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Dissociative Identity Disorder

Dissociative identity disorder (DID) maintains a misunderstood and misrepresented reputation, but the specifics of this disorder have been identified and are well represented among the studious, even though the average layman fails to understand the complexity of this inhumanly caused disorder. Indeed, if the most basic of an infant's innate needs are dismissed, or worse, purposely defiled, then the baby has suffered the initial phase necessary to cause dissociative identity disorder. Those who are sickened by dissociative identity disorder were trapped in an environment, throughout most, if not all of infancy that destroyed their very essence; making it obvious that it is the action or inaction of primary caregivers during this crucial state of child development that sets the stage for dissociative identity disorder. The second step can be initiated anywhere between eleven months of age, to  four years old, when prolonged terror again consumes an early developmental stage of childhood.  The entire process is completed by the time a child is six years old. (Lanius et al., 2014) The result is a damaged child who is quite ill, and unable to "process the bulk" of their rapidly accumulating trauma experience which leads to even more distress.  (Lanius et al., 2014) (Giuseppe et al., 2014) (van der Hart et al., 2006)   

Structural dissociation of the personality
Structural dissociation is a response to unprocessed trauma that remodels the personality, leaving an individual bound in such a way they settle into the mental disorder that was already determined when they, as a child were isolated in a world of unyielding terror. In combination with earlier factors, and through the process of structural dissociation, two contrasting types of "dissociated personality states emerge: "distinct states" and "less than distinct states," and each "type" defines themselves through behavior, maturity, intensity of phobic reaction and emotion. (Lanius et al., 2014) (Giuseppe et al., 2014) (van der Hart et al., 2006) Historically, and when talking specifically about the theory of structural dissociation, the terms used are apparently normal part (ANP) for a distinct state, and emotional part (EP) for a less than distinct state. The following mental disorders are associated with structural dissociation: complex-posttraumatic stress disorder (C-PTSD), other specified dissociative disorder (OSDD), dissociative identity disorder (DID), and if trauma reaches the point it overwhelms an individual with borderline personality disorder (BPD), then they too will suffer the effects of structural dissociation. (van der Hart et al., 2006) See structural dissociation for more.

Distinct personality states
Distinct states display adult-like mentality as they perform daily life actions in response to reactions that the conscious mind can't help but be consumed with. When two distinct states exist together it defines dissociative identity disorder, and their behavior; the states defend themselves without thought, as reflexive efforts isolate them from the influence of the mind's holding of active trauma. (van der Hart et al., 2006) Distinct states in this disorder have true amnesia, and so they learn to fit into the individuals life by merging as seamlessly as possible into any situation they find themselves in. Many such states present with like-behavior while in the conscious mind, at least after years of practice at portraying a confused persona and desperately trying to act like the individual people around them expect. Not all distinct states have this luxury, but when they do it can be difficult to know which distinct state is out. Once distinct states are active inside (a function of advanced integration), inner states can report when a state leaves unconsciousness and becomes the single active state in the conscious mind. In addition, their popping into consciousness without any knowledge of previous events is the only way of life they know. Once an individual feels safe, this will improve and the distinct states will begin to share conscious memory with select others, at first, then with all others until their shared existence becomes fairly seamless. This is the integration process.

Distinct states are fearless and phobic at the same time
Distinct states can seem fearless in so many ways, especially when compared to the distinct state of other disorders, but they are not fearless when it comes to interacting with other states within their personality system or the active trauma those states hold. They have no access to their past trauma, and so they appear to be strong in mind, discounting of the harm done to them and almost ignorant of the pain and suffering of others. Until integration has advanced they are driven to ignore and deny. This behavior might appear odd to those who know them, but they are unwittingly distancing themselves from pain. At the same time, distinct states can be loving and caring for those entrusted to their care. See personality states and integration for more.

Less than distinct personality states
Less than distinct states (discontinuities in sense of self and agency) are child-like, and lack the particular set of traits viewed as elaboration in distinct states. These personality states are saturated in "remembered abuse," neglect, abandonment, affectivity, and visceral reactions of a painful childhood played-out over and over again in the world of the subconscious, engulfing them in an unyielding wasteland of traumatic experience. These types of states are buffered from "outside distractions," and therefore are able to maintain an "opposite stance" from distinct states; less than distinct states in dissociative identity disorder stay in the subconscious (although they do push the boundaries of it) unless they are "face-to-face" with a perceived threat their mind cannot cope with, (van der Hart et al., 2006) and due to the "intensity" of the chemical and neurological makeup of their dissociative boundaries, they are not easily triggered as are those with OSDD and C-PTSD. See personality states for more

Distinct states can be influenced by less than distinct states
Less than distinct states can influence any distinct state that is out in which it shares a certain type of bond; sharing between the state out and a state within is not absolute in dissociative identity disorder. When a less than distinct state from within is successful in sharing their distress, it causes overwhelming confusion, excitability, fear, emotional instability, depression and what feels like dramatic swings in temperament in an otherwise stable distinct state. See personality states for more.

A state in consciousness cannot remember the subconscious world
When speaking of dissociative identity disorder, nothing is more confusing and utterly interesting than the fact that while a personality state is in the conscious mind it cannot recall the world of the subconscious, and in fact, it does not even know who it is. Once out it can recognize certain behaviors, accents, ways of being and speaking that let it know it is a state that has been discussed in consciousness before and with that information can often figure out who they are. It can also ask for the aid of those in the subconscious mind to let them know who just went missing inside. Like all seemingly deceptive characteristics of this disorder there is always a good explanation and this anomaly has one. Dissociative amnesia functions in such a way that it barricades the conscious mind from the unconscious. When a dissociated personality state passes from one part of the mind to the other it meets a fate of amnesia - thus the name dissociative amnesia. This amnesia problem is not always one way either. More often than not, a state in the unconscious mind cannot "recall" their experience while they were the state in the conscious mind. This is all very confusing to the personality states.

Disorders with less than distinct states
There are distinct and less than distinct states in all disorders associated with structural dissociation, and the states in each are unique unto their own disorder, however all other versions are less elaborate, distinct and phobic than the less than distinct states of dissociative identity disorder. (Lanius et al., 2014) (van der Hart et al., 2006) In dissociative identity disorder the less than distinct states are child-like in behavior, like the other disorders, but the complexity of said states in dissociative identity disorder is more so. The less than distinct states of OSDD, C-PTSD and BPD are " trapped at a certain age," where the less than distinct states in dissociative identity disorder are not. (Lanius et al., 2014) They possess complex thinking and reasoning skills that an adult has, and can often rival the complexity of the distinct states in their own system. See personality states for more.

Personality states are proven by fMRI scans
Personality states can no longer be denied as they have in the past, since today's science verifies not only their existence, but their actions, behavior, separation, distinction and identity through the use of fMRI (functional magnetic resonance imaging) scans of the human brain. (Schlumpf et al., 2014) See personality states for more.

fMRI scan identifying personality states in dissociative identity disorder

Image: On the right is a distinct state in the process of switching with another distinct state. The smaller one would be absent on the next frame if it were shown here. The image on the left shows the process as one distinct state is leaving, and another is arriving. The largest red blob shows the distinct state that is actually conscious at the moment. This switching is lightening fast, but today's fMRI imaging is able to capture it. In dissociative identity disorder, as soon as one distinct state replaces another, the state present immediately leaves the conscious mind. No distinct state is ever fully present in consciousness at the same time in dissociative identity disorder.


One state only is ever conscious in dissociative identity disorder
One state only will ever have residence in the conscious mind of an individual with dissociative identity disorder, no matter what degree of integration they have accomplished. This is a fact that has now been verified many times by fMRI scans. (Schlumpf et al., 2014) (Lanius et al., 2014) (Vermetten et al., 2007) (van der Hart et al., 2006) See personality states for more.

Personality state behavior driven by phobia and fear
Phobia is an utterly important factor that influences and directs state behavior, and while the personality states in C-PTSD, BPD, OSDD, and DID all experience phobia, the distinct states in dissociative identity disorder are riddled with it. In fact, the distinct state in dissociative identity disorder that is "out," is trapped in the present, rabidly repelling anything from consciousness that disturbs its reality. It's like having a "coat of armor" protecting it from all it is not accustomed to in daily life; unable to acknowledge that which fails to make sense. It will convince itself that whatever caused confusion never happened. Distinct states in other disorders, never replicate this seamless ignorance. (Lanius et al., 2014) (Giuseppe et al., 2014) (Vermetten et al., 2007) (van der Hart et al., 2006) See personality states for more.

The nature of unprocessed trauma
Trauma held in the mind is complex, with chaotic functions interacting and reacting in active episodes of painful experience from the past. Trauma is destructive in this form, and unsettling to any personality state interacting in the environment; it is loss of the greatest magnitude. In this form, loss is experienced time and time again, but in many different ways. It's unbidden torture; relentless, painful and highly unbearable. (Lanius et al., 2014) (van der Hart et al., 2006) See structural dissociation for more.

Integration work begins when one distinct state recognizes another state's intrusion
If an individual with dissociative identity disorder is ever to heal there must come a time when at least one distinct state, that is commonly out, recognizes the intrusion of less than distinct states that are attempting communication from within the subconscious. Prior to this point,  the dissociative boundaries were too powerful to allow the distinct state out to acknowledge anything at all to do with the inner states. Integration cannot proceed without this initial step. The interaction between the two different types of states will be clumsy at first, but as states within push the distinct state that is out, it will become obvious in many ways. The child-like states within will probably have some fun as the distinct state out finally recognizes them. They might distort the individuals face causing a smile, frown, funny or scary faces, and make body parts move, eye brows itch, ears tingle and much more as they attempt to prove their existence. Convulsions  (a type of pseudoseizure) might  occur at this point, but these types of seizures are harmless. Long ago these things might have been seen as the individuals being possessed or even influenced by Satanic or alien beings, but it's nothing more than playful inner states letting themselves be known. See integration for more.

Communication between personality states
The degree of communication that will take place, between inner states and the state out is dependent on what the fear ridden distinct state out can accept at any given time. The affects of less than distinct states that dissociative boundaries hid in the past will eventually become prominent thorough the process of integration, and symptoms will be felt that were "ignored," including flashbacks, seizures, alien-like movements, and heard voices. In addition, the distinct state while out, might begin to startle as they experience some of the fear felt by inner states. This is what is referred to in the paragraph above as a pseudoseizure. Anxiety and panicking might also be experienced by the distinct state that is out, as will somatic illness, "alien" pain, derealization, and depersonalization. (Lanius et al., 2014) See integration for more. This "film" from medscape near the bottom half of the page shows what this type of pseudoseizure looks like. The legs rotate in a bicycle motion. Other than sore muscles and even extended tendons after an extreme episode, the events seem harmless. These will fade over time as integration proceeds.

Coconsciousness in DID is unlike OSDD
Coconsciousness in dissociative identity disorder is brief, and is experienced as an echo between a distinct state and a less than distinct state. As one leaves the conscious mind, another arrives, and in this fraction of a moment both states can listen to the outer experience for a brief time until the state that was replaced passes further into the unconscious mind. The farther along in the integration process the longer the echo can be. For example, an individual with dissociative identity disorder is in the later part of integration and they are in therapy. The distinct state sitting in the room talking to the therapist can hear what a less than distinct state is saying. While it feels like both states are in the conscious mind, they are not. They are alternating, going back and forth from the conscious to the unconscious mind. See integration for more.

Other specified dissociative disorder (OSDD in the DSM-V which replaced DDNOS DSM-IV)
Individuals suffering from OSDD often feel they have dissociative identity disorder because they don't understand the differences between the two Dissociative Disorders. Sadly there is not enough research, expert written books  and other information specifically focused on OSDD to ease their craving for information. Most information either lumps the two disorders together, or gives preference to the understanding of dissociative identity disorder. The DSM adds to the problem by throwing OSDD into a catch-all category, leaving those with OSDD wanting for the specifics of what it is they suffer from.  Let us say here, that OSDD deserves its own category. It is perhaps the most interesting of all mental disorders, and it is what the public usually thinks of when using the label of multiple personality disorder. Cult programmers know this as the "cult disease," but it is not caused just from purposeful cult abuse and programming. It can be caused by adults outside of the home, which is in stark contrast to dissociative identity disorder, and it's etiology does not have to begin in infancy, unlike dissociative identity disorder. In OSDD all personality states can be present in the conscious mind at one time and the states follow the behavior unique to their disorder, a fact now well represented by fMRI scans. Dissociative identity disorder and OSDD are distinctly different disorders. To confuse them confuses the very essence of human bioneurology and psychoneurology as well as the most basic criteria of neuropsychology and neurobiology. It cannot be stressed enough just how different OSDD and dissociative identity disorder truly are. Each are terrible disorders and each deserves it's own attention. (Lanius et al., 2014) (van der Hart et al., 2006) See OSDD for more.

Inner world of the subconscious
In the subconscious mind of individuals with dissociative identity disorder, distinct states lack "awareness," at least until substantial integration takes place, while the less than distinct states in dissociative identity disorder are forever active in the subconscious mind, and never sleep or get tired. Their "energy" is amazing as they interact with other states and build shared realities. Distinct states are thought of as the more elaborate of the personality states, but less than distinct states can, in their own way, be even more elaborate, but only in dissociative identity disorder. See personality states for more.

True psychological amnesia only exists in DID
Psychological amnesia is either true or dissociative, and "true amnesia" is only experienced when there are two or more distinct states, and so only exists in dissociative identity disorder. Switching of less than distinct states (child-like) are not of importance to the diagnosis of dissociative identity disorder, since this is also observed in OSDD. (Lanius et al., 2014) (van der Hart et al., 2006) See symptoms for more.

Dissociative identity disorders is the only mental disorder where two or more distinct states exist, and it is the only disorder where true amnesia exists. The DSM-5 criteria state that to have dissociative identity disorder there must be two or more distinct personality states and there must be amnesia. If a state is mature and adult-like, and routinely attends to daily life tasks, and it switches with another state that behaves the same way, and if the two states do not have knowledge of the switching or of each other, and if the observations are correct, then it is indeed dissociative identity disorder. (Lanius et al., 2014) (van der Hart et al., 2006)

Dissociative amnesia
Not paying attention, and so not recalling is normal and is certainly not a function of true dissociation. On the other hand, dissociative amnesia is not only a function of dissociation, but its behavior is close to the literal definition of it. When active trauma persists in the mind, daily life events cause reactions in the subconscious. (Lanius et al., 2014) (Nijenhuis., 2011)

Dissociative boundary
Dissociated states exist in C-PTSD, BPD, OSDD, and DID, but each has a dissociative boundary exclusive to the mental disorder it belongs. Neurological makeup defines the excitability, transpiration, absorption, reactibility, critical mass and depth of the states within each different mental disorder. In this way boundaries define innate action and inaction of states, defending (or not) them based on their limitations, and perceptions of what is "seen" as harmful. The most profound states of all belong to dissociative identity disorder, where all are phobic of each other, with the distinct states so phobic they cannot accept other states even exist. Less than distinct states are less straightforward; they are mindlessly selective about which states they are phobic of and which they are not, allowing them to usually communicate (in the subconscious) with at least some other less than distinct states. (Lanius et al., 2014) (Vermetten et al., 2007) (van der Hart et al., 2006) See dissociative boundaries for more.

Symptoms
The affects of dissociative identity disorder are hidden from the afflicted, so direct symptoms rarely bring individuals to therapy until the point is reached where a distinct state that is commonly out can accept the presence of less than distinct states in the subconscious - a fact the less than distinct states will be sure to broadcast once dissociative boundaries abate and it's allowed. At this point in integration, dissociative symptoms are noticed, and phobia and dissociative boundaries between states will continue to abate, causing the distinct state that is out to experience the disabling symptoms they were unable to recognize before. If integration proceeds even further, a distinct state will eventually be able to accept the problem and can then work to solve it, but otherwise, the symptoms are hidden from the only part of the personality system that can initiate the integration process. See symptoms for more.

 

Dissociative Identity Disorder

 

Child abuse and DID
Past thinking was that dissociative identity disorder was not always a function of childhood abuse, and while this may be true, the authors of Neurobiology and Treatment of Traumatic Dissociation point out that this thinking is old. It's now believed that a child must suffer two prolonged stages of "abuse," with the first consuming infancy, and the second completed prior to five years of age in order for dissociative identity disorder to result. Therefore, the reasoning the authors present is this. If an infant has adequate care in their first year of life, no matter what happens later they will never get dissociative identity disorder. If the infant were in a setting away from their caregivers, as in a hospital during their infancy, it is fathomable that it could lay down the groundwork for the disorder, but unless the "abuse" was continued later in childhood, somewhere between 11 months and 5 years of age, that child would not ever have dissociative identity disorder. It only takes one childhood stage to cause OSDD, so the child could become afflicted by OSDD, but not dissociative identity disorder. Hospitals, and orphanages of the past did leave children alone thinking that it would harm the child - parent relationship if workers gave the child much attention, but no more. Today, at least in the US, foster homes encourage relationships, and there are no longer any orphanages. Hospital staff freely give children support, care and attention, and visitors are welcome. It would be hard to fathom anything in the US, in this day and age, other than purposeful abuse that could fully consume the two different childhood developmental stages that are needed to cause dissociative identity disorder.

Posttraumatic stress disorder-like symptoms
An individual with dissociative identity disorder does not also have PTSD, but once they advance far enough into the integration process, they will notice that they do have similar symptoms including exaggerated startle reflex, flashbacks, derealization, depersonalization and fluctuation between hypoarousal and hyperarousal. Making it easy to separate a Dissociative Disorder from PTSD, the individuals will usually begin to notice communication between the distinct state out, and the less than distinct states in the subconscious mind at about the same time they realize the PTSD-like symptoms. (Lanius et al., 2014)

Personality Disorders
While it's been reported that serial killers, and other assorted "bad guys" have suffered from dissociative identity disorder, it's not accurate to say they are afflicted with a Personality Disorder and a Dissociative Disorder unless every single personality state has the Personality Disorder. An individual with dissociative identity disorder can certainly have states that have introjected behavior, and so unwittingly portray a Personality Disorder, but introjected behavior is irrelevant to the determination of a Personality Disorder. For instance, if an individual were to have a distinct state that acted like it had borderline personality disorder, but a child-like less than distinct state that would come out did not, this individual does not have borderline personality disorder, and so they can be cured. A Dissociative Disorder can be fixed, where a Personality Disorder cannot, and therefore, even beyond knowledge and academics, the distinction is important.  (Giuseppe et al., 2014) (Lanius et al., 2014)  See symptoms for more.

Physiological and psychobiological measures
In the same way that a distinct state can introject behavior demonstrated by someone they were persistently exposed to in childhood, they can do the same with some biological and physiological ailments. They also can have somatic responses unique to different personality states which can include visual acuity, medication response, allergies, food intolerance, plasma glucose levels, heart rate, blood pressure, galvanic skin response, muscle tension, immune function, electroencephalography patterns (EKG, ECC), functional magnetic resonance imaging (fMRI) activation, regional blood flow, and taste preferences. This is most dramatically seen in states that are out and are completely blind or deaf, yet when other states are out they can see and hear perfectly well. (ISSTD, 2011) (Howell, 2011, p. 57) (van der Kolk, 2014)

Unification of the personality and amnesia
True amnesia, which along with distinct personality states defines dissociative identity disorder, and it is those factors that play cruel tricks on the person, leaving them with a seemingly short life-span, or at least a short life in which they experienced. For many with this disorder, it's as if they lived two or more different lives and only have knowledge of one - the safe one that does not involve past abuse or anything or anyone associated with it. Either through the long process of integration, or upon unification of the personality, the individual will finally learn who they are and the entirety of their life.  (van der Hart et al., 2006) See integration and symptoms for more.

Letting go: child-like states
It takes years to integrate and through those years the distinct states come to know the child-like personality states in their personality system, and as the process of integration demands, the states must learn to love and accept each other. It's difficult for some people to let go of that when the time comes and they deny the process any further continuation, but for those who do proceed, it's good to know that unification of the personality finally resolves the active trauma and pain that engulfed the very existence of these child-like states. Upon unification of the personality, there will of course be personality states and new ones don't magically appear and replace the old ones, so the states from before are still there in one way or another. They will no longer be distinct, and they will not answer to a name, or even act child-like, but now the individual will intimately know those states like they never could have before.

Prognosis
An infant whose destiny is to succumb to dissociative identity disorder is so tortured psychologically that their being never was able to come together in a way that allowed linking of the states that make up the personality. Think of the pieces of an intricate puzzle as normal states, and the pieces became damaged (such as by getting wet) and so they do not fit together after the damage. The puzzle remains, not broken, split or fractured, but "irregular." This is the problem to be solved and this puzzle is not an easy one to solve. Dissociative identity disorder offers a deity of stumbling blocks that few ever do navigate, and so unfortunately many go to their graves never finding a way to overcome the mental disorder, and many probably never even knew they had it. (Howell, 2011) See integration for more.

The DSM-5 categorizes dissociative identity disorder as a Dissociative Disorder
Dissociative identity disorder consists of two or more distinct states and two or more less than distinct states. When two distinct states exist, as it does in this mental disorder, then the individual experiences true psychological amnesia, while the less than distinct states are limited to dissociative amnesia. Dissociative identity disorder is a disturbance in the normal integrative function of memory, identity and self with the property of true amnesia, of which, only exists between distinct personality states. See DSM-5 and symptom for more.   

DSM-5 Trauma Stressor-Related and Dissociative Disorders
Mental disorders listed under the category of Dissociative Disorders in the DSM-5 include: dissociative identity disorder (DID), dissociative amnesia (DA), depersonalization - derealization disorder (DEP), other specified dissociative disorder (OSDD), and unspecified dissociative disorder (UDD). OSDD and UDD together replaced DDNOS from the DSM-IV. Mental disorders listed under the category of Trauma Stressor-Related Disorders include: reactive attachment disorder (RAD), disinhibited social engagement disorder (DSED), posttraumatic stress disorder (PTSD), and acute stress disorder (ASD). (DSM-5, 2013)

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, and the spread of misinformation has been going on for decades. To confuse dissociative identity disorder with any other disorder, such as other specified dissociative disorder (OSDD), confuses the afflicted, and their therapists and slows the progress of research.

Dissociative identity disorder is caused by an inability to fully integrate states, and that function is believed to take place prior to age four, and certainly by age five.

 

"Child abuse is a human epidemic that is destroying the human race at a pace that far exceeds that of any disease man-kind has ever been faced with."
- van der Kolk

 

 
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To have dissociative identity disorder is like being a puppet, with many masters pulling your strings,
and each master is blind to what the other is doing. ~Elizabeth

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