field experience reveals that many with DID do experience plurality of this type.

In practise, most alters experience communication difficulties. This means they cannot read each others thoughts, they cannot watch each other, and they cannot both be active in order to talk to each other at the same time. This leads to amnesia, where one personality fails to remember what happened while another one was active. They also usually experience control difficulties, where they cannot control who is out in front, and can be pushed to the front through the use of trigger words. A side effect of this is they can almost always switch.

Due to recent changes, "experiences of possession" may now also count as alters.

The Clinical Perspective
The diagnosis was initially created in the eighteen hundreds, at a time when efforts to standardise psychological diagnosis were underway. The subject of multiple personalities were discussed amongst psychologists as a topic of fascination. Around this time, it became recognised that traumatic events could indeed cause long lasting mental harm.

Around the start of the nineteen hundreds, interest in this topic began to wane. This is most likely because the condition was seen as very rare, though accusations of fraud also factored in. Around this time, the diagnosis of Schizophrenia was broadened to be more inclusive, capturing much of what dissociative identity disorder was. This overbroadening of Schizophrenia persisted and got worse, mainly in the united states, but has since been largely rectified, with the creation of a new category of dissociative disorders, one that contains DID, as well as other categories for PTSD and similar, and stricter diagnostic standards for Schizophrenia.

In 1957, a book called The Three Faces of Eve, was published, and created a resurgence in the popularity of the diagnosis. In it, in dramatic fashion, was the depiction of "eve", a person with three personalities. This was further strengthened by the story of "Sybil" (real name Shirly Ardell Mason). Despite a sudden jump in the number of people with this diagnosis, more books, and more research, the diagnosis again died amongst rumours of fraud and fakery.

More modernly, starting roughly in the 1980s, an alternate interpretation of this diagnosis has been put forward. Though it is not to say that those with DID are free of disorder, it may be that they are specifically DID for cultural reasons. This phenomenon is more strongly recognised in the category of culture bound disorders, a category for diagnoses that seem to only happen in one place or time on earth. Many of these are also examples of multiplicity or possible multiplicity, and DID could be an American example of this. One example of this is Ian Hacking's concept of multiplicity within his dynamic nominalism theory.

Also starting roughly in 1980, the diagnosis came back with a vengeance, with a dramatic uptake in the number diagnosed, but fell off sharply again near the end of the millennium. Also roughly during this period, this diagnosis has been refined and split, creating the new dissociative diagnoses, Dissociative Disorder Not Otherwise Specified and Other Specified Dissociative Disorder.

The word hysteria has been associated with this diagnosis during various historical periods, but it was its own diagnostic category.

The Healthy Multiplicity Perspective
After the invention of the internet, starting in the 2000s, A number of people experiencing plurality, many of whom are diagnosed with DID or similar, formed an internet subculture. This is a group most represented by a group of vocal bloggers, and it consists primarily of a loose collection of websites. As a subculture, this group has no unified goals or opinions. They are related by a shared experience of plurality. Nonetheless, certain ideas and opinions have come out of the writings of this group. One such idea is the idea that the alternate personalities are persons in their own right. Another is that multiplicity is not a disorder. Though it is unclear if this means more that people with plurality should not be diagnosed with DID or that DID is not a diagnosis of disorder. Those in the community still recommend that people should look at getting psychological support if they feel that is best for them.

Dealing with plurality is not easy. In asserting that their condition is not a disorder, the community has created the problem that they need to provide support and methods for dealing with plurality in a non-clinical setting. This community has done so, establishing several ideas. A system of organisation should be established, such that the alters can cooperate with each other, schedule with each other, and communicate with each other, creating a mode of organised plurality. Instead of seeking "integration", the psychological process where the personalities are blended into one, those in the healthy multiplicity community seek conflict resolution strategies, so that the various personalities can work together and live as a family.

There has been some feedback from this culture's coping strategies back into psychological theory and practise. Many professional psychologists no longer pursue integration as the first solution to this diagnosis, as one example, and now also look towards conflict resolution strategies.