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Dissociative Identity Disorder Treatment

Contrary to popular belief, dissociative identity disorder (DID) is not rare. It affects about 1 to 1.5 percent of the general population. DID is a complex condition that’s characterized by two or more distinct personality or identity states and recurrent gaps in memory that go beyond ordinary forgetting.

DID is associated with higher rates of childhood trauma than any other disorder. Co-occurring conditions are common, including posttraumatic stress disorder (PTSD), major depression, substance abuse, anxiety disorders, eating disorders, and borderline personality disorder.

In addition, individuals with DID have very high rates of suicide attempts and self-injuring behavior.

While DID is serious and severe, it’s also highly treatable. Psychotherapy is the best way to treat DID. Medication may be prescribed for co-occurring disorders.

Psychotherapy for DID

Psychotherapy is the foundation of treatment for individuals with dissociative identity disorder (DID). According to 2011 treatment guidelines from the International Society for the Study of Trauma and Dissociation (ISSTD), along with other research, treatment should include three phases or stages.

“These treatment phases are not linear, but are often alternated or seamlessly interwoven after an initial period of stabilization, depending on the needs of the patient,” a 2017 paper in the European Journal of Trauma & Dissociation noted.

Stabilization and safety are the primary focus of stage 1 (and are important throughout treatment). The therapist and person with DID work on reducing behaviors that are suicidal, self-injurious, or self-destructive. Individuals learn healthy coping skills and emotion regulation tools, including grounding and relaxation techniques.

Being able to tolerate one’s emotions is particularly critical and foundational to recovery, because it reduces a person’s reliance on non-suicidal self-injuring behavior and other dangerous behaviors. It also reduces dissociation (which typically occurs because the person is trying to manage overwhelming emotions).

In addition, at this stage, therapy might include developing healthy habits and routines, such as getting adequate sleep and rest.

It’s also important that the first stage include “internal cooperation and co-consciousness between identities,” according to the ISSTD guidelines. Specifically, “This goal is facilitated by a consistent approach of helping DID patients to respect the adaptive role and validity of all identities, to find ways to take into account the wishes and needs of all identities in making decisions and pursuing life activities, and to enhance internal support between identities.”

Individuals may move to stage 2 when their ability to identify and tolerate their emotions improves, their dissociation diminishes, and they’ve mastered basic symptom management skills.

Some individuals might not reach stage 2 for a long time—or at all, particularly if they have severe symptoms, substance abuse struggles, and profound attachment issues. These individuals might make significant strides in safety and overall functioning but be unable to intensely explore their trauma. In those difficult cases, stage 1 is the final goal of treatment.

According to the ISSTD guidelines, “In the case of chronically low-functioning patients, the focus of treatment should consistently be stabilization, crisis management, and symptom reduction (not the processing of traumatic memories or the fusion of alternate identities).”

In stage 2, individuals carefully and gradually process their traumatic memories. This is a collaborative process between client and clinician. As a 2017 paper underscored, “In all cases, patients should have informed consent about moving into phase 2 treatment.”

Both client and clinician talk about (and agree on) the specific parameters for this work.

For example, they’ll discuss which memories will be addressed (and the level of intensity to process them); which interventions will be used; which identities will participate; how safety will be maintained; and what to do if sessions become too intense.

According to the ISSTD guidelines, “The process of Phase 2 work allows the patient to realize that the traumatic experiences belong to the past, to understand their impact in his or her life, and to develop a more complete and coherent personal history and sense of self.”

In stage 3, individuals reconnect to themselves and others and refocus on their life goals. Individuals often achieve a more solid sense of self, fusing their alternate identities. (Some individuals with DID choose not to integrate.) They also might work on dealing with day-to-day stressors, which everyone experiences.

Therapists may use cognitive-behavioral techniques, along with other treatments. For example, in 2016, researchers published a paper on adapting dialectical behavior therapy (DBT) and its techniques for stage 1, which focuses on safety and reducing self-harm and posttraumatic stress symptoms (e.g., visualizing a safe place). DBT was originally developed to treat borderline personality disorder (BPD), which often co-occurs with DID.

Hypnotherapy also may be used to treat DID. However, it’s critical to find a therapist who’s certified in using hypnosis and specializes in using it in DID and other trauma-related disorders.

Therapists might teach clients to hypnotize themselves. For instance, when processing traumatic memories, individuals might visualize memories on a screen. They might visualize an internal “meeting place” where all identities meet up to discuss issues and daily concerns and to problem solve.

In addition, expressive therapies, such as art therapy, movement therapy, and music therapy, can help individuals to safely nonverbally communicate underlying thoughts, feelings, stressors, and traumatic experiences.

Sensorimotor psychotherapy can be helpful for individuals with DID because it includes body-centered interventions. For example, these interventions can teach people to pay attention to the physiological signs that an alternate identity is about to arise, which can help them gain control over switching.

Because there’s a shortage of clinicians who specialize in treating DID, researchers have created an online educational program for both individuals and their therapists. The program consists of short educational videos, most of which also include writing and behavioral exercises for applying the content. A 2019 study found that participants’ symptoms improved—no matter their severity. For example, self-injurious behavior diminished and emotion regulation was enhanced.

 Overall, it’s critical for treatment to target dissociation symptoms—such as dissociative amnesia and identity disintegration—because research suggests that when these symptoms aren’t specifically addressed, they don’t improve.

Treatment may take several years. Also, depending on a person’s resources, including their health insurance, sessions may be once or twice a week for up to 90 minutes each.


Medications for DID

Currently, there’s no medication for treating dissociative identity disorder (DID), and the research on medication for DID is virtually nonexistent. Authors of a 2019 review on pharmacotherapy for dissociative disorders published in Psychiatry Research weren’t able to conduct an analysis of some subtypes, including DID, because of the insufficient number of published studies.  

Medication is typically prescribed to individuals with DID for co-occurring conditions or concerns, such as mood and anxiety symptoms. Doctors might prescribe antidepressants, such as selective serotonin reuptake inhibitors (SSRIs).

Benzodiazepines may be prescribed to decrease anxiety, and it’s best that they’re prescribed short term. While they might be helpful for some individuals with DID, there are significant concerns with this class of medication. For instance, because they can be highly addictive, benzodiazepines are problematic for individuals with co-occurring substance use. One source also noted that benzodiazepines can exacerbate dissociation. If a benzodiazepine is prescribed, it should be a longer-acting one, such as lorazepam (Ativan) and clonazepam (Klonopin).

Antipsychotic medication may be prescribed for mood stabilization, overwhelming anxiety, irritability, and intrusive PTSD symptoms.

The medication naltrexone, which is approved by the Food and Drug Administration (FDA) to treat opioid use disorders and alcohol use disorders, may help reduce self-injurious behavior.

Medication for sleep disturbances, which are incredibly common in DID, may be prescribed. For example, prazosin (Minipress) might help to decrease nightmares. However, psychotherapy that addresses fears and nighttime dissociative symptoms is typically a more effective option.

Because of the nature of DID—dissociative amnesia and alternative identities—taking medication as prescribed can get complicated. Guidelines from the International Society for the Study of Trauma and Dissociation (ISSTD) summarized the complexity, noting that alternate identities might report different responses to the same medication:

“This may be because of the different levels of physiologic activation in different identities, somatoform symptoms that can realistically mimic all known medication side effects, and/or the identities’ subjective experience of separateness rather than because of any actual differential biological effects of the medications.”

The authors further note that, “identities may ‘trick’ other identities by not taking medications or by taking more than the prescribed amount of medications, with other identities who wish to adhere to the medication regimen having amnesia for these behaviors.”

It’s important to address these challenges when working with your psychiatrist and/or therapist.


Hospitalization for DID

Hospitalization, or inpatient treatment, may be necessary when individuals with dissociative identity disorder (DID) are at risk for hurting themselves or others, or when their dissociative or posttraumatic symptoms are overwhelming. Hospitalization is typically brief (because of insurance) and focuses on crisis management and stabilization.

However, if resources are available, hospitalization might be a good opportunity to focus on difficult work that’s not possible in outpatient therapy, such as processing “traumatic memories and/or work[ing] with aggressive and self-destructive alternate identities and their behaviors,” according to treatment guidelines from the International Society for the Study of Trauma and Dissociation.

Some hospitals have specialized inpatient programs for dissociative disorders, including the Dissociative Disorders and Trauma Inpatient Program at McLean Hospital in Massachusetts and The Trauma Disorders Program at Sheppard Pratt Health System in Maryland.

Another option is a partial hospitalization program. An individual with DID might attend this kind of program instead of being hospitalized, or they might transition from inpatient treatment to a day program. Partial hospitalization programs might include intensive skills training around relationships and managing symptoms, and use interventions such as dialectical behavioral therapy (DBT). Hours can vary. For example, McLean offers a partial hospital program that is five days a week from 9 a.m. to 3 p.m.


Self-Help Strategies for DID

Practice gentle, compassionate self-care. For example, create a soothing bedtime routine to help you get enough sleep and rest. Participate in restorative yoga classes. Find healthy coping strategies that help you to process overwhelming emotions and tolerate discomfort. This might include journaling, taking a walk in nature, and listening to calming music.

 Make art. Many people with DID find art to be an invaluable coping tool. Art is a powerful, safe way to express yourself and process your emotions and experiences. Carve out some time to draw, paint, sculpt, doodle, take photos, pen poetry, or experiment with other art activities. Another option is to take an art class online or in person.

Learn about others’ stories. If you have DID, know that you’re not alone. And if you’re the loved one of someone with the disorder, learn as much as you can about it. It can help to read about others’ experiences. For instance, Kim Noble is an artist who has DID. Her various personalities have their own distinct artistic styles. She’s also penned the memoir All of Me: How I Learned to Live with the Many Personalities Sharing My Body.

 Attorney Olga Trujillo penned the memoir The Sum of My Parts: A Survivor’s Story of Dissociative Identity Disorder. Christine Pattillo published the book I Am WE: My Life with Multiple Personalities, which includes stories written by her, her alternate personalities, her husband, therapist, and loved ones.

Jane Hart, who was diagnosed with DID in 2016, shares helpful ways to navigate the day to day with the disorder in this post on NAMI.

Mental health advocate Amelia Joubert tells Bustle in this article what it’s really like to live with DID. In this Psych Central piece, Heather B writes about her experience with DID.

An Infinite Mind is a non-profit organization for individuals with DID. This page includes brief stories from individuals who are surviving and thriving with DID. An Infinite Mind also hosts several conferences, such as this conference in Orlando, Fla, and includes a comprehensive list of resources.

For more on symptoms, please see symptoms of dissociative identity disorder.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brand, B., Schielke, H.J., Putnam, K.T., Putnam, F.W., Loewenstein, R.J., Myrick, A….Lanius, R.A. (2019). An online educational program for individuals with dissociative disorders and their clinicians: 1-year and 2-year follow-up. Journal of Traumatic Stress, 32, 1, 156-166. DOI: 10.1002/jts.22370.

Dissociative identity disorder (DID). Shepphard Pratt Health System. Retrieved from https://www.sheppardpratt.org/knowledge-center/condition/dissociative-identity-disorder-did.

Foote, B., Van Orden, K. (2016). Adapting dialectical behavior therapy for the treatment of dissociative identity disorder. American Journal of Psychotherapy, 70, 4, 343-364. DOI: 10.1176/appi.psychotherapy.2016.70.4.343.

Gentile, J.P., Dillon, K.S., Gillig, P.M. (2013). Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innovations in Clinical Neuroscience, 10, 2, 22-29.

International Society for the Study of Trauma and Dissociation. (2011). [Chu, J. A., Dell, P. F., Van der Hart, O., Cardeña, E., Barach, P. M., Somer, E., Loewenstein, R. J., Brand, B., Golston, J. C., Courtois, C. A., Bowman, E. S., Classen, C., Dorahy, M., ̧ Sar,V., Gelinas,D.J., Fine,C.G., Paulsen, S., Kluft, R. P., Dalenberg, C. J., Jacobson-Levy, M., Nijenhuis, E. R. S., Boon, S., Chefetz, R.A., Middleton, W., Ross, C. A., Howell, E., Goodwin, G., Coons, P. M., Frankel, A. S., Steele, K., Gold, S. N., Gast, U., Young, L. M., & Twombly, J.]. Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12, 115–187. DOI: http://dx.doi.org/10.1080/15299732.2011.537247.

Jepsen, E. K. K., Langeland, W., Sexton, H., & Heir, T. (2014). Inpatient treatment for early sexually abused adults: A naturalistic 12-month follow up study. Psychological Trauma: Theory, Research, Practice and Policy, 6, 142–151. DOI: https://doi.org/10.1037/a0031646.

Schielke, H., Myrick, A., Brand, B. (2019, May 6). What the research says about the treatment of patients with dissociative disorders—and an invitation to work and learn together with the TOP DD research team. Trauma Psychology News. Retrieved from http://traumapsychnews.com/2019/05/top-dd-research-team.

Sutar, R., Sahu, S. (2019). Pharmacotherapy for dissociative disorders: A systematic review. Psychiatry Research, 281. DOI: https://doi.org/10.1016/j.psychres.2019.112529.

Van der Hart, O., Steele, K., Nijenhuis, E. (2017). The treatment of traumatic memories in patients with complex dissociative disorders. European Journal of Trauma & Dissociation, 1, 25-35. DOI: https://doi.org/10.1016/j.ejtd.2017.01.008.

 


Margarita Tartakovsky, M.S.

Margarita Tartakovsky, M.S. is an Associate Editor and regular contributor at Psych Central. Her Master's degree is in clinical psychology from Texas A&M University. In addition to writing about mental disorders, she blogs regularly about body and self-image issues on her Psych Central blog, Weightless.

APA Reference
Tartakovsky, M. (2019). Dissociative Identity Disorder Treatment. Psych Central. Retrieved on December 5, 2019, from https://psychcentral.com/disorders/dissociative-identity-disorder/treatment/
Scientifically Reviewed
Last updated: 11 Oct 2019 (Originally: 17 Dec 2017)
Last reviewed: By a member of our scientific advisory board on 11 Oct 2019
Published on Psych Central.com. All rights reserved.