Dissociative Identity Disorder
Reviewed by Sara Staggs, LICSW, MSW, MPH
Dissociative identity disorder (DID) is a disturbance in the normal integrative function of memory, identity and self. (Turkus) Pierre Marie Félix Janet, and Morton Prince, (Noricks, 2011, p.1) researchers in the late 1800's and early 1900's understood there is a connection between past events and present day symptoms of trauma. Janet concluded that the personality is a structure comprised of various systems. (van der Hart, 2006, p. 2) Researchers since have struggled to catch up with Janet, and have not always understood how the separate parts of the personality work together and are made, but more recently, due to significant contributions from excellent researchers, such as the ones seen on our reference list it is now widely accepted and understood that all humans have multiple aspects to their personality. The main difference is that people with dissociative identity disorder lack continuity between their self-states and thus experience their self-states as separate. (Howell, 2011, p. 7)
Terminology of multiple personality parts
The terms personalties, parts and states are correctly used interchangeably, as well as subpersonalities, sides, subselves, internal self states, and ego states. (Noricks, 2011, p.1) These terms are all referring to the same thing, the multiple aspects that make up an individuals one personality. It's the same for those with dissociative identity disorder except the terms alter, alter identity, altered state, distinct state, distinct part and so on are often used in addition to the first labels presented.
II. Parts of the personality
Personality state: A normal personality state maintains a continuous sense of "I, and myself" over time, despite the transition from one state to another, whilst the separate states in individuals with dissociative identity disorder do not. Distinct personality states seen in dissociative identity disorder and normal personality states differ, in that the former have a sense of their own identity, ideation and capacity for initiating thought process and actions. (Howell, 2011, p. 57)
Alters: Dissociated parts are found in all of the dissociative disorders, but parts found in dissociative identity disorder are often called alters and can be dysfunctional to the point where the distinct states have amnesia between them. Contrary to popular belief, not all parts of the personality in individuals with dissociative identity disorder have state dependent amnesia. In fact, the Diagnostic and Statistical Manual of Mental Disorders-5 only requires that two parts have these properties.
Personality: A common misconception about personality is how it forms. The human personality is not a set of innate behaviors present at birth, instead, it is created over time and influenced by internal and external experiences and relationships.
Misconceptions: Unfortunately misconceptions, personal bias, media sources, and various forms of denial have worked together to distort the presentation, epidemiology and etiology of dissociative identity disorder, a mental illness often associated with extreme and early child abuse and neglect. This spread of misinformation has been going on for decades.
Etiology: The cause of dissociative identity disorder simply put is - child abuse. Dissociative identity disorder is precipitated by prolonged exposure to overwhelming circumstances during early childhood. (ISSTD, 2011) This is most significantly noted in the formative years of development where normal integration of parts should occur. Coping by dissociation is an innate ability all children have, but when nurturing and compassion are missing, the infant can rely heavily on dissociation to move their stressful and traumatic memories from consciousness. Depending on the severity of neglect and abuse a trauma memory can be experienced as separate dissociated personality parts. (Howell, 2011, p. 85-108) The age a child is when they experience severe neglect and trauma is critical to the development of dissociative identity disorder
Age, severity of abuse and neglect: Dr. Frank Putam presented a model that explains how relationships shape who we are, and Daniel Siegel today talks at great length about how relationships are important to the formation the personality through his many books, lectures, videos and audio recordings. (Siegel, 2011) According to Putnam's highly accepted model, behavior in infancy is organized as a set of "discrete behavioral states" (DBS). (Don't confuse the DBS with fully developed states.) The infant is malleable and seeking input. That input determines a great deal about who they become. Think of DBS as primitive and undeveloped beginnings of states. Examples of DBS are sleep, waking, and eating. (Putnam, 1989, p. 51)
Normal integration: At birth, behavioral states are not linked, but do integrate over the course of development as a child's needs are met. (Howell, 2011, p. 89) Joyanna L. Silberg PhD., points out that this is an unconscious effort. (Silberg 2011, p. 75) Parts group into sequences, until a sense of cohesive personality emerges that can fluently shift from one task-focused aspect of the personality to another. (Putnam, 1989, p. 51) The parts share and develop a sense of common identity, and retain the ability to easily transition from one state to another. (Howell, 2011, p. 89)
Inhibited integration: Repeated and extreme instances of neglect, abuse and mental torment without nurturing will inhibit normal linking. (Wilkinson 2012, p. 81-93) Abusive and neglectful parenting can create a cycle where distinct, compartmentalized states replace normal states during childhood and integration of pathways are disrupted, thus inhibiting integration. (Silberg 2011, p. 75) Frank W. Putnam brought to light the idea that trauma in childhood causes a "disruption of the developmental tasks of consolidation of self across behavioral states and the acquisition of control over the modulation of states." Then he explains how child abuse creates a situation where it is adaptive for a child to "heighten the separation between behavioral states." (Putnam, 1989, p. 53)
Dissociative identity disorder is not a personality disorder:
Multiple personalities were not mentioned in the DSM-I, but they were listed as a symptom in the 1968 printing of the DSM-II, under the diagnosis of hysterical neurosis, dissociative type. The DSM-III, which was printed in 1980 moved multiple personalities from a symptom of hysteria to its own diagnosis. The DSM-IV, printed in 1994, changed the name to dissociative identity disorder. The Diagnostic and Statistical Manual of Mental Disorders-5 retained the name of dissociative identity disorder, and uses the term distinct personality state. Never has this mental disorder been listed as a personality disorder, and the term personalities, although still used today is only accepted as a term to refer to the multiple parts of an individuals one personality.
DSM-5: Enough diagnostic criteria is included in the Diagnostic and Statistical Manual of Mental Disorders fifth edition for trained mental health professionals to make an accurate diagnosis of dissociative identity disorder. The DSM-5 emphasizes distinct states and amnesia, and adds the disruptive effect of symptoms that affect consciousness. This version of the DSM includes a broader definition of symptoms than previous versions. (Spiegel, 2011)
DSM criteria: Dissociative identity disorder is the most complex and misunderstood of the dissociative disorders, and is listed in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (APA DSM-5) as dissociative identity disorder, and in the International Classification of Diseases (ICD-10 WHO, 1992) as multiple personality disorder. Below is an abbreviated form of the DSM-5 diagnostic criteria.
• Disruption of identity characterized by two or more distinct personality parts. This disruption may be observed by others, or reported by the patient.
• Amnesia between parts of the personality.
• The disturbance is not a normal part of broadly accepted cultural, religious practice,
or part of the normal fantasy play of children.
The last two points are commonly
stressed with any mental illness.
• Causes clinically significant distress and impairment in social, occupational, or other important areas of functioning.
• The disturbance is not due to the direct physiological effects of a substance.
See our page on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Physiological measures: A variety of distinguishing physiological measures have been found in distinct personality states including: visual acuity, medication response, allergies, plasma glucose levels in diabetic subjects, heart rate, blood pressure, galvanic skin response, muscle tension, immune function, electroencephalography, evoked potential patterns, functional magnetic resonance imaging activation, brain activation and regional blood flow. (ISSTD, 2011)
Psychophysiological measures: Distinct parts also often have different psychophysiological organizations, such as different allergies, taste preferences, handedness, eyesight and prescriptions for glasses, and responses to medications. (Howell, 2011, p. 57)