Mental health practitioners without dissociative disorders training are likely to struggle to recognize dissociative identity disorder (DID) if a client presented with this condition. There are three primary reasons practitioners would have difficulty detecting DID.
First, DID is misunderstood and in turn misrepresented in popular media. People with DID are often depicted in films and TV series (e.g., Split, United States of Tara) as completely different persons at times, attracting attention, wearing unusual clothes, lacking control, and violent. DID rarely manifests in this manner and people with DID are not more likely than the general public to engage in violence.
Second, the most common symptoms of DID are not visible to an observer and less frequent ones that may be visible at times are typically subtle. For example, people with DID may appear calm and attentive to a listener while experiencing intense internal dialogues.
Third, the criteria selected in the Diagnostic and Statistical Manual of Mental Disorders (DSM) to characterize DID provide limited insight into the signs and experience of DID. For example, Criterion A in the DSM-5 refers to a “disruption of identity characterized by two or more distinct personality states."
A therapist reading this is left to wonder, what does it mean or look like to have distinct personality states?
Dissociation, which refers to a disconnection from one’s sense of self or surroundings, is a common response to an emotionally overwhelming event or series of events (e.g., physical violence, car accidents, childhood abuse). To reduce the psychological effects of a traumatic event and preserve functioning following it, a dissociative response creates a sense of distance from the event and limits conscious access to parts of it or to the whole event (i.e., compartmentalization). For example, someone being assaulted may feel like they are watching rather than experiencing the assault and have difficulty recalling parts of the event or all of it.
DID is a dissociative disorder that primarily develops in early childhood among those experiencing repeated trauma. It occurs in approximately 1% of the general population, and until 1994 when the DSM-IV was published, it was referred to as multiple personality disorder. Typical types of trauma contributing to the development of DID are emotional, physical, and/or sexual abuse and neglect at the hands of caretakers.
In early childhood, children may utilize developmentally appropriate unconscious magical thinking processes to cope by displacing painful thoughts, memories, and emotions onto other personified entities (e.g., toys, stuffed animals, and imaginary friends). For example, a child may state that their imaginary friend or Mr. Potato Head had a difficult day, but their day was okay.
In DID, personified entities develop in one’s mind and allow a young child to think that “this experience, thought, or feeling I’m having is not mine, it belongs to someone else living inside of me.” Thus, a child experiencing abuse may cope by thinking that it is occurring to someone else and that distressing thoughts and emotions resulting from these events do not belong to him (e.g., “I’m not a bad boy but Mark is, and people are mean to him because of that”). Contrary to popular depictions of DID, the overt display of personified entities is rare and the internal fragmentation people feel is hidden.
These remarkable abilities to create distance from traumatic events and to compartmentalize them through personified entities allow the child to limit the impact of her traumatic experiences on her daily functioning and development. While highly adaptive during development or when abuse persists, detachment and compartmentalization can be disruptive in adulthood.
The hallmarks of DID are experiences of detachment, memory challenges, and intrusions, and profound self-puzzlement due to these experiences.
Detachment experiences refer to a subjective sense of disconnection from one’s body, self, or actions, and/or from one’s environment. For example, a client may describe to their therapist a meeting at work where it seemed that they were watching themselves from a point outside of their body, that it feels like they do not have a body below their head, or that yesterday the workplace they had been to countless times seemed unfamiliar and they struggled to navigate in it. Detachment experiences are so common among those with PTSD that to diagnose PTSD, practitioners must determine whether the individual meets the criteria for the dissociative subtype of PTSD—a diagnosis that combines PTSD and detachment symptoms.
Memory challenges include difficulties with day-to-day memory, sensing that one is forgetting important events, noticing that chunks of time have passed—such as several hours—without being able to account for that time, finding oneself in circumstances or locations without knowing how one got there such as hiding in a closet or in the middle of exercising, learning from others about behaviors one does not remember enacting, finding items one does not recall purchasing and evidence of actions one does not remember. A client may describe arriving at work at 9:00am and suddenly realize it is 3:00pm without having a good sense of what they did during that time, or colleagues may thank them for a heartfelt speech they gave at a gathering, but the client will have no recollection of being at the gathering.
Intrusions include unexpected emotions, impulses, and thoughts that arise and seem like they do not belong to oneself, and internal voices that feel as if they are someone else’s, for example the voice of a child, or voices that are arguing or commenting on one’s actions. Importantly, people with DID have intact reality testing and are not experiencing psychosis. They sometimes experience flashbacks and like others with PTSD who experience flashbacks they temporarily lose awareness of the present in the midst of one. Intrusions also include a sense that someone else is acting rather than oneself, the temporary loss of skills or knowledge, and bodily perceptual alterations (e.g., felt disconnect between one’s image in a mirror and internal self-perception). While speaking to a therapist, a person with DID may experience an intrusion of a teenage voice in her head telling her not to share information with the therapist and another child voice asking her to do so. It may feel loud in her head and that these are voices in her head rather than her own loud thoughts. She may also feel that someone else is speaking to the therapist while she is observing the exchange. It does not make sense to her that someone else inside of her is speaking to her or to the therapist, yet it feels that way. She is highly reluctant to share any of this experience with others because she thinks it is crazy and that she will be seen that way.
Since DID is associated with recurrent experiences of trauma in childhood, individuals with DID often present with other common signs among interpersonal violence survivors including challenges with relational trust, shame, self-destructive behaviors, suicidal and self-injurious thoughts, anxiety, depression, body image, healthy eating behaviors, and substance use.
DID is treatable and practitioners can do so successfully with trauma and dissociation training and/or expert consultations. Professional treatment guidelines developed by a large group of experts outline a three-staged model briefly described below. The overarching goals of this treatment model are for clients to experience stability and safety and ultimately a reduction in the reliance on dissociation. Each treatment stage may take several years and the stages often overlap. This model always prioritizes stability and slow progression to avoid harm and re-traumatization.
The first stage of DID treatment focuses on developing and maintaining safety and stability, including the reduction of symptoms such as PTSD, depression, and anxiety. One example of work at this stage that clients and therapists collaborate on to gradually enhance stability is the exploration of ways to improve daily functioning. This may involve discussions of potential recreational activities the client can try out and routinely engage in, ways to balance work, rest, and recreation, physical self-care, and related external and internal barriers. A good life in the present is critical to work towards and maintain at this stage because it gives clients a reason to be in the present, and clients will experience increased confidence and competence by controlling what they can in the present. Another example of a practice pursued at this stage is the exploration of ways harmful behaviors help and protect the client—they often help clients avoid thoughts, emotions, memories, and sensations that are more painful—and the identification of less harmful ways to achieve related goals.
The second stage of DID treatment focuses on traumatic memories. Once people with DID experience some stability and a reduction in PTSD and related symptoms, they may begin to recognize and process that compartmentalized memories, emotions, and thoughts from childhood that feel like they are not theirs indeed are. At this stage, they can develop an understanding of the role traumatic experiences have played in their lives and of their challenges as natural adaptations to overwhelming events, and form a coherent narrative of their lives. One practice a therapist may pursue at this stage is the exploration of conflicting feelings the client has towards the perpetrator so the client can move forward with these relationships in a manner that is aligned with their values and well-being.
Finally, the third stage of DID treatment is centered on working to engage in daily life without detaching and compartmentalizing. Engagement in daily activities in the present and new coping practices prevent immersion in past trauma and support increased stability, self-esteem, and tolerance of interpersonal connection. One example of work clients and therapists collaborate on at this stage is discussing grief clients feel for the pain they have suffered because of traumatic experiences and for challenges life will continue to pose at times. This process may allow clients to devote more energy to living in the present and adapting to it.
If you would like additional practical guidance on each of these treatment stages, the resources listed below will provide you with ample support. Additionally, the International Society for the Study of Trauma and Dissociation offers multiple trainings and learning opportunities.
Boon, S., Steele, K., & Van Der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. WW Norton & Company.
Chefetz, R. A. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: W.W. Norton.
Chu, J. A. (2011). Rebuilding shattered lives: Treating complex PTSD and dissociative disorders. John Wiley & Sons.
Herman, Judith. 2015. Trauma and Recovery. New York, NY: Basic Books.
International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2): 115–187.
Steele, K., Boon, S., & van der Hart, O. (2016). Treating trauma-related dissociation: A practical, integrative approach. WW Norton & Company.
This post would not be possible without the generous mentorship I’ve received from Milissa Kaufman, MD, PhD, Lauren Lebois PhD, and Sherry Winternitz, MD, and the work of Bethany Brand, PhD, Paul Dell, PhD, James Chu, MD, Richard Loewenstein, MD, Richard Chefetz, MD, and many other trauma and dissociation scholars.