DISSOCIATIVE IDENTITY DISORDERS

DISSOCIATIVE IDENTITY DISORDERS

• Disorder formerly known as Multiple Personality Disorder.

• A person may adopt up to 100 identities (average ≈ 15).

• Identities (“alters”) can be:

  • Fully developed with unique behaviors, voices, and gestures.

  • Or partially independent with only some distinct traits.

• Core feature: fragmentation of identity + amnesia (DSM-5).

Case Example: Jonah

• Alters identified:

  • Sammy → rational, calm.

  • King Young → focused on sexual activity.

  • Usoffa Abdulla → violent protector.

• Triggers: severe stress & trauma:

  • Saw mother stab father (Sammy emerged).

  • Mother cross-dressed him (King Young appeared).

  • Attacked by youths at age 9–10 (Usoffa Abdulla emerged).

Jonah had violent blackouts (e.g., attacks, chases, threats) with no memory afterward.

Characteristics of DID

• Host identity: Seeks treatment, attempts to keep identity fragments together, but usually not the original personality.

• Alters: May serve specific roles (e.g., sexual, protective, cross-gender).

• Switching: Rapid, often instantaneous shift between alters.

  • May involve physical changes: posture, facial expressions, handedness (37% of cases).

• Memory gaps: Host and alters may have different awareness levels of one another.

Can DID Be Faked? Concerns of malingering

• DID patients are highly suggestible. Alters may be unintentionally created by therapist suggestion (especially under hypnosis).

• Example: Kenneth Bianchi (Hillside Strangler) claimed DID during trial. Produced a fake alter (“Steve”) when asked. Expert Martin Orne proved he was simulating.

Can DID Be Faked? Experiments

• College students could fake alters when suggested it was plausible.

• DID patients perform like simulators in memory tasks (implicit memory unaffected across alters).

Can DID be faked? Sociocognitive model

DID may arise through therapist suggestion + reinforcement (Spanos, 1996).

Evidence Supporting Authenticity of DID

• Physiological differences among alters:

  • Different electrodermal activity, EEG patterns, brain imaging (hippocampal/temporal activity).

  • Optical changes (eye movements, vision differences) that are hard to fake.

• Clinical observations:

  • DID patients often reluctant to show symptoms, unlike malingerers who exaggerate

Prevalence & Controversy

• No clear consensus: Only ⅓ of psychiatrists fully endorse DID as valid DSM diagnosis.

• Public fascination fueled by media (e.g., Three Faces of Eve, Sybil).

• Some cases are questioned for accuracy, but physiological studies suggest DID can involve genuine neurobiological changes.

Key takeaways

• DID = severe fragmentation of identity with amnesia.

• Alters may serve functional roles (protective, sexual, aggressive, cross-gender).

• Switching is sudden and can involve physical/neurological changes.

• DID is controversial: debate over authenticity vs. suggestion/faking.

Evidence suggests at least some cases are genuine, supported by neurophysiological differences.

STATISTICS

Average 15 alter personalities

• Ratio of females to males (DID) = 9:1

• Data is based on accumulated case studies rather than survey research

Onset

almost always in childhood (as young as 4 years old) 

• But it is usually approximately 7 years after the appearance of symptoms before the disorder is identified

Course

• Chronic in the absence of treatment 

• The form DID takes does not seem to vary substantially over the person’s lifespan, although some evidence indicates the frequency of switching decreases with age

• Different personalities may emerge in response to new life situations

Incidence

There are no comprehensive epidemiological studies on the prevalence of the disorder in the general population, although investigators now believe it is more common than previously estimated.

• For example, semistructured interviews of large numbers of severely disturbed inpatients found prevalence rates of DID of between 3% and 6% in North America 

• Approximately 2% in Holland.

• In the best survey to date in a nonclinical (community) setting, a prevalence of 1.5% was found during the previous year

Comorbidity Research

• A large percentage of DID patients include anxiety, substance abuse, depression, and personality disorders. 

• More than 100 patients have more than seven additional diagnoses

• Comorbidity: DID frequently overlaps with other disorders, especially borderline personality disorder (BPD).

• Overlap with BPD: Similarities include self-harm, suicidality, and emotional instability.

• Misdiagnosis:

• DID is often confused with psychotic disorders due to auditory hallucinations

Dissociative Identity Disorder voice vs Psychotic voice

DID VOICES	PSYCHOSIS VOICES
internal	external
The patient is aware that they are hallucinations.	Often not recognized as hallucinations

The characteristics of DID voices

• Nature of voices: Often command-like, urging harmful or unwanted actions.

• Cultural manifestation: In some cultures, DID is seen as demonic possession.

• Global prevalence: Evidence shows DID exists in 21+ countries 

• Lack of research: Few systematic studies on DID across cultures

CAUSES

Almost every patient presenting with this disorder reports to their mental health professional being horribly, often unspeakably, abused as a child.

Children experiencing severe trauma, such as abuse, may be unable to escape physically or seek help. 

• As a coping mechanism, they often retreat into fantasy and create alternate identities to endure the pain. 

• This process can lead to the development of Dissociative Identity Disorder (DID). 

• Research shows very high rates of childhood trauma among DID patients, with most reporting physical or sexual abuse, including extreme cases of torture or incest. 

• Investigators have confirmed abuse histories in some cases, though there are also instances where memories may be confabulated or inaccurate.

• Not all the trauma is caused by abuse:

  • E.g., a young girl in a war zone who saw her parents blown to bits in a minefield 

  • In a heart-wrenching response, she tried to piece the bodies back together, bit by bit

Root cause of DID

DID is rooted in a natural tendency to escape or “dissociate” from the unremitting negative affect associated with severe abuse

A lack of social support during or after the abuse also seems implicated. 

• A study of 428 adolescent twins demonstrated that a surprisingly major portion of the cause of dissociative experience could be attributed to a chaotic, nonsupportive family environment. Individual experience and personality factors also contributed to dissociative experiences

Behavior and Emotions that make up DID

• Seems related to otherwise normal tendencies present in all of us to some extent 

• Quite common for otherwise normal individuals to escape in some way from emotional or physical pain 

• Example: survivors of life-threatening events reported unreality, emotional numbing, and out-of-body experiences

Dissociative Amnesia and Fugue States

• Clear reactions to severe life stress

• Response to current severe stress, and not just childhood trauma 

• Triggers: legal problems, family stress, job stress

Diathesis-Stress Model states that

Not everyone under extreme stress develops DID or severe dissociation

• (Diathesis-Stress Model) Pathological dissociation occurs only if: 

1. Stress (Trauma, severe life event)

2. Vulnerability/Diathesis (predisposition)

Dissociative Identity Disorder (DID) and Posttraumatic Stress Disorder (PTSD)

• Share similarities in that both are strongly linked to severe trauma. 

• However, not everyone exposed to trauma develops PTSD. 

• The risk depends on individual biological and psychological vulnerabilities, particularly a predisposition to anxiety. 

• While moderate trauma leads to PTSD mainly in vulnerable individuals, severe trauma increases the likelihood for almost anyone, though some remain resilient. 

This highlights the interaction between trauma severity and individual vulnerability in the development of PTSD, including its dissociative subtype.

DID is an extreme subtype of PTSD

But with a much greater emphasis on the process of dissociation than on symptoms of anxiety, although both are present in each disorder

Developmental Vulnerability

• Critical Period: Approximately 9 years of age

• Trauma before age 9 → higher risk of DID.

• Trauma after age 9 → more likely to have PTSD.

• Shows the role of the developmental stage in psychopathology

Limitations in research

• Evidence mainly from retrospective case studies & correlational data

• Few prospective studies (tracking trauma survivors over time).

• Psychological and biological risk factors are not well-defined.

• Some individual differences may influence who develops DID vs. PTSD.

SUGGESTIBILITY

the degree to which a person is inclined to accept and act on the suggestions of others, even without critical analysis or independent judgment

• Some people are more suggestible than others

• Some are relatively immune to suggestibility, and the majority fall in the midrange.

• Having an imaginary childhood playmate

• It is one sign of the ability to lead a rich fantasy life, which can be helpful and adaptive.

• But it also seems to correlate with being suggestible or easily hypnotized

• ~50% of DID patients recall them in childhood.

• Unclear if these formed before or after trauma.

HYPNOTIC TRANCE

similar to dissociation

• People in a trance tend to be focused on one aspect of their world, and they become vulnerable to suggestions by the hypnotist

SELF-HYPNOSIS

 which individuals can dissociate from most of the world around them and “suggest” to themselves that, for example, they won’t feel pain in one of their hands.

Autohypnotic Model

• Suggestible people can use dissociation as a defense against trauma.

• DID arises as an extreme form of dissociation

Role of Suggestibility to DID

• High suggestibility → more likely DID.

• Low suggestibility → more likely PTSD.

Trauma Impact

• Severe trauma → identity splits into multiple dissociated selves

• Children’s blurred boundary between fantasy & reality allows DID to form.

• After age 9, DID is unlikely; trauma is more likely to form into PTSD

BIOLOGICAL CONTRIBUTION

Like PTSD, Dissociative Identity Disorder (DID) likely involves a biological vulnerability, though it is difficult to identify. 

• Twin studies suggest that DID is shaped entirely by environmental factors rather than heredity. 

• However, heritable traits such as stress reactivity and tension may indirectly increase risk. 

Neurobiological evidence

DID patients may have reduced hippocampal and amygdala volumes, similar to findings in PTSD.

Neurological Disorders and Dissociation

• Seizure disorders are linked to dissociative symptoms

• Temporal lobe epilepsy is especially associated with dissociation

• Key distinction: 

• seizure-related dissociation = adulthood onset, not trauma-related 

• DID without seizures = trauma-related, often begins in childhood.

Head injury can cause amnesia/dissociation, but:

• Generalized, irreversible.

• Clear cause (head trauma).

• Easier to diagnose

Sleep deprivation

• Produces hallucinations and dissociative symptoms 

• DID patients report worsening symptoms when tired

• Described as feeling like jet lag

REAL MEMORIES AND FALSE

A major controversy exists: some researchers argue that many recovered memories may actually be false, implanted by suggestive or careless therapists. 

• This debate highlights the unreliability of memory

• People may forget real events or recall events that never occurred. 

• Believing false memories → risk of harming innocent people (e.g., false accusations).

• Dismissing true memories → risk of invalidating real trauma survivors.

A therapist's suggestion can create false but convincing memories

Risk of False Memories

• False accusations against loved ones.

• Family breakdown.

• Unjust prison sentences.

• Lawsuits against therapists → millions in damages

Evidence for false memory creation

Established psychological processes can generate false but vivid memories

ONGOING CONTROVERSY

PRO SIDE	CONS SIDE
Trauma may cause selective dissociative amnesia → impaired recall of abuse	Doubt that people can encode trauma yet fail to recall it

Both false memories and genuine repressed trauma exist and  need caution in therapy and legal settings

• No all-or-none answer

Elizabeth Loftus and colleagues

have demonstrated that false or illusory memories can be created through suggestion. 

• In one classic experiment, individuals were convinced they had been lost in the mall as children, even recalling additional invented details over time. 

• Despite later being told the event never happened, participants insisted the memory was real. 

• Other research shows that implanted false memories (getting sick from egg salad) can influence behavior, such as developing aversions to certain foods (participants avoided egg salad months later)

These findings provide strong experimental evidence that memory is malleable and vulnerable to distortion, which has major implications for the recovered memory debate.

CHILDREN’S MEMORY ACCURACY

Children, particularly very young ones, are prone to memory errors.

• Emotional content (e.g., trauma, abuse) further reduces accuracy

• The testimony of very young children may be unreliable.

• Important caution for legal settings (child abuse cases, witness reliability

Research study on CHILDREN’S MEMORY ACCURACY

Ceci’s Child Studies

• 58% of preschool children described fictitious events as if real.

• 25% reported them as real most of the time.

• Narratives were detailed, coherent, and elaborated beyond the original suggestion.

• 27% insisted the false memories were real even after being told they were not.

“Alien Abduction Story”

• Participants were divided into 3 groups:

1. Recovered memories of alien abduction.

2. Repressed beliefs (believe abduction occurred, but no memories).

3. Controls (no such beliefs)

• Findings:

• Groups with recovered/repressed memories showed more false recall and recognition in lab tasks.

• They also scored higher on suggestibility and depression than controls

Memory is malleable and vulnerable to distortion. Certain personality traits (e.g., absorption, vivid imagination, openness to unusual ideas) make some people more likely to form illusory or false memories

THERAPIST IMPORTANCE

Therapists must remain sensitive to possible trauma in patients with dissociative disorders or PTSD, even when such trauma is not immediately remembered. Research shows mixed findings:

Williams (1994)

• Studied 129 women with documented childhood sexual abuse.

• 38% did not recall the abuse even after probing, especially if the victim was young or knew the abuser.

Goodman et al (2003)

• Interviewed 175 people with documented abuse histories.

• 81% remembered and reported their abuse.

• Higher recall was linked to older age at abuse end and emotional support after disclosure.

McNally & Geraerts (2009)

• Some individuals may simply forget abuse (ordinary forgetting, not repression).

• Memories can return naturally when encountering reminders outside of therapy

Reports of childhood sexual abuse memories fall into four possible categories

1. Always remembered the abuse.

2. False memories (created inadvertently).

3. Recovered memories in therapy (of “repressed” abuse).

4. Forgotten and later remembered abuse (ordinary forgetting, later triggered).

FALSE MEMORIES

Can be created through repeated suggestions by authority figures (therapist)

Therapist Responsibility

• Must understand memory science.

• Avoid leading/suggestive questioning.

Problem with untrained therapists

They can unintentionally implant elaborate false memories.

Example Cases:

• Satanic ritual abuse accusations in daycare centers.

• Now seen as false memories induced by aggressive interviewing.

• Resulted in wrongful life sentences for elderly caregivers

TREATMENT for dissociative amnesia or fugue state

Most individuals with dissociative amnesia or a fugue state recover on their own and eventually regain their lost memories.

• Cause: Closely tied to present life stress (not just past trauma, so preventing recurrence involves resolving the stress and strengthening coping skills.

When therapy is needed, the focus is on treatment is

• Recall forgotten events.

• Integrate experiences into consciousness.

• Use collateral reports (family/friends) to aid reconstruction.

• This helps the individual confront the events and make them part of conscious awareness.

TREATMENT FOR DISSOCIATIVE IDENTITY DISORDER (DID)

Treatment for Dissociative Identity Disorder (DID) is far more challenging than for dissociative amnesia or fugue. Since DID involves a fractured sense of identity, reintegration can seem nearly impossible, but some therapeutic success has been documented.

• Evidence of success: Long-term psychotherapy has led to integration in some cases

• Prognosis: Generally guarded/poor

• Course: chronic and rarely improves without treatment

• Studies:

• 5/20 patients achieved full integration

• 12/54 patients (22.2%) achieved integration after 2 years

• Limitations: Lack of controlled studies; improvements may be due to other factors, not necessarily therapy

Current treatment strategies for DID

Current treatment strategies for DID draw from both clinical experience and PTSD treatment methods. The main goals are:

1. Identify & neutralize triggers → cues that provoke traumatic memories or dissociation.

2. Confront & relive trauma → patient gradually re-experiences the trauma in therapy to transform it from a re-living into a memory.

3. Regain control → therapy focuses on giving patients mastery over traumatic memories rather than being overwhelmed by them.

Techniques for treating DID

• Visualization & reliving trauma → guided by the therapist slowly and carefully.

• Hypnosis → sometimes used to access unconscious memories and bring alters into awareness. This may be effective because dissociation itself resembles hypnosis, though there’s no evidence hypnosis is essential for treatment.

Risk of dissociation during therapy

When traumatic memories resurface, they may trigger further dissociation, so therapists must stay alert and manage this carefully.

Trust is essential

• While trust is always important in therapy, it is absolutely crucial for DID treatment, given the vulnerability and fragmentation of identity.