Dissociative Identity Disorder

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The Diagnostic and Statistical Manual of Mental Disorders (DSMPublished by the American Psychiatric Association as the standard classification of mental disorders used by US mental health professionals. It consists of diagnostic classification, the diagnostic criteria sets, and descriptive text. The DSM-II listed multiple personality disorder as a symptom of hysterical neurosis, dissociative type. The DSM-III (1980) moved Multiple Personality Disorder from a symptom to its own disorder. The DSM-IV changed the name to dissociative identity disorder (1994) and the DSM-5 (May 2013) updated the listing to current standards. <ref name=DSMIV/> <ref name=DSM5/> <ref name=Dell2009/>{{Rp|384}}-5), released to the public May 27, 2013, is the most current publication used today by mental health professionals. This diagnostic tool is limited to providing the minimum criteria needed to diagnose a mental disorderThe DSM-5 psychiatric manual defines this as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."<ref name=DSM5Deskref/>{{Rp|20}}. [2]:19 Pages 291-298 of the DSM-5 give a written account that follows an older, more or less general consensus to what dissociative identity disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, <ref name=ICD10/> even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}}Dissociative identity disorder is a disorder of mental states, where a individual switches from one distinct state to another distinct state, which distinguished it from OSDD/DDNOS, BPD and PTSD. <ref name=Dell2009/>{{Rp|557-570,487-494,471-486}} {{See also| Dissociative Identity Disorder}} is, but it's not up to par with the superior criteria that is presented in the DSM-5. [2]:291-298 [3]:243-470 [4] [5] [6] [7] 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 here on this page. [8] [9] [3]

DSM-5 300.14 criteria for dissociative identity disorder (paraphrased)
  • A. Two distinct states present with disruption in identity. [2]:291-298
  • B. Amnesia between two distinct states. [2]:298-302
  • C. The individual is significantly impaired due to the presenting symptoms.
  • D. This is not a temporary state created purposefully.
  • E. The symptoms are not attributed to anything else.
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. [10]:73-88 The amnesia criteria helps to distinguish distinct states from less than distinct states. [3]:5-28
What you are looking at in the left image is a minute section of a fMRIA type of neuroimaging. Neuroimaging is an approach that allows researchers to view areas of the brain that become active during behavioral events such as emotion, perception and cognition. It is part of the science of in psychophysiology.<ref name=Andreassi2010/> scan showing activity as a switch results in one distinct state (ANP) switchingFull dissociation is when an alter switches with the alter currently in executive control, resulting in amnesia for that alter. (see executive control) <ref name=Howell2011/>{{Rp|4-6}} In full dissociation, there is complete amnesia between dissociated states, which is a <ref name=Dell2009/>{{Rp|228}} criteria for a diagnosis of dissociative identity disorder in the DSM-5. {{See also| Dissociation}} with another distinct state (ANP). The images catches the leaving distinct state (ANP) before it fully exits consciousness, which is a process that is only possible in "dissociative identity disorder" (DIDDissociative identity disorder is a disorder of mental states, where a individual switches from one distinct state to another distinct state, which distinguished it from OSDD/DDNOS, BPD and PTSD. <ref name=Dell2009/>{{Rp|557-570,487-494,471-486}} {{See also| Dissociative Identity Disorder}}). In other specified dissociative disorder (OSDD) only one distinct state exists, and so obviously a switching of distinct states will never be seen on an fMRI. In both dissociative identity disorder (DID) and other specified dissociative disorder (OSDD) there will be at least two, and usually several - less than distinct states (EP) switching with each other. In posttraumatic stress disorder (PTSD) there is only one less than distinct state (EP) and only one distinct state (ANPA distinct state who performs the job of daily activities and does not hold trauma memories. Dissociative identity disorder is the only mental disorder where an individual can have two or more ANP. <ref name=HauntedSelf/> {{See also| structural dissociation}}), and both states will remain lit up until something triggers the less than distinct state (EP), and then the distinct state (ANP) is no longer visible. That triggerA reactivating stimulus in trauma disorders. A stimulus in the present which is a reminder of a part of a traumatic [[memory]], which can cause the part of an individual that hold the trauma (EP) to feel as if it is reliving past trauma experience. <ref name=Boon2011/>{{Rp|166-186}} Also known as a trauma trigger. resulted in some sort of reaction (flashbackA flashback is a reactivated traumatic memory experienced as intrusive thoughts, feelings, or images associated with past trauma, but lacking a sense of being from the past. <ref name=Siegel2012/>{{Rp|30}} It is experienced by the state referred to as the EP. {{See also | Grounding techniques}} for example) to their unprocessed memories. When an individual has posttraumatic stress disorder (PTSD), with the dissociative symptoms of depersonalization and derealization, then there is always two less than distinct states (EP), which can be identified on an fMRI scan, but both will not always be visible together. The authors of the theory of Structural Dissociation call this form of PTSD, complex-posttraumatic stress disorder (C-PTSD). Borderline personality disorder is an odd ball in this bunch because the disorder is not caused by Structural Dissociation, but after the disorder already exists, the individual with BPD can be overwhelmed by trauma memories resulting in Structural Dissociation and then they will have dissociative symptoms. On their fMRI scans we see one distinct state (ANP) and one less than distinct state (EP), but the distinct state (ANP) is the only part visible until the individual is in distress, and then the less than distinct state (EP) shows up. This state will not take over as is seen in posttraumatic stress disorder (PTSD) and so there are no flashbacks or similar symptoms, but instead are the dissociative symptoms of derealization and depersonalization. Go to links for the referenced information. [11] [3] [10] [12] [13] [14] [15] [8]

A short history and where we are today

Research has finally focused on identifying a distinct state, in contrast to less than distinct states. It was 1940 when Charles Samuel Myers (born March 13 1873, London and died October, 12 1946, Winsford in Somersetshire) said:

"Now and again there occur alterations of the 'emotional' and the 'apparently normal' personalities, the return of the former often heralded by severe headache, dizziness or by a hysterical convulsion. On its return, the 'apparently normal' personality may recall, as in a dream, the distressing experiences revived during the temporary intrusionParts of the [[personality]] influence each other, whether they are aware of others or not. Any part may intrude on, and influence the experience of the part that is functioning in daily life, without taking full control of functioning. <ref name=Boon2011/>{{Rp|27}} In dissociative identity disorder and other disorders, dissociative symptoms are felt when one dissociated state intrudes into the experience of another. Intrusions occur in perceptions, ideas, wishes, needs, movements and behaviors. <ref name=Boon2011/>{{Rp|18}} In partial dissociation, amnesia is not present. <ref name=Dell2009/>{{Rp|228}} of the 'emotional' personalityEvery individual has a personality that is composed of many diverse, fragmentary and generally illusory images of [[Personality|self]]. (see multiples) <ref name=Noricks2011/>The DSM-IV uses the term identity in its definition of dissociation. (see identity) <ref name=Dell2009/>{{Rp|127}}." - Myers (1940) [9]:22
Around the same time Pierre Marie Félix Janet, (born May 30, 1859, Paris, France and died February 24, 1947, Paris) a French psychologistPsychologists usually have an advanced degree, most commonly in clinical psychology, and often has extensive training in research. Psychologists use psychotherapy (often referred to as "talk therapy" or just "therapy") to treat mental disorders. Some psychologists specialize in psychological testing and evaluation.<ref name=AboutPsychiatry/> and neurologist was explaining something similar and he went into amazing detail. Ellert Nijenhuis, Onno van der Hart and Kathy Steele brought Janet's and Myers work back to the spotlight in their 2006 book, "The Haunted SelfThe DSM-IV uses the term identity in its definition of dissociation. (see identity) <ref name=Dell2009/>{{Rp|127}}," and they reintroduced the idea of two explicitly different types of personality states and used the terminology introduced by Charles Samuel Myers. [10]:vii-xi 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". [10]:28-43
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What is now known as Structural Dissociation explains that the only disorder with two distinct states is dissociative identity disorder. [6] [3]:1-243 [10]:8 Recently other researchers found themselves in agreement, and many have done their own research and have drawn their own conclusions, but the spark that led to it all belongs to Janet. Not everyone shares the same terminology, and so to make it easier to understand, on this page we will use the terms distinct state and less than distinct state.

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Fast forward to 2014, and we can introduce the highly significant work that neurologists have contributed this year. Lanis et al., begins page 34 of the 2014 book "Neurobiology and Treatment of Traumatic DissociationDissociation is a compartmentalization of experience, where elements of a trauma are not integrated into a unified sense of the self. <ref name=Dell2009/>{{Rp|4-810, 127}}The lay persons idea of [[dissociation]], that which exists in the normal mind, is not what is referred to in this document. <ref name=Dell2009/>{{Rp|233-234}} Toward an Embodied Self" with the following heading: trauma has an impact on the representations of the self in the midbrain; understanding dissociative identity disorder is understood only after an in-depth examination of the capacity of the midbrain. [3]:34 A vignette is presented below to explain this.

Vignette: midbrain and distinct state creation

It's Annabelle's 6th birthday and she has spent the last 5-years of her life in a literal struggle to survive, even though she appears normal to casual observers, it's far from the truth. Annabelle is dying mentally and she must do something different if she is going to survive at this point in her life. Her midbrain has been remiss until now, but suddenly its on "full alert." Annabelle is dying and if this important part of her brainThe brain is a approximately a 1300-gram organ containing 100-billion neurons. It is the control center of the central nervous system. The mind and brain are not the same thing. (see mind) The mind emerges out of interactions between the brain and relationships during the earliest years of childhood. Different child-parent attachment relationships form differing physiological responses, patterns for interpersonal relationship and how an individual views the world. <ref name=Siegel2012/>{{Rp|9}} (see attachment) does not eliminate her "stress" she will mentally give up and most likely die. Her dissociative identity disorder takes an overwhelming amount of energy and she does not have much left to function with. In response, her brain interacts with her mind to create a new distinct state to take the pressure off of Annabelle's nervous system. As a result Annabelle will loose access to the memories that tell her who she is, because to save Annabelle her painful memories must be separate from the distinct state that acts as Annabelle most often. Annabelle's mind and brain will create as many distinct states as she needs to survive. Other disorders are not able to create more than one distinct state. [3]:29-50, 34-50, 105-129, 131-152 The work of Stephen Porges, who you might recall is responsible for the Polyvagal Theory, is critical in bringing the world's knowledge to where it is today.

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Amnesia and dissociative identity disorder
Amnesia is often reported that involves less than distinct states, but it's amnesia between distinct states that defines dissociative identity disorder, because for a correct diagnosis it's the distinct states that are sought out and not the amnesia itself. [10]:73-88 Individuals with posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), and other specified dissociative disorder often report amnesia, but what they experience is amnesia of traumatic events both in past and present time, flashbacks and normal breaks of memory in daily life. [3]:1-130 Individuals with dissociative identity disorder cannot tell if they have amnesia between their distinct states, but trained observers can. The 2006 version of the theory of Structural Dissociation explained amnesia in dissociative identity disorder as a function of unnoticed passed time, [10]:91-94 but since then, Nijenhuis and van der Hart have changed their stance to agree with what was mentioned at the start of this paragraph. Research in 2014 is settling in on the idea that only dissociative identity disorder has two or more distinct states. [16] [10]:8
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Dissociative identity disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, <ref name=ICD10/> even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}}Dissociative identity disorder is a disorder of mental states, where a individual switches from one distinct state to another distinct state, which distinguished it from OSDD/DDNOS, BPD and PTSD. <ref name=Dell2009/>{{Rp|557-570,487-494,471-486}} {{See also| Dissociative Identity Disorder}} is the only disorder with two or more distinct personality states

Brain scans have recently called for a strong acceptance of the two different types of states and how their separateness and variations act visually on a scan. An fMRI is a meticulous method of telling a distinct state from a less than distinct state, [16] but a knowledgeable and trained trauma therapistPyschotherapists are often called a 'therapists'. These professionals may be a psychiatrist, psychologist or other mental health professional who have specialist training in psychotherapy. They are qualified to work with patients in a clinical setting. should be highly proficient in telling one from the other without it. [17] Once a therapist can tell one state from another, they can then observe to see if switches exist only from a less than distinct state to a distinct state and from a distinct state to a less than distinct state and of course from a less than distinct state to another less than distinct state. If the later is the case, then the diagnosis would be other specified dissociative disorder, or possibly other disorders such as borderline personality disorder (BPD), schizophrenia, posttraumatic stress disorder (PTSD), all of which a competent diagnostician would have ruled out almost immediately. [9] To be clear, an individual with dissociative identity disorder must be observed switching from one a distinct state to another distinct state and it's important to note that without a great deal of integration work, this switch will involve amnesia between distinct states and the later stages of integrationIntegration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." <ref name=Siegel2012/>{{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. <ref name=Siegel2012/>{{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." <ref name=Siegel2012/>{{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. <ref name=Howell2011/>{{Rp|143}} the amnesia is not going to be present. [10] The ISSTD and other organizations do offer training for mental health professionals.

Vignette: creating a distinct and less than distinct state

Annabelle just turned 6-years old a month or so ago, and she already has two distinct states, and 8 less than distinct states. Today she is in a horrible car accident that instantly killed the driver, and she is left alone in the car with injuries. Her head is bleeding, her right ankle is crushed, and her left arm is pinned between two objects and she can't pull it free. This is traumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. <ref name=Howell2011/>{{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. <ref name=Howell2011/>{{Rp|83}}. She already has dissociative identity disorder, and she knows how to create distinct states, but of course it's not something she does knowingly. She calms and her mind goes to thoughts that are not related to the situation she is in, and she is mentally drifting away. If she were too mentally weak then she could die, but Annabelle's mind is far from weak. Her mind has had to work harder than any mind should just so she can thrive, and her busy mind is certainly not at rest during trauma. Adrenaline is flowing through her tiny body, and her brain is highly active. Time is passing while Annabelle is alone with her thoughts, but she does not feel any pain because her mind is actively engrossed in the Freeze-Flight-Fight-Fright-Faint.' [3]:105-129 She is lost in one of them. Let's say it's the fight response. That 6-year old little girl is a fighter and she is not giving up. Remember the vignette where her midbrain came to action? It's again busy and it's creating a brand spanking new distinct state that, when this little girl is safe, will take over and it will have no idea of anything that happened in the accident.

You might wonder how creating a distinct state is different from trauma creating a less than distinct state in response to the accident, and it's highly likely that she did create unprocessed memories, which when they become overwhelming will create a new less than distinct state, which that state will most likely remember every detail of the accident and in horrifying detail. Let's go back to the accident and take a better look at what Annabelle is doing. She was in the backseat and was looking out the side window when she saw a truck headed for the car she was in and crash into the side of it. At that moment the brain signaled the mind that it's in distress and if Annabelle survives the impact she is going to need to respond. [3]:105-129 She is trapped and can't move around the car too much, but she can see the driver is non-responsive, her ankle is damaged, and there is a cut over her left eye, and she knows she can't get her left arm free. She has not froze, she can't run away she is trapped, she is afraid, but not so afraid she can't function, and she has not fainted. Annabelle is fighting, and so is actively participating in her own rescue, and she has eight less than distinct states that were immediately signaled by the brain and the most prepared for this problem will take over. Since he is the one at the accident, then he is the one that is going to hold the memory"Memory is not a static thing, but an active set of processes." <ref name=Siegel/>{{Rp|51}} "Our earliest experiences shape not only what we remember, but also how we remember and how we shape the narrative of our lives. Memory can be seen as the way the mind encodes elements of experience into various forms of representation. As a child develops, the mind begins to create a sense of continuity across time, linking past experiences with present perceptions and anticipations of the future." <ref name=Siegel/>{{Rp|11}} of that trauma. If and when he becomes overwhelmed by either that trauma, or another one down the road, then another less than distinct state will be created, but the trauma memory stays with the state that had the experience.

Distinct personality states

"Distinct personality states" are highly phobic of "anything of emotion" that they do not relate to as an "acceptable" and self acknowledged pattern of reliability. [4] [10]:216-336 Fear directs how all personality states relate to each other, but distinct states appear to be lacking what is needed to control fear, or at least the types of fear that are primate in nature, and so distinct states are literally riddled with fear. [10]:291-298, 216-336 [16] Phobic inhibitions prevent distinct states from sharing information with states of any magnitude, within their realm. [10]:216-336Distinct states have two ways of being present; one realm is the inner world 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 states which are subjectively intrusive and this helps to define partitions between states. Once fear is reduced to an "acceptable level" then intimacy between states can progress. [10]:216-336

Less than distinct personality states include observing and experiencing states

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 also of like-states, for that matter. Fear directs a dissociated state's very nature and frames its disposition and character. [10]:89-108 When created, "less than distinct states" take the form of either observing or experiencing. [3] [10]:66-71 In Structural Dissociation this is called "parallel dissociationDissociation is a compartmentalization of experience, where elements of a trauma are not integrated into a unified sense of the self. <ref name=Dell2009/>{{Rp|4-810, 127}}The lay persons idea of [[dissociation]], that which exists in the normal mind, is not what is referred to in this document. <ref name=Dell2009/>{{Rp|233-234}}." [10]:66-67 There is little in the literature beyond what is found in the theory of Structural Dissociation, and whether or not these states are created in pairs with an observing state paired with experiencing states is yet to make it to the literature, but it makes sense that they do. Individuals with dissociative identity disorder often describe at least one observing state [3]:258-259 that has learned to harness innate skills and become "powerful" in the inner world. There have been many labels attached to these states including inner self helper, and hidden observer. Other observing states are often companions to "experiencing states." An experiencing state compared to an observing state is basic and unyielding. It tends to stay stuck in the experience of which it was created, but can still learn and evolve in other ways. [4] An observing state could be described as embellished, extravagant, complex, curious, learning and even limitless. [12]

Vignette: switching between distinct and less than distinct states

Annabelle, a 25 year old woman gets in her car and drives to her appointment with Dr. Getsitright, a mental health professionalThe various mental health professionals provide services basked on their training and area of expertise.. She (distinct state-1) knocks on his office door and when it opens she becomes slightly disoriented, but quickly pulls herself together in an almost seamless manner. (Distinct state-2) walks into the office, introduces herself and a large bookcase catches her attention. The shelves are filled with a variety of books, journals, nick-knacks and a few wood and metal antique toys near the bottom. Dr. Getsitright invites Annabelle to have a seat, but then her eyes are drawn to the bottom of the bookcase where she sees a "happy meal" bag and she switches to a less than distinct, child-like state. She kneels down on the floor in frontA term sometimes used by those with dissociative identity disorder to refer to the alter who is either in executive control of the individual, or who has come close to the one that is in executive control. (see executive control) of the bag and inhales, but the familiar odor she was looking for is not there and so she looses interest. Then she is startled as she suddenly hears a noise and notices that someone is in the room with her. This causes the child-like less than distinct state to switch to (distinct state-3), who quickly tries to make sense of where she is at. This is a new place to her, but she can't accept that and tries to make sense of her surroundings. No other disorder will have a personality statePersonality state - Many terms are used that have the same meaning including: parts, selves, part of the Self, subselves, selves, parts of the personality, subpersonalities, sides, internal Self-states, identities, states, ego states, part of the mind, and entity. The personality is an agglomeration of many personality states. <ref name=Noricks2011/>{{Rp|1}} that constantly does this. (Distinct state-3) is unable to acknowledge that she does not know what is going on and so she repeats her familiar pattern, which is to attempt to fit into the situation. Dr. Getsitright is observant and has noticed the switching, but he wants to see if he can get (distinct state-3) to switch directly to another distinct state. He asks, have you decided which movie you and I are going to go and watch? (Distinct state-3) looks at Dr. Getsitright and replies. You choose. Dr. Getsitright then says, look at the time. We have gone far past our session time. That causes (distinct state-3) to switch to (distinct state-2,) who was the one that first walked into the office. She glances at the clock on the wall and says, Dr. Getsitright, I have only been here a few minutes. You must be mistaken. Then Dr. Getsitright replies, Annabelle, don't you remember that I told you my clock is broken? Had it started to rain yet when you arrived here today? (Distinct state-2) switches to (distinct state-1) who says, no, there was not a cloud in the sky. Then she glances at the clock and mentions how quickly the time has passed during her session and how she wishes they had more time.

Notice that distinct states can fail to share memory with both distinct states and less than distinct states, but the distinct states will usually disregard the fact that they often have no idea how they get from one place to another or what might have happened in "their life" before they step into it. [10]:74 This is not purposeful disregard, but is a function of amnesia and dissociation. It's due to the chemical, neurological and physical makeup of the distinct states and the dissociative boundaries associated with them. Distinct states in dissociative identity disorder are highly phobic of the other states in the personality systemAll states that make up the personality in an individual. and they cannot acknowledge them until they have had a great deal of work to aid them in that direction. [10]:74

Symptoms

This graph shows how distinct states differ from less than distinct states by measuring the activity between them, which shows how each state is able to share memory and other aspects of itself with other states. A distinct state exhibits far greater isolation than a less than distinct state. When viewing the less than distinct states the observing selves show the least isolation of all states, and the experiencing states are somewhere between the observing and the distinct states. Read this important study here.

Distinct states are the states that act adult-like when wearing the face of the person [10] and react to situations where an adult is needed, however individuals with dissociative identity disorder report that the same distinct states can act and look child-like while in the inner worldInner reality in dissociative identity disorder (Closed System). In this disorder each dissociated state has its own inner reality, while at the same time there is a common inner reality where states have a distinct, phantom appearance. <ref name=Dell2009/>{{Rp|301}} A closed system is a self care system that helps a child manage [[Attachment disorder|traumatic attachments]], and provide as a supplement to the scarce supplies available in an abused child's interpersonal environment. <ref name=Howell2011/>{{Rp|71}}. The distinct states are rarely ever able to tell anything is wrong with them, no matter how ill the individual actually is, due to what has already been described as the phobia between the states, resulting in an inability of the distinct states to acknowledge any other state. The distinct states are often high functioning and successful at work where they tend to dominate, but they fail in their relationships and personal lives where child-like, less than distinct states interject vehement emotions into their lives. [10]:73-88 [3]:1-212, 243-498

Most less than distinct states are child-like and highly aware that they are in distress, unlike distinct states. [15] [10]:73-88 The main symptom of dissociative identity disorder is dissociation. [18]:1-148 [19] [20]:447-469 [15] The individual as a whole is subject to the following symptoms: amnesia, voices heard, conversion"The development of symbolic physical symptoms and distortions involving the voluntary muscles or special sense organs; not under voluntary control and not explained by any physical disorder." Sadock (2008). Functional Neurological Symptom Disorder is the new name for Conversion Disorder in the DSM-5 manual, and is part of the Somatic Symptom and Other Related Disorders category. Somatization Disorder was removed during the changes, but is represented in this category. <ref name=DSM5changes/>{{Rp|11}}Conversion symptoms are most common in conversion disorder, but also seen in a variety of mental disorders." <ref name=Sadock2008/>{{Rp|23}}"Conversion disorders" is the ICD-10 category includes somatoform dissociation within dissociative disorders of movement and sensation.<ref name=Nijenhuis2001/> {{Rp|9}}{{See also| Somatoform Disorders}} symptoms, self alteration, derealization, depersonalization, flashbacks, trance"periods of absence-like staring and unresponsiveness; well documented in severely dissociative people for over 100 years"<ref name=Dell2009/>{{Rp|229}}, identity confusionDefined as "a feeling of uncertainty, puzzlement, or conflict about one's own identity. "<ref name=Steinberg1994/>{{Rp|13}}. The structured clinical interview for the dissociative disorders and other diagnostic tools assess identity confusion. {{See also| Identity confusion}} {{See also| Diagnosis}}, and awareness of other states. They also experience the Schneiderian first-rank symptoms that include voices arguingTwo or more voices conversing, they may be arguing. Common in both schizophrenia and dissociative identity disorder. This is a type of auditory hallucination. <ref name=Sadock2008/>{{Rp|45}} In dissociative identity disorder the voices belong to alter identities and this may extend to alters who are contending for physical control, for example involving the person feeling a force or an "other" that ties to control or change the person's actions, or feeling or hearing an angry other that tries to control the person.<ref name=Dell2009/>{{Rp|230}}, voices commentingRefers to voices commenting (in the form of a running commentary) on the person's behavior or thoughts. Common in both schizophrenia and dissociative identity disorder. This is a type of auditory hallucination. <ref name=Sadock2008/>{{Rp|45}}<ref name=Dell2009/>{{Rp|230}}, thought withdrawalThe person believes thoughts have been taken away from his/her mind. This is a symptom of schizophrenia,<ref name=Sadock2008/>{{Rp|45}} but either thought withdrawal and thought insertion are also very common in people with Dissociative Identity Disorder. <ref name=Dell2009/>{{Rp|527}}, thought insertionThe person believes that thoughts that are not his/her own thoughts have been inserted into his/her mind. <ref name=Sadock2008/>{{Rp|45}}This is a symptom of schizophrenia, but either thought withdrawal and thought insertion are also very common in people with Dissociative Identity Disorder. <ref name=Dell2009/>{{Rp|527}}, made impulsesThese impulses for action are imposed on the person and do not feel like they belong to the person, who feels like the impulses are "coming from somewhere else or someone else". In dissociative disorders this can some other part is trying to overrule the host/apparently normal part of the personality. A Schnieder first-rank symptom often present in schizophrenia but common in DID.<ref name=Dell2009/>{{Rp|231}}In schizophrenia or psychosis the impulses may be given a delusional explanation, for example naming a person or object who the impulses appear the be coming from., made feelings'Made' or intrusive feelings and emotions are unexpected surges of feeling-pain, hurt, anger, fear, shame, and so on. Often these surges of feeling are inexplicable and frankly puzzling". A Schnieder first-rank symptom often present in schizophrenia. These tend to be partially dissociated intrusions from another self-state, fairly common in "PTSD, borderline personality disorder, bipolar disorder, panic disorder and ADHD."<ref name=Dell2009/>{{Rp|231}} and made actions. Finally these individuals struggle with auditory hallucinationsThe DSM-IV-TR psychiatric manual defined hallucinations as a "sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations are common both in schizophrenia and dissociative identity disorder. <ref name=Dell2009/>{{Rp|525}}Hallucinations can be auditory (voices, noises or other sounds), voices commenting on the person's behavior or thoughts, voices conversing, somatic or tactile (peculiar physical sensations), olfactory (unusual smells), visual (shapes or people that are not present). <ref name=Sadock2008/>{{Rp|45}}Visual hallucinations are the most common type of hallucination and are often in geometric forms and figures <ref name=Sadock2008/>{{Rp|127}} Illusions are similar to visual hallucinations but are based on real images or sensations. and visual hallucinations which are not psychoticA person experiencing psychosis, or a characteristic of psychosis. <ref name=Sadock2008/>{{Rp|24}}, but the symptoms imitate psychotic symptoms. [20]:228-234 [21]

Epidemiology

Dissociative identity disorder is not rare; it is thought to occur in 1% to 3% of the world's general population. [22] 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. [2]:294

Etiology

Even though the vast membership of the International Society for the Study of Trauma and Dissociation (ISSTD) does not agree on everything to do with dissociative identity disorder, they do all agree on one important factor, and that is this disorder is caused by early childhood trauma. [22]:133 [20]:585-598 [15] [8] In the 2014 book, "The Body Keeps The Score," Bessel van der Kolk offers an interesting view when he argues that all trauma is harmful, and that trauma is either buried or accepted. [19] Other authors maintain that only "subjective trauma" causes problems. [21] Whichever view you take, there does not seem to be any genetic factor for this disorder since anyone can, with the right circumstances, develop dissociative identity disorder. [12] Dissociative identity disorder results from a combination of factors that come together to create the perfect storm with "traumatic neglect" experienced within more than one "childhood developmental stage". [23]:208-211 [13]

Cause of dissociative identity disorder includes two phases
Phase I: events occurring in the first year of life or so
The infant is consistently overwhelmed.
Adults in the infants life do not sooth the infant.
Phase II: age 1 to age 6 or so
The child is consistently overwhelmed.
Adults in the child's life do not sooth the child.
A secure attachment has not been formed with any adult.
Trauma memories are not being processed.
Eventually the buildup of trauma memories result in Structural Dissociation of the child's personality.
The child now has distinct and less than distinct states making up their personality. Their personality is no longer normal, and is damaged.
Integration of what were normal ego"the notion of a being who both thinks and acts". Feeling is also a characteristics of the ego. (van der Hart & Horst (1989){{Rp|2}}) Ego states is a term sometimes used to refer to several different identities within a person with Dissociative Identity Disorder, i.e., several different dissociative parts of the personality, each with his/her own sense of "me". states is no longer possible.

Etiological vignette

Anabelle is a few days old and has already been suffocated, starved and has not felt love and comfort from any caretaker. She is vulnerable to all sorts of mental disorders because of this neglect. Through the early months of her life she lies in her crib alone with her thoughts, and is not comforted, held, or played with. She is hungry, her diaper is rarely changed and she has no one who will respond to her basic needs. An infant in this situation becomes lethargic and fails to thrive and dies, or copes through dissociation. Annabelle is learning a "basic animal response" and no longer responds to the constant pain she has, such as hunger or diaper rash. Annabelle survives, and is very busy at the job of survival. She is learning to comfort and sooth herself since she only has herself to turn to. At 12-months old she displays the behavior observed in a child with disorganized attachmentThe communication of emotion between an infant and their primary caregiver(s) is essential to shaping the developing mind. "Emotion serves as a central organizing process within the brain. In this way, an individual's abilities to organize emotions - a product in part, of early attachment relationships directly shapes the ability of the mind to integrate experience and to adapt to future stressors." <ref name=Siegel/>{{Rp|9}} Interruption in the attachment pattern of young children with their caretaker(s) has been shown to be a primary precursor to Dissociative Disorder pathology. (see etiology) <ref name=Medscape/> <ref name=HauntedSelf/>{{Rp|85}} <ref name=Howell2011/>{{Rp|97}}. She is confused, and desperately needs a caregiver, but hers are not safe, which is evident in her behavior when she interacts with them. Her brain needs nourishment and stimulation and she has not had enough of either. Her mind is actively stimulating her brain, and in fact, it's doing it in excess to make up for the lack of external stimulation. She is creating the base that is needed to have a complex Dissociative Disorder. There are only two complex Dissociative Disorders and just one requires that Annabelle's first year of life involves unprocessed trauma. The other complex Dissociative Disorder, other specified dissociative disorder does not have this requirement.

The synonym TRAUMA sums up DID etiologyThe study of the cause of a disorder or disease. In the case of dissociative identity disorder, early and severe childhood trauma, especially abuse is considered to be the cause. <ref name=ISSTD.org/>
  • T rauma - overwhelmed resulting in Structural Dissociation
  • R ejected - feeling unloved, unwanted and alone
  • A ge - neglected as an infant, and again between age 1 and 6
  • U nhappy - highly traumatized and overwhelmed
  • M emories - trauma memories are unprocessed
  • A ttachment - inability to form an attachment with an adult

DSM-5 mentions of dissociative identity disorder outside its category

In the section titled Somatic Symptoms and Related Disorders, and under conversion disorder (functional neurological symptom disorder)the DSm-5 mentions 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. [2]:321

Treatment

Medication does not aid in the treatment of dissociative identity disorder. [24] The only treatment that has ever been proven to result in full unificationAlso known as final fusion. See 'integration'.Integration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." <ref name=Siegel2012/>{{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. <ref name=Siegel2012/>{{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." <ref name=Siegel2012/>{{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. <ref name=Howell2011/>{{Rp|143}} of any individual with dissociative identity disorder is talk therapy. What's this work achieves is support and encouragement while the patient changes the way their mind and brain work through the hard work of trauma memory processing, reduction of fear, and acceptance of all self states. [25] [26]

IntegrationIntegration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." <ref name=Siegel2012/>{{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. <ref name=Siegel2012/>{{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." <ref name=Siegel2012/>{{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. <ref name=Howell2011/>{{Rp|143}}

ToleranceIn substance and/or drug use tolerance refers to a decreased response to a drug dose that occurs with continued use. Increased doses are needed to produce the same effects. One of the criteria for the dependence syndrome. <ref name=WHOdrugterms/>{{Rp|62}} is primary, followed by partial acceptance and state fear reduction, then some memory sharing before finally cultivating in "unification," which is a normal personality construction. [3] During most of the work there will be overlapping phase work until a unified personality can become a reality. [20]:599-652 [9] [27] There are no medications to cure or manage dissociative identity disorder; the best results are obtained when trauma memories integrate. [28] See our detailed section on integration for more.

Prognosis

When untreated there is chronic and recurrent symptoms varying overtime including long-lasting effects. [29] [20]:637-652 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. [1] [20]:637-652 Estimates of patients that do obtain full integration range from 16.7% to 33%. [30]

History

Paul F. Dell led a drive to understand PTSD, 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, [31] [12] but there was little agreement at that time and the book strongly reflected that fact. [21] 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. [23] [32] Janet, amid an onslaught of naysayers, determined that the mind's ability to dissociate, a term he coined, was influenced by what he called "dissociative determinations," which are referred to today as subjective trauma. [32] Janet insisted that the mind is made up of a network of neurons that when healthy, work together in harmony, but when "infected" by a trauma memory the mind has no choice but to react to and interact with stimulus. [25] [32] Janet pointed out that while the process had purpose in human evolution it is counter-productive in modern man. [12] [33] Janet's work was stifled by influential researchers that took another path after Janet died. [32] 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 maybe even other comorbidComorbid means the the presence of more than one psychiatric diagnosis at once, with substance use this is often referred to as "dual diagnosis" Also see [[Cormobid]]. disorders. All this confusion created a Frankenstein effect that was more fantasy than reality. [23]

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. [10] There were earlier journal articles by the three authors, but it was the book that fully introduced the concept of what today is called Structural Dissociation of the Personality. [20]:3-26 Now in 2014 fMRI scans exist that support Janet's ideas, and most neurologists that write about dissociative identity disorder share similar views, even if they don't use the same terminology. [34]

Mention in the DSM

There was nothing about "multiple personalities" in the DSM-I, but the DSM-II did mention the term as a symptom of neurosisNeurosis is an emotional disorder. Neurotic refers to a person displaying a symptom of emotional distress, which could range from anxiety, panic attacks depression, and lying, to promiscuity. <ref name=Hook2004/>{{Rp|97}} This historical term referred to a very large group of conditions, which were later divided between Mood Disorders, Dissociative Disorders, Anxiety Disorders, Somatization Disorder and Personality Disorder. Neurosis was removed from the DSM completely because it suggested a "cause" common to the categories under that term, and to "reduce confusion" <ref name=Decker2013/>{{Rp|272}}. The DSM-III was the first time that "multiple personality disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, <ref name=ICD10/> even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| 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.

OSDD, BPD, PTSD, Schizophrenia

Mental health professionals with inadequate training have misdiagnosed dissociative identity disorder throughout history, [35] 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.

We encourage those with knowledge of the trauma-stressor and dissociative disorders to join our project and help to create an accurate and helpful information based wiki. To do so, simply make an account and review our editor guidelines.
New Editor Information

Other branches of the Trauma and Dissociation Project

Dissociative Identity Disorder.org is a multi-authored peer written site, reviewed by a health care professional.

References

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