Dissociative identity disorder (DID), known previously as multiple personality disorder, is not a real disorder. At least, that’s what you might’ve heard in the media, and even from some mental health professionals. DID is arguably one of the most misunderstood and controversial diagnoses in the current Diagnostic and Statistical Manual of Mental Disorders (DSM). But it is a real and debilitating disorder that makes it difficult for people to function.
Why the controversy?
According to Bethany Brand, Ph.D, a professor of psychology at Towson University and an expert in treating and researching dissociative disorders, there are several reasons. DID is associated with early severe trauma, such as abuse and neglect.
This raises the concern over false memories. Some people worry that clients may “remember” abuse that didn’t actually happen and innocent people may get blamed for abuse. (“Most people with DID don’t forget all their abuse or trauma,” Brand said; “sufferers may forget episodes or aspects of some of their trauma,” but it’s “fairly rare not to remember any trauma at all and suddenly recover memories of chronic childhood abuse.”) It also “pries into families’ privacy,” and families may be reluctant to reveal information that might put them in a negative light.
In the mental health field, myths persist because of a lack of education and training about DID. These myths create a mystique around the disorder and perpetuate the belief that DID is bizarre. For instance, one prevalent myth is that there are “different people inside someone with DID,” Brand said. Adding to the problem are poorly trained therapists who promote atypical treatments that aren’t supported by the expert clinical community. “Mainstream, well-trained dissociative experts don’t advocate using bizarre treatment interventions. Rather, they use interventions that are similar to common ones used in treating complex trauma,” she said.
What Is DID?
DID typically develops in childhood as a result of severe and sustained trauma. It’s characterized by different identities or “self-states” (there is no integrated sense of self) and an inability to recall information that goes beyond forgetfulness. Prone to amnesia, people with DID sometimes “can’t remember what they’ve done or said,” Brand said. They have a tendency to dissociate or “space out and lose track of minutes or hours.” For instance, it’s “common [for people with DID] to find they’ve hurt themselves [but] don’t remember doing that,” Brand said. The loss of memory isn’t due to drugs or alcohol, but a switch in self-states, she noted. Here’s a list of the DSM criteria for DID.
7 Common DID Myths
It’s safe to say that most of what we know about DID is either exaggerated or flat-out false. Here’s a list of common myths, followed by the facts.
1. DID is rare. Studies show that in the general population about 1 to 3 percent meet full criteria for DID. This makes the disorder as common as bipolar disorder and schizophrenia. The rates in clinical populations are even higher, Brand said. Unfortunately, even though DID is fairly common, research about it is grossly underfunded. Researchers often use their own money to fund studies or volunteer their time. (The National Institute of Mental Health has yet to fund a single treatment study on DID.)
2. It’s obvious when someone has DID. Sensationalism sells. So it’s not surprising that depictions of DID in movies and TV are exaggerated. The more bizarre the portrayal, the more it fascinates and tempts viewers to tune in. Also, overstated portrayals make it obvious that a person has DID. But “DID is much more subtle than any Hollywood portrayal,” Brand said. In fact, people with DID spend an average of seven years in the mental health system before being diagnosed.
They also have comorbid disorders, making it harder to identify DID. They often struggle with severe treatment-resistant depression, post-traumatic stress disorder (PTSD), eating disorders and substance abuse. Because standard treatment for these disorders doesn’t treat the DID, these individuals don’t get much better, Brand said.
3. People with DID have distinct personalities. Instead of distinct personalities, people with DID have different states. Brand describes it as “having different ways of being themselves, which we all do to some extent, but people with DID cannot always recall what they do or say while in their different states.” And they may act quite differently in different states.
Also, “There are many disorders that involve changes in state.” For instance, people with borderline personality disorder may go “from relatively calm to extremely angry with little provocation.” People with panic disorder may go “from an even emotional state to extremely panicked.” “However, patients with those disorders recall what they do and say in these different states, in contrast to the occasional amnesia that DID patients experience.”
As Brand points out, in the media, there is a great fascination with the self-states. But the self-states are not the biggest focus in treatment. Therapists address clients’ severe depression, dissociation, self-harm, painful memories and overwhelming feelings. They also help individuals “modulate their impulses” in all their states. The “majority [of treatment] is much more mundane than Hollywood would lead us to expect,” Brand said.
4. Treatment makes DID worse. Some critics of DID believe that treatment exacerbates the disorder. It’s true that misinformed therapists who use outdated or ineffective approaches may do damage. But this can happen with any disorder with any inexperienced and ill-trained therapist. Research-based and consensually established treatments for DID do help.
The International Society for The Study of Trauma and Dissociation, the premier organization that trains therapists to assess and treat dissociative disorders, features the latest adult treatment guidelines on their homepage. These guidelines, which Brand helped co-author, are based on up-to-date research and clinical experience. (The website also offers guidelines for kids and teens with dissociative disorders.)
Brand and colleagues recently conducted a review of treatment studies on dissociative disorders, which was published in the Journal of Nervous Mental Disease. While the reviewed studies have limitations—no control or comparison groups and small sample sizes—results revealed that individuals do get better. Specifically, the authors found improvements in dissociative symptoms, depression, distress, anxiety, PTSD and work and social functioning. More research is needed. Brand along with colleagues from the U.S. and abroad are working on a larger scale study to test treatment outcomes.
5. Therapists further develop and “reify” (regard them as real or concrete) the self-states. Quite the opposite, therapists try to create an “inner communication and cooperation among self-states,” Brand said. They teach patients to manage their feelings, impulses and memories. This is especially important because a person switches self-states when they’re faced with overwhelming memories or feelings such as fear and anger.
Therapists help patients integrate their states, which is a process that happens over time. Unlike movies and media depict, integration isn’t “a big dramatic event,” Brand said. Instead eventually, the differences among states diminish, and the person is better able to handle strong feelings and memories without switching self-states and retreating from reality.
6. Only people with DID dissociate. People dissociate in response to trauma or other overwhelming situations such as intense pain or anxiety. So individuals with other disorders such as anxiety disorders and PTSD also dissociate. (In about six months a journal that specializes in depression and anxiety will focus its entire issue on dissociation.)
Researchers in other fields, specifically PTSD, are starting to reanalyze their data and categorize individuals into high dissociatives and low dissociatives. They’re learning that people who are high dissociatives often have a slower or poorer response to treatment. This shows that much more research is needed to learn how to better treat dissociative individuals, Brand said.
Also, brain studies have shown that high dissociatives exhibit different brain activity than low dissociatives. A 2010 review in The American Journal of Psychiatry concluded that people who have the dissociative subtype of PTSD “tend to have less activation in the emotional centers of the brain while recalling their traumas and while dissociating than do people with classic PTSD.”
7. Hypnosis is used to access or explore hidden memories. Some therapists used to believe that hypnosis could help clients retrieve accurate memories (like memories of abuse). Now, compelling research has shown that “experiences recalled under hypnosis can feel very true,” even though the person never experienced these events, Brand said. She added that all the reputable professional associations that provide training in hypnosis “educated therapists that they should never use hypnosis to try and facilitate recall of memory.” So if a therapist says they use hypnosis to explore memories, Brand underscored the importance of obtaining information about their trauma training.
Well-trained therapists use hypnosis only to manage common symptoms such as anxiety and chronic pain. People with DID tend to struggle with insomnia, and hypnosis improves sleep. It also “helps contain PTSD flashbacks,” and provides “distance from and control over traumatic, intrusive memories,” Brand said. People with DID often experience severe migraines, which may be “correlated with internal conflict amongst personality states.” For instance, one self-state may want to commit suicide while the others don’t.
Chronic health problems are common among people with DID. The underlying reason may be stress. The ACE studies have found a link between “adverse childhood events (ACE)” like parents’ substance abuse and divorce, as well as childhood abuse, and various psychological and medical problems.
Brand uses hypnosis in her sessions, which she describes as “facilitating a positive change in state of consciousness.” Many people with DID are actually highly hypnotizable, she said. To hypnotize a client, Brand simply says: “I want you to breathe slowly and deeply and imagine being in a safe place.”
An Example DID Case
So what does DID look like? According to Brand, picture a middle-aged woman who’s been in the mental health system for about 10 years. She comes into therapy seeking help for her self-destructive behaviors. She cuts herself, has made several suicide attempts and struggles with a disabling depression. She never mentions having DID. (Most people with DID don’t realize they have it, or if they do, they keep it hidden because they don’t want to be seen as “crazy.”)
But she’s aware that she “loses” gaps of time and has a bad memory. During sessions with her therapist, she spaces out. Often the therapist has to call her name to bring her back to the present. People have occasionally mentioned her out-of-character behavior. For instance, even though she rarely drinks, she’s been told that at times, she drinks a lot of alcohol. She realizes that this must be true because she’s felt hungover before but couldn’t remember having a single drink. “However, she admits only to herself that she cannot recall what she did for several hours on the nights before the hangovers. She tries not to think about these unexplained, frightening experiences.”
She also experiences PTSD-like symptoms. She recalls being choked and sometimes coughs profusely and feels like she can’t catch her breath. Or she gags when brushing her teeth. She struggles with a poor body image, low self-esteem and a number of chronic health problems, including fibromyalgia and migraines.
(Keep in mind this example contains generalizations.)
Regardless of the controversy, dissociative identity disorder is a real disorder that disrupts people’s lives. But there is hope and help. If you’re struggling with DID, check out this list of therapists from the International Society for the Study of Trauma and Dissociation.
You can learn more about DID from the International Society for The Study of Trauma and Dissociation. A highly regarded expert on the disorder, Richard P. Kluft, M.D., talks about DID and the TV series “United States of Tara” in this video.