Dissociative Identity Disorder

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In "image B", this 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 shows a distinct state 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 an other distinct state, which is only possible in 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}}, because this is the only disorder with two or more distinct states. "Image A" shows three less than distinct states which are the parts that manage "unprocessed trauma," and react to it with vehement emotion. This is obviously an fMRI scan of DID since it shows there are two distinct states and three less than distinct states. In OSDD fMRI scans reveal only one distinct state is possible, and it switches with less than distinct states randomly, and the distinct state also switches in response to a "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.." In contrast to DID, every single state can literally be conscious (lit up) at one time, but in response to a trigger, all but one state will leave consciousness, which is again in contrast with DID. In PTSD there is only one less than distinct state and one distinct state, and both stay conscious until a trigger causes the less than distinct state to respond, (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}}, fear, anxiety or other like symptom) and when it does the distinct state leaves consciousness. In the complex version of PTSD there are always two less than distinct states, and one distinct state. The less than distinct states are polarized, staying together, with both always conscious at the same time, but otherwise behave the same as simple PTSD. BPD involves one distinct state and it's always conscious until the individual is in distress, and then two less than distinct states show up together, but unlike C-PTSD these less than distinct states do not take over consciousness. The distinct state always remains with them. There are no flashbacks or other symptoms caused from unprocessed trauma events in BPD like there are in all the other disorders mentioned so far, but there are other dissociative symptoms. [2] [3]

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 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}}," 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 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' "personality state,"." - Myers (1940) [4]:22

Pierre Marie Félix Janet, (born May 30, 1859, Paris, France and died February 24, 1947, Paris) a French psychiatristProfessionals who are medically trained doctors with specialist training in psychiatry. They can prescribe medication, diagnose and conduct research. Besides psychiatric medication treatments include ECT and psychotherapy. <ref name=AboutPsychiatry/> and neurologist also understood that there are two distinctly different types of states among those afflicted with dissociative symptoms, but he further reported there were two also two completely different disorders. Today we know those disorders as the complex Dissociative Disorders: other specified dissociative disorder and 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}}.

More recently, Ellert Nijenhuis, Onno van der Hart and Kathy Steele brought Janet's work to the spotlight in peer reviewed journal articles 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." [3]: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," [3]:28-43 but here on this site we use the more universal terms distinct state and less than distinct state. Lanis, Paulsen and 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"specific, unconscious, intra-psychic adjustment that occurs in order to resole emotional conflict and to reduce an individual's anxiety. A mental mechanism, an ego defense mechanisms, or an adjustive technique."<ref name=Hook2004/>{{Rp|97}} 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 EPAn state that holds trauma memory. A term used in structural dissociation. <ref name=HauntedSelf/>{{Rp|38-39}}'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 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}}'s. These self-states are more likely separated at a subcortical level-thalamocortical loops through the basal ganglia. [5]:21

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." [5]. 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. [6]

Trauma effects on the 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/> of DID

Consistent, overwhelming early childhood trauma maintaining a degree of terror in the 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) 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. [7] This second stage is what separates victims of this disorder from those that have other specified dissociative disorder. 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," [8] [9]:208-211 [10] but it's also imperative to note that this process involves at least two childhood developmental stages, with one stage consuming infancy, and the other before the age of 4 or so. [5] 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"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 terror, and the shame of utter weakness and vulnerability. While we want to move beyond 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}}, the part of our brain that is devoted to ensuring our survival (deep blow our rational brain) is not very good at denialPsychology - Defense mechanism in which the existence of unpleasant realities is disavowed; refers to keeping out of conscious awareness any aspects of external reality that, if acknowledged, would produce anxiety <ref name=Sadock2008/>{{Rp|24}}Crime - "various processes by which individual actors, social groups or states either 'block, shut out, repress or cover up certain forms of disturbing information [about wrong doing] or else evade, avoid or neutralize' its consequences. (Cohen (1995){{Rp|19}}) Refers to the denial of a perpetrator of a crime, for example denying the crime or the impact of the crime, denying the victim, counter-attacks and appealing to "higher loyalties".<ref name=CrimeDict/>{{Rp|125}}. 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. [7]:1-2

Christine Courtois and Julian Ford wrote this in their book Treatment of Complex Trauma.

We define "complex trauma" as traumatic 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}} 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. [11]

As you can see complex trauma "shatters" the human psycheThe Greek word for soul. It is also used in psychology to signify the mind and/or personality. Psyche was also Carl Jung's term for total personality. <ref name=Basavanna2000/>{{Rp|338}}, especially when it's introduced and maintained exceptionally early in life.

The image is a dendrite receiving chemical signals, but communication is not limited to chemical transpiration. The mind of an individual with DID realizes a complex arrangement of signals transpiring through multitudes of neurons and other connections in the brain, and those signals are like a "rabbit in the hat". They are there, then they are gone, but they can be "grabbed out of thin air" before they are gone and interpreted by the subconsciousness mind to be “people and places in an inner world.” The inner world is a fantasy place in the subconscious mind, which is "real" to the states that "exist" there. The brain/mind system of individuals without DID do this too, but to a far lesser extent; individuals with DID vary in the degree in which they experience their inner world. Distinct states often remain unconscious in the inner world until their "imagination" catches up with the less than distinct states, and then they become active inside and interact with the other states. Elaboration defines the appearance of the inner world which many states experience as the same detailed environment. "An individual in "stage II" of therapy for DID, who has awareness of their inner world describes it like this. "Less than distinct states" are far more visual and imaginative than "distinct states", and therefore experience an existence there sooner. My distinct states were "seen", but never aware in the inner world until centuries had passed, and my integration had progressed to the point where communication between the distinct state that was "out," and the "less than distinct states" that were inside was fluent. Inside the experience of the states could be one less than distinct state painting, another playing piano, another the guitar, a couple playing chess, while still another might be writing chemistry equations on a blackboard and explaining it to others inside, and another is "listening" to a recorded memory of a Beethoven sonnet, while still another is crying, and soothed by another, and still another is telling me what to write on this page. The intelligence of the states vary, which I find interesting, and when a state is in the inner world, its intelligence is different from when it is "out." It's as if while out, any state is operating with a completely different set of "memory skills," and the integration level seems to dictate this. Distinct states are even more confusing because at first mine were not aware inside, and so when they were out they had no recall of the inner world. Later after integration had progressed they were aware inside, but while out they still had no memory of the inner world. Another interesting point is that there is no age that the states think they are (as opposed to OSDD), but they do maintain a certain level of maturity or immaturity. Their appearance is something they have learned to change at will, but in the past it reflected who they were in the inner world. In this way elaboration and distinction evolved beyond the time these states were out."

Etiology

The required sequence of external reaction 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. After infancy, troublesome hot spots usually remain without relief and if so, then that child is on the fast track to structural dissociation; a personality restructuring that attempts to calm the mind/brain system. There could be a lull in the child's environment where the mind/brain system can calm somewhat, but prior to age 4 or so, the child will again be in the environment that caused their mind/brain system malfunction and they will again be in a constant state of terror. This second phase is required or other specified dissociative disorder will be the result.

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 feigningA 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}} do little for an infant in a hostile environment, and so the baby dwells in the fear response, where the brain is unable to calm. 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, but after infancy and prior to age four or so. This second phase is critical to the ontogeny of dissociative identity disorder, and without it only one distinct state will ever evolve, and the very definition of dissociative identity disorder is it's the only 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}} with two or more distinct states. [5] See the fig. on this page labeled: dissociative part-dependent resting-state activity in dissociative identity disorder: a controlled fMRI perfusion study.

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}}, 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. [5]

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}}

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: [5]

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 dissociationStructural dissociation (SD) is one of the three accepted etiological ideas for the etiology of dissociative identity disorder. <ref name=HauntedSelf/> <ref name=Dell2009/>{{Rp|158-165}} It also explains other specified dissociative disorder, dissociative forms of borderline personality disorder, and dissociative posttraumatic stress disorder {{See also| Structural dissociation}}Structural dissociation of the personality is a theory that describes the effect of trauma on the personality. It applies to PTSD, complex PTSD, other specified dissociative disorder and dissociative identity disorder. 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. [5]

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. [5] 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. [3]

Personality statesThe highly dissociated and compartmentalized personality states found in dissociative identity disorder occur in various mental disorders. Other terms meaning the same thing include: dissociated part, dissociated part of self and disaggregate self-state, but often the same terms used for non-dissociated state are used for dissociated states. {{See also| Alters}} {{See also| Personality}}

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. [12] [3]:216-336 Fear directs how all dissociated personality statesThe highly dissociated and compartmentalized personality states found in dissociative identity disorder occur in various mental disorders. Other terms meaning the same thing include: dissociated part, dissociated part of self and disaggregate self-state, but often the same terms used for non-dissociated state are used for dissociated states. {{See also| Alters}} {{See also| Personality}} relate to each other. Distinct states lack what is "needed" to control fear, and are literally riddled with phobiaPhobia of dissociated states is evident in all dissociative disorders, but in dissociative identity disorder it is highly evident.. [3]:291-298, 216-336 [13] Phobic inhibitions prevent distinct states from sharing information with "subjectively offensive states" within their realm. [3]:216-336Distinct 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. [3]:216-336

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. [3]:89-108 When created a, less than distinct state takes the form of either observing or experiencing. [5] [3]:66-71

  • Observing states: Individuals with dissociative identity disorder often describe at least one observing state [5]:258-259 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 triggeredA 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. 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. [5]

Diagnosis of DID

Evidence gained from fMRI 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. [5]

Dissociative identity disorder PlosOne.jpg.

AmnesiaMemory loss. {{See also| 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. [3]:73-88 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. [5]

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. [5] It is possible for the person with dissociative identity disorder to have a 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]]. 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. [5] 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." [7]

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 dissociationStructural dissociation (SD) is one of the three accepted etiological ideas for the etiology of dissociative identity disorder. <ref name=HauntedSelf/> <ref name=Dell2009/>{{Rp|158-165}} It also explains other specified dissociative disorder, dissociative forms of borderline personality disorder, and dissociative posttraumatic stress disorder {{See also| Structural dissociation}}Structural dissociation of the personality is a theory that describes the effect of trauma on the personality. It applies to PTSD, complex PTSD, other specified dissociative disorder and dissociative identity disorder. 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, [14] 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. [15]:429-434
  • 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. [10] [16]
  • PTSD would be eliminated quickly, when the elaboration of the less than distinct states is observed in dissociative identity disorder. [15]:447-470 [15]:495-510
  • Schizophrenia is not a disorder involving any dissociative state, but instead has a delusionalA delusion is a "false belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief." <ref name=Sadock2008/>{{Rp|24}}Delusional perception is a "perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation". A Schniederian first-rank symptom often associated with schizophrenia <ref name=Sadock2009/>{{Rp|1434}} but not associated with dissociative identity disorder. <ref name=Dell2009/>{{Rp|391}} pattern of "state shifting." [15]:557-570
    DID VS OSDD
    Behavior Behavior
    Lacks recall of childhood Has an almost "normal" memory of childhood
    No effectual ability to self access Overwhelmed by the illness
    Distinct (adult-like) states switch with each other. Switchingrefers to identity alteration in dissociative identity disorder and otherwise specified dissociative disorder, it occurs with a person changes from one identity to another. {{See also| Alters}} between adult-like states is absent.
    States are unable to identify an age of"creation" Many states believe they were created at a certain age
    Structural dissociation Structural dissociation
    Only one state can be conscious at any time Literally all states can be conscious at once
    Triggers rarely cause any reaction Triggers are highly influential
    Dissociative states are highly phobic of each other Dissociative states are moderately phobic of each other
    True amnesiaMemory loss. {{See also| amnesia}} between distinct states Dissociative amnesiaDissociative amnesia (DA) was previously called psychogenic amnesia is a form of temporary amnesia that presents often in traumatic situations; for example in car accidents or victim or witness of a violent crime. Dissociative Amnesia is described in the DSM as a disorder that causes significant distress or impairment in functioning, such as when a person cannot remember significant events that happened to them. <ref name=ISSTD.org/> between states
    Two or most distinct states, and two or more less than distinct states make up the personality. One distinct state, and two or more less than distinct states make up the personality.

    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.

    Charles-myers.jpg
    Pierre-Marie-Felix-Janet.jpg
    Stephen-porges.jpg
    Bessel-van-der-kolk.jpg

    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 systemAll states that make up the personality in an individual.. They can't acknowledge the existence of other states. [3]:73-88 [5]:1-212, 243-498 [17] [3]:73-88True 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. FlashbacksA 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}} are common in dissociative identity disorder and tend to be glaringly obvious prior to trauma processing. The symptom called: "trance"periods of absence-like staring and unresponsiveness; well documented in severely dissociative people for over 100 years"<ref name=Dell2009/>{{Rp|229}}" (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. [7] [5] 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. [5]

    Epidemiology

    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 not rare; it is thought to occur in 1% to 3% of the world's general population. [18] The 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 reports that a US community was tested and the findings revealed 1.5% with dissociative identity disorder and it was almost equal among genders. [19]:294 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 selfNormal sense of self is experienced as alterations in consciousness, but the sense of self remains stable and consistent. In individuals with a Dissociative disorder the sense of self alternates and is inconsistent across time and experience. <ref name=Dell2009/>{{Rp|160}} There is no unified sense of self. due to severe, chronic childhood abuse"interactions in which one person behaves in a violent, demeaning or invasive manner towards another person (e.g. child or partner)" <ref name=VandenBos2007/>, often involving a caretaker. 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}} 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 [20]

    Treatment

    Medication does not aid in the treatment of dissociative identity disorder. [21] The only treatment that has ever been proven to result in full unification of any individual with dissociative identity disorder is talk therapy. A 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. (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. [22] [23]

    TRAUMA in DID
    • T rauma resulting in structural dissociation
    • R est between trauma events is less than required to process trauma events
    • A ge neglected & traumatized as an infant, and then again between age 1 and 5
    • U nprocessed trauma overwhelms a child resulting in structural dissociation
    • M otion exists between the mind and the brain, but it's inadequate to process trauma
    • A ttachment - inability to form a secure attachment with a primary caregiver

    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}}

    This work is done between the states as was just explained in the above paragraph. 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}} 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. [5] During most of the work will overlap. [15]:599-652 [4] [24] [25] 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. [26] [15]: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] [15]:637-652 Estimates of patients that do obtain full integration range from 16.7% to 33%. [27]

    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, [28] [8] but there was little agreement at that time and the book strongly reflected that fact. [29] 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. [9] [30] Janet, amid an onslaught of naysayers including Sigmund Freud, determined that the minds ability to dissociate, was influenced by what he called "dissociative determinations," which is referred to today as subjective trauma. [30] 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 memory, the mind has no choice but to react and interact with stimulus. [22] [30] Janet pointed out that while the process had purpose in human evolution, it is counter-productive in "modern man". [8] [31] Janet's work was stifled by influential researchers that took another path after Janet died. [30] 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. [9]

    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 SelfThe DSM-IV uses the term identity in its definition of dissociation. (see identity) <ref name=Dell2009/>{{Rp|127}}: Structural Dissociation and the Treatment of Chronic Traumatization. [3] 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." [15]:3-26 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. [32]

    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 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 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. [19]:19 Their intent is to give the minimum criteria needed to diagnose a disorder. The criteria listed here is paraphrased.

    DSM5.jpg

    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. [19]:291-298 [5]:243-470 [12] [33] [34] [35] 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. [36] [4] [5]

    DSM-5 was last updated May 2013
    • A. Two distinct states switch with disruption in identity. [19]:291-298
    • B. True amnesia, not dissociative amnesia is present between two distinct states. [19]:298-302
    • C. The individual is significantly impaired due to the presenting symptoms.
    • D. This is not a "temporary state" created purposefully by cultural practice.
    • 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, and thus the only disorder where true amnesia takes place between states. [3]:73-88 The amnesia criteria helps to distinguish distinct states from less than distinct states. [5]:5-28

    In the DSM-5 section: Somatic Symptoms and Related Disorders, and under 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}} 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. [19]:321

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