Alters in dissociative identity disorder are dissociated identity states. They have obtained their own identity, experience themselves as separate from other alters and can have their own consciousness, memory, skills, emotions, worldview and view of themselves. Dissociative identity disorder is the only disorder with alters.
An alter is never a full personality: every person has one personality and it all alters together make up a person's full personality. Integration is how the various alters can be merged (fused) into one whole personality. It is now agreed that there is no 'original' or 'core' alter/personality (ISSTD, 2011, p. 10), although the experience might be different.
Each alter has its own way of being, often including its own name, age (differing from the individuals age) and an appearance in an inner world (which is not usually of their choosing).
There are various terms used to refer to alters, all focusing on different aspects:
- Terms emphasizing differences: alters, others, personalities, alter personalities.
- Terms emphasizing a single dissociated entity: ego-states, self-states.
- Terms emphasizing the partitioning of the personality: parts, aspects, fragments. (Shusta-Hochberg, 2004, pp. 18-19)
- 1 The experience of alters
- 2 Treatment of alters in therapy
- 3 Development of alters
- 4 Memory in alters
- 5 Differences between alters
- 6 Types of alters
- 7 Structural dissociation
- 8 References
- 9 Further reading
The experience of alters
People with DID generally "experience their different dissociated parts as different 'people.' They do this even when at the same time they consciously acknowledge that their different identities are all part of the same person." (Howell, 2011, p. 55) Some people who know they have DID may refer to themselves as "we" rather than "I." (Miller, 2012, p. 20). While all alters or identities are part of a single personality or personality system, the Guidelines for Treating Dissociative Identity Disorder state that the identity that is in control "may disown other parts or be completely unaware of them," (ISSTD, 2011) which is not surprising given that some amnesia between alters/parts is essential for DID to be diagnosed.
Alters or identities within a person can physically take control of the body. This is known as taking "executive control".:151
The misleading term "multiple personality disorder"
Dissociative identity disorder was previously called multiple personality disorder (MPD), this term lead to a number of incorrect assumptions, such as the belief that DID is a personality disorder (despite MPD being in the Dissociative Disorders section of the DSM manual rather than the Personality Disorders section). The term "multiple personality disorder" also lead to many people judging the disorder as being primarily or only about the different identities, interpreting them as "the problem" and thinking that the identities they are less familiar with as somehow less "real". The focus on "multiple personalities" can lead to people with limited knowledge of dissociative identity disorder to confuse it with "role-playing" and disregard the other significant dissociative symptoms, such as amnesia between alters. These assumptions still have an impact on people with DID, including the stigmata from people they know, in the media and difficulties with diagnosis.
Treatment guidelines state that "The difficulties in diagnosing DID result primarily from lack of education among clinicians about dissociation, dissociative disorders, and the effects of psychological trauma, as well as from clinician bias. This leads to limited clinical suspicion about dissociative disorders and misconceptions about their clinical presentation. Most clinicians have been taught (or assume) that DID is a rare disorder with a florid, dramatic presentation. Although DID is a relatively common disorder, R. P. Kluft (2009) observed that “only 6% make their DID obvious on an ongoing basis” (p. 600)... instead of showing visibly distinct alternate identities, the typical DID patient presents a polysymptomatic mixture of dissociative and posttraumatic stress disorder (PTSD) symptoms that are embedded in a matrix of ostensibly non-trauma-related symptoms (e.g., depression, panic attacks, substance abuse, somatoform symptoms, eating-disordered symptoms) (ISSTD, 2011, p. 123).
Treatment of alters in therapy
Helping the identities to be aware of one another as legitimate parts of the self and to negotiate and resolve their conflicts is at the very core of the therapeutic process (ISSTD, 2011, p. 170).
Dr Alison Miller, a well known Canadian psychotherapist gives these pieces of advice to therapists:
You should not assume that the adult who function in the world, or who presents to you, week after week, is the "real" person, and the other personalities are less real. The client who comes to therapy is not "the" person; there are other personalities to meet and work with." (Miller, 2012, p. 21)
“It is important to learn about being multiple, and what works for their healing, from your client. To work with the alters, rather than trying to get the ANP to control the rest of the personality system.” (Miller, 2012, p. 21)
Dr Miller states "I recently consulted to a therapist who felt he had accomplished something by getting his dissociative client to remain in her ANP throughout her sessions with him. His view reflects the fundamental mistake that untrained therapists tend to make with DID and DDNOS. Although his client was properly diagnosed, he assumed that the ANP should be encouraged to take charge of the other parts at all times. He also expected her to speak for them—in other words, to do their therapy. This denied the other parts the opportunity to reveal their secrets, heal their pain, or correct their childhood-based beliefs about the world. If you were doing family therapy, would it be a good idea to only meet with the father, especially if he had not talked with his children or his spouse in years? Would the other family members feel as if their experiences and feelings mattered?Would they be able to improve their relationships? You must work with the parts who are inside of the system. Directly.” (Miller, 2012, p. 23)
Treating DID does not involving attempts to "remove" alters
The Guidelines for Treating Dissociative Identity Disorder in Adults states that "it is countertherapeutic to tell patients to ignore or “get rid” of identities (although it is acceptable to provide strategies for the patient to resist the influence of destructive identities, or to help control the emergence of certain identities at inappropriate circumstances or times)." (ISSTD, 2011, p. 133) Some people with DID may have alters who are seen as "undesirable" by the person, for example "demons". The person may ask for an "exorcism ritual" to be carried out to remove them. However, any alters who identify as "demonic" are simply dissociated parts of the person's personality system, and such rituals "have not been shown to be effective for permanently “removing” alternate identities." Instead exorcism rituals conducted outside psychotherapy have been shown to have negative effects in samples of DID patients who experienced them (ISSTD, 2011, p. 170). People with DID should also not be encouraged to create additional alternate identities (ISSTD, 2011, p. 133).
"A desirable treatment outcome is a workable form of integration or harmony among alternate identities." (ISSTD, 2011, p. 20)
It is also common for clinicians, especially those new to DID, to on some level subjectively experience different personalities as different "persons," especially when there are significant differences in voice tone, inflection, posture, facial expression, attitude, use of language, and so on. The clinician must tread a fine line with respect to honoring the patient's subjective experience but also be clear that, even though experientially different, all of the parts participate in one overall personality system, as well as sharing one body. The different identities are highly interrelated parts of a system that comprises the total person." (Howell, 2011, p. 55)
Development of alters
The current theories concerning the development of dissociative identity disorder (DID) all state that alters are a result of overwhelming childhood trauma. The model of structural dissociation, the most popular theory of structural dissociation accepted by the ISST-D describes the division of the personality into one apparently normal part (ANP) and one emotional part (EP). More identity states (alters) can then be developed to cope with more trauma (ISSTD, 2011, 123).
In this model of structural dissociation, everyone has parts to their personality. Everyone has self-states that become activated when they are needed. In DID, these self-states or identity states become divided in one part that functions in daily life (the ANP), and one that has the task of physical or psychological defense. Because they are divided, they do not and cannot work together, so they can be activated when they are not needed or suppressed when they are needed. For example, an identity state for defense may get activated when there is nothing to defend against. (Van der Hart, 2006)
Elizabeth F. Howell describes this well:
The self of all of us is not a unity but consists of multiple self-states that emerge and alternate in accordance with which self-state is in the forefront of consciousness at a given time. Current research in neurobiology, cognitive psychology, and developmental psychology indicate that the brain, the mind, and the self are normally multiple. Neurobiologists increasingly understand the brain as organized into neural systems that to some degree function independently of one another. (Howell, 2011, p. 7)
To recap, current theories of dissociation describe the development of alters not as the splitting from a 'core' or 'original' personality but as the failure to integrate various self-states due to overwhelming childhood trauma. (ISSTD, 2011, p. 123)
Dissociation can be and is initially usually adaptive, by not having to acknowledge certain events happened (via amnesia) or by having certain intolerable feelings outside of conscious awareness (Howell, 2011, p. 76). For example, a neglected child may dissociate the need for connection to the parents so it does not have to deal with the too-difficult to accept reality of being neglected.
Memory in alters
The frequency of which an alter fully takes over consciousness determines the degree to which memory is held by a particular alter. This is called full dissociation, and in Dissociative identity disorder is often referred to as time-loss or state-dependent memory. (citation needed)
Differences between alters
Each alter has its own way of being - complete with idiomatic autobiographical memory, procedural and general knowledge, behavior, physical sensations, emotions and skills unique to them.
Physiological differences have been found between alters, even some that may seem to be purely biological (ISSTD, 2011, p. 121). The more obvious differences are for example differences in response to medication, allergies, visual acuity (an alter may need different glasses) and heart rate. Other more medical differences are differences in glucose levels in diabetes patients, brain activation patterns and blood flow and immune function.
Other differences have been found relating to the interaction between the body and the mind (psychobiological differences), like heart rate and blood pressure. Interestingly, in one study (ISSTD, 2011, p. 121) these differences are found while the study subjects listened to a trauma script, and not when listening to a neutral one. In that same study, differences in blood flow in the brain is also only found while listening to such a trauma script.
Psychobiological differences have been shown to exist between alters, for example differences in regional cerebral blood flow in a person occur between different alters within the same person (Reinders, 2006). Neuroimagery has also found changes in "localized brain activity" consistent with the ability of people with DID "to generate at least two distinct mental states of self-awareness" (Reinders, 2003). Reinders (2012) determined that people highly prone to fantasy and attempting to simulate different alters (identity states) in DID are unable to show the same differences in "psychophysiological and neural activation patterns" as people with DID have. This shows motivated role playing, high fantasy proneness and suggestion are no viable explanations of DID. Studies of people with posttraumatic stress disorder (PTSD) have also found differences in the brain compared to people without PTSD. These changes have been shown to be reversible.
Psychotherapist Dr Alison Miller describes how people with DID or other specified dissociative disorder are "probably not visually different from anyone else"... and cannot just become a person with a single, non-fragmented personality "at will". This can only happen if the "barriers between the parts of the self are removed" (Miller, 2012, p. 20).
Types of alters
There are various common roles or types of alters found in DID, like a 'host', 'protectors', 'caretakers' etc. Especially for those with DID, it is important to remember that roles are not fixed. For example, not every system has a clear host alter. Here is just a list of the common roles alters may take.
- Abuser alters
- Abuser alters are often introjects of the original abuser(s) - the parents in most cases. These alters are actually trying to protect the individual and not trying to injure them. The abuse results because they feel that they are protecting the system of alters by preventing actions that, when the individual was a child, might have caused further harm from the original abuser. (Howell, 2011, p. 62)
- Apparently normal part (ANP, see structural dissociation below)
- (See host) The apparently normal part of the personality is a dissociative state that has a key part in daily living. Usually there are at least two ANP in those with dissociative identity disorder, and often many more. Those with acute stress disorder (ASD), posttraumatic stress disorder (PTSD), dissociative disorder not elsewhere specified (DDNES), and borderline personality disorder (BPD) have only one ANP (Van der Hart, 2006, p. 80). ANP normally have the job of integrating memory, but fail in the case of trauma memory. ANP do not normally remember trauma events clearly, if at all. What does exist of the trauma memory is depersonalized to the ANP. Some ANP can recall a traumatic event, but the recall lacks the emotional and physical feelings that should be present. (Van der Hart, 2006, p. 81)
- Child alter
- A child alter may act like a child while in the inside world and/or the outside world. They may also look like a child when in the inside world, but act mature when in the outside world (Ringrose, 2012, p. 7). In either case they are not real children, and therefore can have advanced intellect and knowledge (Howell, 2011, pp. 60-61), but they may not always have experienced mental growth and development (Van der Hart, 2006, p. 81). Child alters have nothing to do with the concept 'inner child'.
- Dead alter
- Some alters endured events where they felt they had died, such as being strangled until the child passed out, and then were replaced by another alter who then took over their job. If there is no one that can help the alter "assimilate the experience of near death and to recognize that they actually lived through it" (Howell, 2011, p. 64), the part is in essence dead.
- Emotional part (EP, see structural dissociation below)
- The emotional part of the personality, the EP, is fixated in process that was activated at the time of traumatization, leaving the EP with their own inflexible patterns of behavior. For example, an EP may be very cautious for danger while the need to be so alert has long passed. Although the ANP does feel emotion, EP's emotion is vehement, meaning that their emotion is not adaptive, and instead overwhelming and the expression of this emotion is not helpful (Van der Hart, 2006). An EP may have trauma memory with some verbal narrative that is not traumatically experienced, but their main job is to hold unintegrated trauma memory. An EP remembers and experiences the emotion associated with the original trauma that they experienced (Van der Hart, 2006, pp. 38-39). Trauma memory is quite different from autobiographical memory.
- Observing emotional part (OEP)
- Observing EP have the ability to see and hear many alters that others alters within the system cannot. Some OEP "seem to develop more secondary elaboration, and appear highly intellectualized, non-feeling, and are sometimes quite insightful. Some OEP are involved some level of care taking. OEP typically do not interact externally in the world, but they can be active internally." (Van der Hart, 2006, pp. 68-69 323-324)
- Emotional Part & Apparently Normal Part (ANP) mixture
- ANP and EP mixtures are common in those that are polyfragmented. With polyfragmented DID, abuse began exceptionally early and was so extreme that these children had to alternate quickly and frequently between emerging defensive and daily life actions in order to survive (Van der Hart, 2006, pp. 78-79).
- Differently gendered alter
- Alters that are the opposite gender from the body are common in those with DID (Howell, 2011, p. 63).
- A fragment is a dissociated part of the personality that may be too limited to see as an alter, yet it still usually is an alter in those with DID. A fragment usually holds one or two emotions or responds to a few specific situations (Howell, 2011, p. 58).
- Gatekeeper alter
- A label that is sometimes used by those with DID to refer to those alters who keep other alters from doing things and function as the one who watches and/or remembers events (Howell, 2011, p. 58).
- See host alter.
- Disabled alter
- Alters do not change appearance - at least not on their own. Until helped many are deaf, blind, missing limbs, sickly, dying, bloody, bruised and so on.(citation needed)
- Host alter
- The host is a role in a system. "The host is an alter that has the function of living daily life" (Howell, 2011, p. 58). The role of host is usually taken by an "apparently normal part", but multiple alters may fulfill the role of host (Van der Hart, 2006). It is important to understand the host is not a complete personality (ISSTD, 2011). There is no such thing as an original alter.
- Original alter
- There is no such thing as an 'original alter' or 'birth personality' (ISSTD, 2011). Dissociated parts of the personality emerge due to a disrupted personality development, not from the 'splitting' off a single unified 'birth personality'.
- Inner self helper (ISH)
- The ISH is a dissociated part that is usually unable to communicate with other alters, yet has the ability to watch and hear everything going on inside a system. The ISH will usually display little emotion or affect. Because the ISH observed inner events, it has access to the memories of the individual as a whole, as well as to the memories of each alter individually. Other names include: internal self helper, guidance, unconscious mind, observing ego, higher self, and inner wisdom. Those without DID also have this part of the self, and it is commonly called the hidden observer. (citation needed)
- These alters are sometimes called as "copy alters" and are internal copies of another person, often they are an internal representation of an attachment figure such as a parent, abusive introjects alters are very common in dissociative disorders (Miller, 2012). Miller (2012) states that an introject may be an internal "mother" or "father" alter which warns the child not to act in a way which would cause the child's real external mother or father to punish them, protecting the child from physical harm. See also Abusive alters. Introjects can be calming and soothing if they are representations of caring people. Introjects exist outside of dissociative disorders, and are first developed in early childhood as internal thoughts representing the views of care givers. In DID they can taken the form of independent, autonomous alter personalities who may actually believe they are the person copied rather than a part of another person. (Miller, 2012)
- Little alter
- A little, is a term often used by those with DID. This type of alter is a "developmental state that is encapsulated and stored inside the brain," which acts 7 years old or younger (Haddock, 2001, p. 38).
- Manager alter
- A system manager might be seen as a leader to the other alters. They are involved inside and outside if needed - including acting as a temporary host, but mostly they operate inside. They direct what is going on in the system in many ways. Although the system managers usually know all parts of the system and have memory back to the beginning, they are not ISH's.
- Main alter
- (See host) The alter out most often.
- Memory trace alter
- One that has a more or less complete life, unlike how many alters which have a limited range of memories. System managers and ISH's often have this ability.
- Middle alter
- A term often used by those with DID to describe an alter that appears to be between the ages of 8 and 12 (Haddock, 2001, p. 38).
- Non-human alters (animals, spirits and demons)
- These types of alters believe they are any form other than human, such as animal alters, demons, spirits, or inanimate objects. Animal alters are often linked to ritual abuse (Miller, 2012; Oksana, 1994). Historically, several of Freud's most famous cases are recognized by an animal component, such as the rat man (Freud, 1955). Clinical reports of non-human alters are limited, (Henrickson, 1990) but are demonstrably linked to abuse, such as childhood trauma involving being forced to act or live like an animal, witnessing animal mutilation, being forced to engage in or witness bestiality, or experiencing the traumatic loss of or killing of an animal (Henrickson, 1990; Carlson, 1986; Smith, 1989).
- The ISST-D treatment guidelines for DID explain that the "demon" alters are just dissociated identities, like other alters, and their link to abuse:
Although patients may experience certain parts of themselves as demonic figures—and occasionally positive spiritual entities such as angels or saints—and as “not-self,” clinicians should regard these entities as alternate identities, not supernatural beings. Names of alternate identities such as “Devil” or “Satan” may reflect patients’ concrete culture-bound stereotyping of their self-aspects using religious terminology rather than evidence of a demonic presence. Malevolently labeled self-states also may reflect specific spiritual and/or religious abuse, such as abuse by clergy and/or projection of blame by the abuser. For example, a child may be told that punishment is necessary because he or she “is filled with the devil.” The child may encapsulate forbidden behaviors and affects in a malevolently named “other” identity, thereby preserving a sense of self as “good.” (ISSTD, 2011)
- Psychologists agree that putting together the memory of the traumatic experiences which lead to the belief in "possession" or a demon alter is crucial (Miller, 2012). The belief can be caused by costumes, magic tricks, shaming a child and telling them they are evil or forcing them to do evil and using hallucinogenic drugs, but "demon" alters are just dissociated identities formed from a child, and need to be cared for and to know that the responsibility for the abuse belongs with the abusers. Attempting an "exorcism" of the "demon" parts of a person hinders healing (Miller, 2012) and have not been shown to be effective (ISSTD, 2011).
- Protector alter
- There are three types: persecutory, fight and caretaker alters which all, in their own way, protect the system and can "dominate consciousness. (Van der Hart, 2006, p. 83)
- Persecutory alters (see protector alters)
- Persecutory alters defensively protect the system, but their idea of how to do this, once the body is no longer a child, can be damaging to the whole - in fact they can terrorize the person in the same way the original abuser did. They are often introjects of the original abuser(s) and tend to respond to both inner and external perceived threats, harming alters inside and out the same way the original abuser did. In addition they often self harm, including cutting and purging. These parts do not have skills to regulate feelings such as anger, fear, pain, shame and needs. (Van der Hart, 2006, pp. 82-83)
- Fight alters
- Fight alters appear almost fearless in their protection. They protect from both inside and outside abuse. (Van der Hart, 2006, p. 82)
- Caretaker alters (soother alter)
- Caretaker alters are true protectors of the system. They act as caretakers both internally and externally, but are limited to care of others and are depleted easily, lacking awareness needed for self care. They are often introjects of caring adults. (Van der Hart, 2006, p. 83)
- Secret-keeper alter
- A term used by some with Dissociative identity disorder to refer to an alter that keeps information of abuse or other information away from others in the system.
- Sleeping alter
- Time passes for a sleeping alter without knowing.
- Slider alter
- An alter whose age varies (Haddock, 2001, p. 38).
- Sexual alters
- A term sometimes used by those with DID to refer to parts that are often sensual and perform the job of sex and even romance.
- Suicidal alters (see protector alters)
- Often there is a least one alter in a system that will harm other alters (including the host alter) and even attempts to kill them. They threaten and hurt others to keep parts from telling about the system or about the abuse they suffered.
- Teen alter
- Teen alters appear to be between the ages of 13 and 18 (Haddock, 2001, p. 38).
- Twin alters
- Twins appear the same in many ways, and may even have the same name. One twin can good while the other is bad.
The theory of structural dissociation describes two types of alters.
The "emotional" part
The emotional part of the personality (or EP) is the part that initially keeps the trauma memories. In PTSD, these parts may gain a rudimentary sense of self.:5-6 In DID, these parts can get as developed as ANPs (apparently normal parts), blurring the distinction between EP and ANP.
The "apparently normal" part
The apparently normal part of the personality (or ANP) keeps the appearance of normality. It does not know about the trauma, or does only so semantically (lacking personification: knowing it did happen, but not feeling any attachment or feelings to it). Often, this part avoids anything related to the trauma (also when it does not know about it, or about parts of it).
The ANP is not always 'apparently normal'. Often, the ANP has a (slightly) lower level of functioning, due to avoidance of trauma (related memories), and due to amnesia. And intrusions by the EP(s) make functioning and appearing normal harder.:6-7
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