Dissociative Identity Disorder is often portrayed in the movies and media as a villainous, dangerous, and unpredictable threat to people and society. The unfortunate fact about this message is that it is drastically inaccurate. Interestingly though, getting a real world view of the disorder is also somewhat difficult (as I would say it is for many mental illnesses). If you put into Google the search terms "What is Dissociative Identity Disorder like?", you receive some results of blogs with real experience, however, the overwhelming majority of links are those such as WebMD, who give accurate information regarding the DSM criteria, but often don't consider what the disorder is like in the real world.
Being a clinician that has special interests in DID means that I often see clients with an existing diagnosis of DID, but I also see clients that have been misdiagnosed with another mental illness and upon further investigation, DID is a much better description of their struggles. When these clients go to look for information on DID,
they quickly feel like their new diagnosis of DID is not real because none of what they experience is on these WebMD-esque websites. This blog post is therefore aimed at increasing the amount of real information that is out there.
Dissociative Identity Disorder: Criterion A
What I will do, is use the theoretical information (DSM 5 criteria) that is often found on WebMD to discuss how the disorder presents in real life experiences. So, DID is a disorder in which people feel like a different person and experience some degree of memory loss in their life. Feeling like a different person is termed in the DSM 5 as a distinct personality state (from here I will call them parts). The DSM 5 states that each part represents a 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".
I have put in bold the main key terms in this criterion that would be helpful to explain. The first term of distinct personality states is important to consider because it can help distinguish between other diagnoses such as personality disorders. Oftentimes clients will tell me they don't believe their DID diagnosis because they feel they are just a "good chameleon" that suits themselves to scenarios. Whilst this may be true, those with DID don't just fit into individual situations however they can, they have distinct and specific part(s) of themselves that are consistently present in those types of situations. Those with DID will begin to feel different but it will be consistently different and the same way each time. I am aware that there are what is called "polyfragmented" individuals, who have many parts and these individuals may have so many parts that they can feel different each time, however, they still lose their own sense of self when they switch.
Feeling different is what is meant by discontinuity and can happen with or without awareness of it happening. I will discuss the concept of amnesia in DID later in this post, however people with DID can have full awareness and memories of feeling like a different person in their life and still be diagnosed with DID. Individuals with DID can recognise that they are doing things they would not normally want to do or enjoying things they would normally dislike.
These changes in behaviour or experiences create a change in the person's sense of self or sense of agency. The sense of self could be boiled down to the question, if you think and feel who you are, what do you notice? As I sit here,
I notice that I have the drive to write about the things I feel aren't recognised enough for people with mental illness, I can also recognise that I enjoy true crime podcasts and enjoy watching comedy shows such as Seinfeld. The things that bring me enjoyment, the things that bother and upset me, my past experiences in the world, and how I see my current world all form together to create a very complex sense of who I am. However, separate parts in DID have different memories and experiences, therefore have not formed their sense of self on the same information, or messages, as what other parts have received. This leads to a discontinuity in their sense of self.
Due to this different sense of self, experiences, memories, etc., the person might experience different affect in different situations. An example, one part may hold the memories of trauma that happened to the body. If they are approached by someone similar in age and gender as their perpetrator, they will be extremely wary, possibly
stressed and avoidant. This is because every time they have been hurt, it was someone that age and gender. If the same person then switches to a part that has no memories of trauma and that same perpetrator was only ever nice to the person when this part was out, they would have no reason to be scared or wary, they will be welcoming and possibly even very loving. This is an example of different affect, behaviour, memory and perception and different experiences can lead to a change in the experiences.
Dissociative identity Disorder: Criterion B
The second criterion for the DSM 5 includes consideration for "amnesia", or forgetting events. The DSM 5 states "Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting."
I have highlighted "and/or traumatic events" because I regularly have clients with DID attend appointments and state that there is no way they have DID because they don't experience daily amnesia, or "coming too" on a regular basis. Whilst it is common for people with DID to experience "coming too" phenomena, it is not a definite thing and is not required for a diagnosis. The individual can have significant memory loss for trauma events only and remember their day-to-day experiences well and still have DID.
Dissociative Identity Disorder: Criterion C
As per any DSM 5 diagnosis, an individual must have significant distress or impairment from the symptoms in order to receive a diagnosis of DID. This can be tricky in a diagnosis of DID because the individual may not remember their distress and they may not even know they have amnesia. Individuals may not only say they don't think they have distress, but they also say "no, I have no gaps in my memory and I definitely do not experience any distress over symptoms". These are the difficulties in DID diagnosis and why purposeful and slow attention must be made to each client with dissociative symptoms which is one of the reasons why misdiagnosis occurs regularly.
Dissociative identity Disorder: Criterion D
The fourth criterion for DID includes that "The disturbance is not a normal part of a broadly accepted cultural or religious practice.". This criterion considers the context that the individual comes from, as some cultures and religions have practices such as talking with loved ones that have passed that can be mistaken for a range of mental illnesses, including DID but also psychosis. Clinicians must consider whether the individual has a cultural or spiritual background that would better explain the phenomenon. Within Australia, the most noteworthy culture that this may occur with is the Indigenous population, as their beliefs often include connection with the spirits of those passed. Importantly, the person's perspective of normal can be helpful to determine the definition of normal. Due to DID not being a psychotic disorder, the person should not have struggles with a loss of touch with reality and believing things they do not ordinarily believe, therefore, getting a sense of their normal can be helpful in understanding this.
Additionally, the fourth criterion for DID has a note stating "In children, the symptoms are not better explained by imaginary playmates or other fantasy play." Now, I will put a disclaimer that I do not work regularly with children and therefore won't talk much about this note as it is not my area of expertise. However, children can be diagnosed with DID as early as 7 years old and there has been talk in the past of people (lay population, not literature from what I have seen) stating that children cannot be diagnosed before a certain age because they simply have imaginary friends. However, there is a marked difference between imaginary friends and parts, specifically that parts will take over the child's body, whereas imaginary friends may talk in their mind etc. but rarely do they take over a body. There would undoubtedly be more information about this, but I will leave it there for now as I said I do not know enough to do that topic justice.
Dissociative Identity Disorder: Criterion E
The final criterion is "The symptoms are not attributable to the physiological effects of a substance (eg. blackouts or chaotic behaviour during alcohol intoxication) or another medical condition (eg. complex partial seizures).". This criterion is also found in most DSM-5 diagnoses, similar to the previous two criteria. The final criterion is important to note because the rates of substance use disorder and PTSD are highly correlated. With DID being brought on by trauma in the majority of cases, substance use will be a common occurrence and sometimes, figuring out whether DID symptoms are occurring during substance use or not can be difficult when the individual is regularly intoxicated. If you have DID, or someone you know has DID and uses substances regularly, that will be one of the first things a clinician may work on with the individual. Getting some support as early as possible is the best bet and I will put some links at the end of this post to resources that are helpful for substance use. Motivational Interviewing is a great tool, as it meets the person where they are at and it allows them to make their own choices, as opposed to pushing themselves away from treatment.
Diagnosis of Dissociative Identity Disorder can be difficult, as there are invariably many pieces of information involved. However, any mental health diagnosis should be complex to some degree, as you are not figuring out what is happening as much as you are ensuring you know what is not
happening. Every mental illness has common differential (better fit) and comorbid (at the same time) diagnoses that should be considered comprehensively. However, the diagnostic process is possible and unfortunately often overlooked by clinicians. Just as DID can look like certain diagnoses, it also has diagnoses that can look like it. For my next post, I plan to begin systematically considering each differential diagnosis stated for DID in the DSM-5 and discussing the similarities and differences for people to begin informing themselves of their own mental health and to be able to go through a diagnostic process, therapy, or any mental health appointment with information about what might be happening for them.
Until then, thanks for reading and I will catch you on the next post.
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