Dissociative identity disorder

Dissociative identity disorder, (multiple personality disorder) is one of two complex Dissociative Disorders according to the DSM-5.

The most current information today is focused on identifying and understanding "distinct states" and "less than distinct states," as did important research of the past. It was 1940 when Charles Samuel Myers (born March 13 1873, London and died October, 12 1946, Winsford in Somersetshire) reported:

"'Now and again there occur alterations of the 'emotional' and the 'apparently normal' 'personality state,' the return of the former often heralded by severe headache, dizziness or by a hysterical convulsion. On its return, the 'apparently normal' 'personality state,' may recall, as in a dream, the distressing experiences revived during the temporary intrusion of the 'emotional' 'personality state,'.' - Myers (1940)"

Pierre Marie Félix Janet, (born May 30, 1859, Paris, France and died February 24, 1947, Paris) a French psychiatrist and neurologist also understood there are two distinctly different types of states among those afflicted with dissociative symptoms, but he further reported there are two also two completely different disorders. Today we know those disorders as the complex Dissociative Disorders: other specified dissociative disorder and dissociative identity disorder.

More recently, Ellert Nijenhuis, Onno van der Hart and Kathy Steele brought Janet's work to the spotlight in peer reviewed journals and in their 2006 book, "The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization," introducing a modified concept. They call their conceptualization "structural dissociation of the personality." In structural dissociation, a "distinct state" is referred to as the "apparently normal part of the personality" and the "less than distinct state" is known as the "emotional part of the personality," but the more universal terms distinct state and less than distinct state is more widely accepted. Ulrich Lanius, Sandra Paulsen, and Frank Corrigan offer a definition of states, which agrees with the original by van der Hart et al., and adds that distinct and less than distinct states are unique unto themselves and lack functional overlapping.

"Separate self-states can be complex emotional states based in truncated defense responses and have relatively independent interpretive loops through the brainstem, the body, the spinothalamic tracts, and the cortex. At the other extreme are separate body states that have circuits through the brainstem and body with little involvement even of thalamic structures. They resemble what van der Hart et al. refer to as EP's. Other self-states are stored in cortico-striato-thalamo-cortical loops that have little affective or defensive loading. These different states resemble what van der Hart et al. (2006) describe as ANP's. These self-states are more likely separated at a subcortical level-thalamocortical loops through the basal ganglia."

Ulrich Lanius, Sandra Paulsen, and Frank Corrigan, along with fourteen other contributors have provided a neurological view of the concept in their 2014 book "Neurobiology and Treatment of Traumatic Dissociation Toward an Embodied Self." . A less in-depth, but supporting work is "Neuroscience and Psychoanalysis," authored by Allan Schore, Bessel van der Kolk, David Mann, George Northoff, Robert Stickgold, Grigoris Vaslamatzis, Matthew Walker and edited by Giuseppe Leo.

Etiology
Consistent, overwhelming early childhood trauma, maintaining a degree of terror in the brain of a young child throughout infancy, and also existing in another patterned early "childhood developmental stage" is required before dissociative identity disorder can fully engage. This second stage is what separates victims of this disorder from those that have other specified dissociative disorder(OSDD). Every credible author today reports that dissociative identity disorder is caused by a combination of environmental factors that come together to create the "perfect storm,"  but it's imperative to note that this process involves at least two childhood developmental stages, with one stage consuming at least most of infancy, and the other prior to age four, and extending as long as five years of age. This is called complex trauma and it literally changes the way the mind and brain function. In the book "The Body Keeps The Score," Bessel van der Kolk wrote the following:

"Trauma by definition is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability. While we want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep blow our rational brain) is not very good at denial.  Long after a traumatic experience is over, it may be reactive at the slightest hint of danger and mobilized disturbed brain circuits and secrete massive amounts of stress hormones.  This precipitates unpleasant emotions intense physical sensations, and impulsive and aggressive actions."

Christine Courtois and Julian Ford wrote the following in Treatment of Complex Trauma.

"We define 'complex trauma' as traumatic attachment that is life or self-threatening, sexually violating, or otherwise emotionally overwhelming, abandoning, or personally castigating or negating, and involves events and experiences that alter the development of the self by requiring survival to take precedence over normal psychobiological development."

Complex trauma changes the human psyche, especially when it's introduced and maintained exceptionally early in life.

All this can be summed up by saying, that the required sequence of external actions enacted onto an infant sufficient enough to carry out the "neurological process" culminating in dissociative identity disorder is not magical; it's the "natural process" that the mind/brain system follows. If this path is forsaken, then resulting "neural, physiological and mental complications" lead to death. The infant in this environment has literally been in a "state of terror" throughout their young life. Troublesome hot spots infest the mind, and without relief prior to age five, they result in structural dissociation; a personality restructuring that attempts to calm the mind/brain system.

Polyvagal responses
An infant in a "harsh enough environment" to cause dissociative identity disorder is living in constant terror, which is a state of arousal caused by a sequence of polyvagal responses including: fight, flight, fear, freeze, and feign. A defenseless baby cannot attempt flight or fight, and freezing and feigning do little for an infant in a hostile environment, and so the baby dwells in the fear response, unable to calm their mind. Still, the resulting developmental course is insufficient to cause dissociative identity disorder; the cycle of tenacious "assault" resulting in unsoothed terror, must replicate its previous intensity again prior to age five. This second phase is critical to the ontogeny of dissociative identity disorder, because without it only one distinct state will ever evolve, if any, and the very definition of dissociative identity disorder is it's the only mental disorder with two or more distinct states. See the fig. on this page labeled: dissociative part-dependent resting-state activity in dissociative identity disorder: a controlled fMRI perfusion study.

Attachment, abandonment, loss
An infant is wholly dependent on their caregivers for protection, and while safety is paramount to an infant, basic cleanliness, nutrition and a kind face to greet them (mirror) affects neurological processes and activity in the mind/brain system. Without proper nurturing, a confused sequence of feelings repeat in an infant's mind, that if put into words goes something like this:

''Why am I alone? Why do I feel rejected? Why do I exist if I am alone. Why do I exist if I am rejected? Why do I exist? I want to die.''

When a child has a loving adult supporting them, then they don't feel the mental anguish of loss, absolute abandonment and helplessness that an unsupported child does. The mind of a supported infant will express a sequence like this:

My caregiver is trying to help me, my caregiver cares about me, my caregiver is kind to me, my caregiver wants me to feel good, I belong in this world, I belong to someone that is kind to me, I have someone that will try and keep me safe and does not harm me, I am supported.

When basic needs are not met, a secure attachment is at risk, which is an invisible link from a child's developing mind/brain system to their primary caregiver which determines what functions will develop in the mind/brain system of the child. A secure attachment does not seem to be about love, or hope or even kindness. It appears to be a life-line; a developmental milestone that must be reached prior to the third developmental stage (age 5-8) in childhood, or it will never be reached. A secure attachment to a primary caregiver brings with it a "sense of self" that cannot be found in any other way. It's a tether to a supporting adult that gives a child strength to explore and enrich their life, and it's essential to good mental health. Of course you can attach to other people later in life, but that does not fix the damage caused during early childhood.

Identity confusion
A child failing to realize a secure attachment, more often than not, goes into his own subconsciousness searching for the only perceived kindness and "comfort" in their life, which germinates role confusion. If there were to be a pet in the home, then the confused signals and interpretation might go like this:

''Puppies are smelly. Puppies are affectionate. Puppies have sharp nails. Puppies bark and scare me. Puppies lick me. Puppies cuddle with me. Puppies are nice, but dangerous. Puppies are like mommy. Mommy is dangerous. Maybe mommy is affectionate too.''

''Cats are smelly. Cats are affectionate. Cats cuddle with me. Cats are nice. Cats are comforting. Cats are my friend. I need a friend. I love cats. I love my cat. I love my cat when it cuddles with me. I can survive as long as I have my cat.''

The child's mind/brain system is sending signals back and forth, desperately seeking a reason for the child to live. What they find will not repair the early childhood loss of attachment to a primary caregiver, but it might make it easier to exist. If the child has nothing but their subconsciousness to turn to, it will lead to even more confusion about the very essence of self, because in that inner world of the subconscious there is no one but themselves to turn to. (Later after structural dissociation there will be states that will offer interaction.)

Complex trauma cannot flow to the brain to be processed into memory
The action and "inaction" of a primary caregiver, followed by a "structural deformity" (not in the literal sense) "breaking the link" between the mind and hippocampus of the brain, leaves an afflicted child incapable of processing trauma. Instead of trauma flowing through the natural system, and culminating in memory processing, the process becomes "backed up." Imagine a "living bus" traveling though a tunnel that is barely wide and tall enough for it to pass through, and before the bus can leave the tunnel it stopped at a red stop light, but the warning was too late since the bus had already traveled halfway though a barricade of tire shredders. It cannot back up or the tires will be flat. The bus carries files, and it plays those files like a relentless and realistic horror movie that has no end. The bus feels the overwhelmingly tragic emotion of the stories from each of the files. The red light is broken and keeps sending out a signal to a repair man who's job is to come and reset the tire shredder so the bus can move on, but the repairman can't understand where the broken light is. Problems accumulate as the visually unstable tunnel begins to crumble, adding external stress to the already tense situation. If the bus hears something from outside the tunnel reminding it of horror from the files, then he reacts in a free-for-all of pandemonium. Nothing is working right, and fear becomes exaggerated. There is no escape from any of it. The bus is trapped in a nightmare of events past.

Structural dissociation and creation of personality states
Continuing with our parody from the paragraph above, the "pandemonium" eventually results in drastic changes meant to calm down the bus, repair the structure of the crumbling tunnel, make sense of the crippled signals to and from the stop light, and at the same time attempt to stop any "words from above" from bombarding the bus with disturbing emotion. In response, the bus changes and instead of files, it becomes filled with people who bring their own files with them, and they may or may not have access to the original files or even their own files. One side of the bus has kids who are hurt and highly emotional; they are unable to forget the nightmare of their past, and on the other side of the bus are adults who want nothing at all to do with the entire process, let alone their past and so they ignore the kids, and them even become afraid of them - even phobic! The kids are distressed and don't understand why the adults avoid them. This is quite a mess, and it gets worse. Cars lacking the ability to go in reverse travel the tunnel and become trapped behind the bus. Each car is filled with either a kid that reacts to their haunted past, or an adult that is phobic of the kids and all the other adults. The adults are phobic of their past and just about anything but daily life activities, and so stay in their cars paralyzed with fear that keeps them from interacting with anyone. The kids sometimes stay in their cars, but other times run around causing havoc because they need comforting, and most of all, they don't want to be alone. After the bus is gone, then the cars don't necessarily have to leave in the order they arrived.

To describe structural dissociation in technical terms, it is a default process that replaces the path that would lead to the death of the child. The younger the child is when all this "confusion overwhelms" them, the sooner they will be struck with structural dissociation. The process of structural dissociation calms the "pandemonium" in the mind, reroutes communication between the hippocampus of the brain, and reduces stress on the child's physical health. If the external environment that caused the problem in the first place is to continue, which it does in those destined to have dissociative identity disorder, the fixes do not work efficiently, and actually add to the problem. The mind continues to be bombarded with distress signals from the brain, and when the mind does figure out how to respond, the brain can't interpret the signal correctly. The personality becomes polarized with one area available only for trauma and the other repelled by trauma. States are created, and in dissociative identity disorder there is always two or more distinct states and two or more less than distinct states. The less than distinct states hold, act and interact with the trauma, while the distinct states are not only phobic of the trauma, but they also are phobic of the states that interact with it.

Trauma that follows structural dissociation (the cars behind the bus) wants to complete the normal cycle and process trauma in the hippocampus, but is unable to because the trauma is stuck in their confused mind. Research is leaning toward the idea that the "original trauma" is blocking the subsequent trauma from moving forward through the process - which is the bus in our parody. The bulk of trauma remains in the mind, unprocessed and causing disruption. The individual is physically, mentally and overall exhausted; when a malfunction continues for a long period of time it's enormously taxing. Meanwhile the same trauma events keep playing, time and time again, each time hoping for a resolution to the pain, but none will ever come while the trauma is still stuck in the mind. Do note that structural dissociation does not mean anything is split, fractured or broken into pieces, but the personality does create a barrier between trauma and the part of itself that abhors trauma. The personality is not a thing, or even a set place; it's pervasive, accessing many areas of the mind. The process leading to structural dissociation is complicated, involving chemical and physical reactions, plus neurological behavior, all reacting and interacting with trauma.

Personality states
After structural dissociation the resulting states are either distinct (adult-like) or less than distinct (child-like). Further the less than distinct states can either be experiencing states or observing states.

Distinct personality states
Distinct states are highly phobic of "anything of emotion" that they do not relate to as an "acceptable" and self acknowledged pattern of reliability. Fear directs how all dissociated personality states relate to each other. Distinct states lack what is "needed" to control fear, and are literally riddled with phobia. Phobic inhibitions prevent distinct states from sharing information with "subjectively offensive states" within their realm. Distinct states have two ways of being present; one is the inner world (subconscious) and the other is "the face" of the individual. The inner world is directed by innate and primal fear which has properties to help fend off "offensive states" which are subjectively intrusive. The phobia between the states is thought to define the partitions between each, and once fear is reduced to an "acceptable level" through processing trauma and integration of states, then intimacy between states can progress.

Less than distinct personality states are either observing or experiencing
In the inner world there are both distinct and less than distinct states, and each of these types of states are fearful of one another to one extent or the other, and of like-states, for that matter. Fear directs a dissociated state's very nature and frames its disposition and character. When created a, less than distinct state takes the form of either observing or experiencing.


 * Observing states: Individuals with dissociative identity disorder often describe at least one observing state that has learned to harness innate skills and become "powerful" in the inner world, but all observing states have this potential. There have been many labels attached to these states including inner self helper, and hidden observer.
 * Experiencing state" These states tend to stay in the "experience in which they evolved;" they are triggered by like occurrences (unprocessed trauma events). In dissociative identity disorder, unlike other specified dissociative disorder, less than distinct states are not "stuck" at certain ages, but instead remain within a certain range of emotional experiences.

Diagnosis
Evidence gained from fMRI (functional magnetic resonance imaging) has recently demanded a strong understanding of distinct and less than distinct states. Any disorder caused by complex trauma has states unique to one specific mental disorder, the ailment of which was determined prior to structural dissociation, in response to mostly external stimuli and lack of attention given to innate human needs by caregivers. Exclusive properties belonging to dissociative identity disorder revolve around the fact that it's the only mental disorder with two or more distinct states. In addition, dissociative identity disorder is the only disorder where only one state, be it distinct or less than distinct, is conscious alone. Later in the evolution of the disorder, if the integration process develops, there is eventually communication between the state that is out, and a state or states in the subconsciousness, but that does not mean two states are out at once, even though it might seem like it to the individual. Instead, it's the breaking down of the dissociative barriers that are associated with the states in question, allowing those in the subconscious to venture closer to consciousness, but they never will obtain it fully. In other specified dissociative disorder, literally every state in the system can, and often is in consciousness at one time.

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Amnesia
Dissociative amnesia involves less than distinct states, but it's true amnesia between the distinct states which defines dissociative identity disorder. A knowledgeable diagnostician understands that for a correct diagnosis of dissociative identity disorder, it's the distinct states that are sought out and not the "amnesia" itself. Individuals with posttraumatic stress disorder (PTSD) and other specified dissociative disorder often report time loss, which is dissociative amnesia rather than true amnesia. Dissociative amnesia is an effect of unprocessed trauma such as flashbacks, where true amnesia is caused by a full switching of distinct states with one another.

Symptom confusion and introjected disorders
Symptoms can be confusing if the state that is out is modeling behavior learned early in childhood. Common "interjected behaviors" (somatic illness) are borderline personality disorder, narcissistic personality disorder, antisocial personality disorder, and other disorders that caregivers of severely traumatized children might have. The individual who is modeling, does not have the disorder, but they "think" (an insanely complicated process) they do, and so they exhibit the symptoms. It is possible for the person with dissociative identity disorder to have a comorbid disorder, but if this is the case then all states in the individual will always have that disorder. PTSD is the most common comorbid disorder. Somatic illness is also responsible for psychological blindness, deafness, and an inability to move limbs, among other things, but unless all states have the "disability", it's just the very complicated process of "modeling learned behavior."

OSDD, BPD, PTSD, Schizophrenia
The first step is to rule out all other less complex disorders that are dissociative in nature. Posttraumatic stress disorder is the most basic, and it would be immediately rules out as soon as elaborate states are observed, which would also be the case for borderline personality disorder, complex-posttraumatic stress disorder and to a less extent, other specified dissociative disorder. In addition, borderline personality disorder that has undergone structural dissociation would evident as soon as the individual showed their inability to regulate true emotions. This means that although less than distinct states might be explosive in dissociative identity disorder, the distinct state is not. In borderline personality disorder, the individual cannot control the emotions of their distinct state. Mental health professionals with inadequate training have misdiagnosed dissociative identity disorder throughout history, but with today's knowledge this should be a thing of the past. Below are common disorders that use to be confused with dissociative identity disorder. Mixing up either dissociative identity disorder or other specified dissociative disorder with borderline personality disorder (BPD), schizophrenia, or posttraumatic stress disorder (PTSD) is unforgivable in this day and age. The ISSTD and other organizations do offer training for mental health professionals.
 * Other specified dissociative disorder is eliminated when there is never a switch between two distinct personality states, because only one distinct state exists in this disorder.
 * Borderline personality disorder is difficult to separate from other specified dissociative disorder, because the less than distinct states react in the same way, but the states in the later are far more elaborate than in the former. Borderline personality disorder should never be confused with dissociative identity disorder, because the less than distinct states in dissociative identity disorder do not behave as they do in borderline personality disorder. They instead behave with intense phobia which directs their actions. In borderline personality disorder, and in other specified dissociative disorder, there is some phobia between the states, but it is not literally directing the behavior of the states.
 * PTSD would be eliminated quickly, when the elaboration of the less than distinct states is observed in dissociative identity disorder.
 * Schizophrenia is not a disorder involving any dissociative state, but instead has a delusional pattern of "state shifting."

While an fMRI is a meticulous method used to identify a distinct state or a less than distinct state, a knowledgeable and trained trauma therapist should be highly proficient in doing the task without a scan, and should be able to also influence their occurrence. If there is never such a switch from one distinct state to another distinct state then the diagnosis would be other specified dissociative disorder, which is a very different and fascinating disorder unto itself, and is probably closer to the TV and movie portrayals than dissociative identity disorder.

Symptoms
Less than distinct states are child-like and highly aware that they are in distress, while distinct states in dissociative identity disorder are rarely able to tell anything is wrong with them due to the massive phobia these states have in response to other states within the personality system. They can't acknowledge the existence of other states. True amnesia, that is psychological in nature only exists between distinct states and so is only found in dissociative identity disorder, which is a diagnostic marker for the disorder. There are several other symptoms but they are shared with others disorders that are influenced by dissociation. Voices "heard" between states is a symptom, and so is self alteration, which means the individual switches to address a presenting external, and on rare occasion an internal situation. The ability to notice this is commonly referred to as "consciousnesses," which is simply a point in integration where communication between parts has been gained. Flashbacks are common in dissociative identity disorder and tend to be glaringly obvious prior to trauma processing. The symptom called: "trance" (staring off into space) is more prominent prior to any therapy. Derealization and depersonalization are feelings that are hard to identify for a distinct state in dissociative identity disorder, because this type of state is devoid of personal acknowledgment in the disorder, and so they can't recognize what is going on in relation to themselves. With a great deal of integration these two "feelings" (symptoms) can be better identified. Identity confusion is unmistakeably present in this disorder, but the distinct state that is out won't notice it until a great deal of integration work has been done. It's important to understand that without trauma processing and integration work an individual with dissociative identity disorder is not going to recognize symptoms in themselves, which is in contrast to the the other complex Dissociative Disorder: other specified dissociative disorder. Somatic symptoms are also present, and can range from a simple itch to complete blindness, deafness or an inability to walk or move limbs. The individual with dissociative identity disorder is often successful, with distinct states functioning efficiently at work, where they tend to dominate consciousness, but they fail in their personal lives where child-like states, (less than distinct states), interject vehement emotions into their world, and at times take over completely, acting in behalf of the individual.

Epidemiology
Dissociative identity disorder is not rare; it is thought to occur in 1% to 3% of the world's general population. The DSM-5 reports that a US community was tested and the findings revealed 1.5% with dissociative identity disorder and it was almost equal among genders. This disorder does exist in childhood, but is rarely found until as an adult, the individual finds their way to therapy.

''DID is conceptualized as a childhood onset, posttraumatic developmental disorder in which the child is unable to consolidate a unified sense of self due to severe, chronic childhood abuse, often involving a caretaker. Dissociation during and after the repeated episodes of abuse allows the child to psychologically detach from the emotional and physical pain, in turn potentially resulting in alterations in memory encoding and retrieval. Over time, this leads to fragmentation and compartmentalization of memory, as well as difficulty retrieving memory. Exposure to early, typically chronic, trauma results in the elaboration of discrete physiological, psychological, and behavioral states that can persist and, over later development, become increasingly developed, ultimately resulting in dissociative emotional/behavioral/memory self-states.'' -Bethany L Brand and Ruth A Lanius

Treatment
Medication does not aid in the treatment of dissociative identity disorder. The only treatment that has ever been proven to result in full unification of any individual with dissociative identity disorder is talk therapy. A therapist (or another) provides support and encouragement while the afflicted individual literally changes the way their mind and brain work. This is a powerful statement, but the work being done is what should have occurred naturally in the first years of life, but it was prevented by outside forces. The brain and mind will keep attempting the process, and once the work is brought to conscious thought enough, the natural process moves forward, but it can take years of hard work. The individual states must reduce fear between themselves enough that there can be acceptance of all self states. Communication will follow, and finally processing of trauma, reduction of symptoms, followed by a return to the natural way the mind and brain were meant to be.

Integration
This work is done between the states as was just explained in the above paragraph. Tolerance between states is primary, followed by acceptance, and fear reduction, with overlapping episodes of trauma event processing. The process of integration leads to a unified personality, which is a normal personality construction void of distinct and less than distinct states, which in no way means that any state is destroyed, but they will no longer be dissociated and isolated due to dissociative boundaries. The individual will finally be able to process trauma memories and will now fail to suffer from the symptoms of structural dissociation. Upon unification all states still exist and communicate with each other, but in a smooth way that causes no harm. The states will be trauma free and free of the disease that was inflicted upon them. During most of the work will overlap. See our detailed section on integration for more.

Prognosis
When untreated there is chronic and recurrent symptoms varying overtime including long-lasting effects. because the brain and mind will keep going around in circles unable to find resolution until the matter is brought to consciousness to be worked on. At least four-years of psychotherapy are usually needed for adults (less for children) to allow time for trauma memory processing, elimination of dissociative boundaries and to obtain a unified sense of self. Estimates of patients that do obtain full integration range from 16.7% to 33%.

History
Paul F. Dell led a drive to understand posttraumatic stress disorder, the Dissociative Disorders and dissociation in his multi-authored, 864 page book titled: Dissociation and the Dissociative Disorders: DSM-V and Beyond. The massive book was an attempt made in 2009 to bring to the forefront the main ideas of the research community,  but there was little agreement at that time and the book strongly reflected that fact. More recently, Ellert R.S. Nijenhuis and Onno van der Hart have led the field with an unearthing of knowledge that was influenced by the French genius, Pierre Marie Félix Janet. Janet, amid an onslaught of naysayers including Sigmund Freud, determined that the mind's ability to dissociate, was influenced by what he called "dissociative determinations," which today is referred to as subjective trauma. Janet insisted that the mind is made up of a network of neurons that when healthy, work together in harmony, but when "infected" by trauma, the mind has no choice but to react and interact with its influence. Janet pointed out that while the process had purpose in human evolution, it is counter-productive in "modern man". Janet's work was stifled by influential researchers that took another path after Janet died. There was a media circus in response to movies, books and other public information sharing including "Sybil," "Three Faces of Eve," and the Billy Milligan story. The symptoms and presentation were mixed portrayals of dissociative identity disorder, and other specified dissociative disorder and other comorbid disorders and somatic disorders. All this confusion created a Frankenstein effect that was more fantasy than reality.

Rational took over when Ellert R. S. Nijenhuis and Onno van der Hart dug into the original writings of Janet and brought them to light. They demanded that Janet's work be heard and understood as they worked together to process the historic information. Later, Kathy Steele joined the two men and the three researching clinicians published the landmark book: The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. There were earlier journal articles on this subject by the three authors, but it was the book that fully introduced the concept of what today is called "structural dissociation of the personality." Now in 2014 fMRI scans exist that support the continuing efforts by Ellert R. S. Nijenhuis and Onno van der Hart. Most neurologists that write about dissociative identity disorder share similar views, even if they don't use the same terminology.

Mention in the DSM's of the past
There was nothing about "multiple personalities" in the DSM-I, but the DSM-II did mention the term as a symptom of neurosis. The DSM-III was the first time that "multiple personality disorder" was listed in a DSM as a diagnosis of its own. The name was misleading however, since this mental disorder has never been listed as a Personality Disorder and has nothing significant in common with Personality Disorders.

Diagnostic manual
'''Diagnostic manuals like the DSM and ICD are not meant to be used to understand any mental disorder. Their intent is to give the minimum criteria needed to diagnose a disorder. The criteria listed here is paraphrased.''' The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), was released to the public May 27, 2013. Pages 291-298 of the DSM-5 give a written account that follows an older, more or less general consensus to what dissociative identity disorder is, but it's not up to par with the superior criteria that is presented in the DSM-5. Although what a distinct state is and is not, has been known, and then lost throughout history, the information is accepted well enough today to be presented with full confidence.

The main DSM-5 criteria used to diagnose dissociative identity disorder pinpoints the very characteristic that separates it from all other mental disorders, by exposing this disorder as the only one with two or more distinct states, and thus the only disorder where true amnesia takes place between states. The amnesia criteria helps to distinguish distinct states from less than distinct states.

In the DSM-5 section: Somatic Symptoms and Related Disorders, and under conversion disorder (functional neurological symptom disorder) there is a note that dissociative symptoms are common in individuals with conversion disorder, and if both conversion disorder and a Dissociative Disorder are present, then both diagnosis should be made separately.

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