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Dissociative identity disorder
Specialty	Psychiatry, psychology
Frequency	1.5% (United States of America)

Dissociative identity disorder (DID, also known as multiple personality disorder in the ICD-10) is a psychiatric diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM) its essential feature "...is the presence of two or more distinct identities or personality states...that recurrently take control of behavior." The diagnosis requires that at least two personalities (one may be the host) routinely take control of the individual's behavior with an associated memory loss that goes beyond normal forgetfulness; in addition, symptoms cannot be the temporary effects of drug use or a general medical condition. Memory loss will occur in those with DID when an alternate part of the personality becomes dominant. DID is less common than other dissociative disorders, occurring in approximately 10% of dissociative disorder cases and .5-1% of the general population.Women tend to outnumber men in this disorder, resulting in about a 9:1 ratio. Diagnosis is often difficult as there is considerable co-morbidity with other conditions and many symptoms overlap with other types of mental illness. There is much controversy regarding the validity of this disease. Many in the psychological community argue that it is a iatrogenic disorder, or that it is often another disorder that is being misinterpreted. It is diagnosed significantly more frequently in North America than in the rest of the world.

Individuals diagnosed with DID frequently report severe physical and sexual abuse as a child. The etiology of DID has been attributed to the experience of pathological levels of stress which disrupts normal functioning and forces some memories, thoughts and aspects of personality from consciousness, though an alternative explanation is that dissociated identities are the iatrogenic effect of certain psychotherapeutic practices or increased popular interest. The debate between the two positions is characterised by passionate disagreement. While the disorder is considered very debilitating, there is debate about whether the disease exists due to concerns over false reporting and its use by defendants in civil cases.

Signs and symptoms

The Diagnostic and Statistical Manual of Mental Disorders criteria for DID include the presence of two or more distinct identities or personality states. At least two personalities take control of the individual's behavior on a recurrent basis, accompanied by inability to recall personal information beyond what is expected through normal forgetfulness. The diagnosis excludes symptoms caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures and normal fantasy play in children.

The DSM diagnostic criteria has been criticized as focusing solely on amnesia and alternate identities instead of the wide range of symptoms present in those diagnosed. In addition to the unique characteristics of multiple personality states with amnesia, the full syndrome of DID includes an array of pathological dissociative symptomatology as well as many symptoms resembling other mental illnesses. Daily functioning can vary from severely impaired to normal to high. Symptoms can include:

• Current memory loss of everyday events
• Depersonalization
• Depression
• Derealization
• Disruption of identity characterized by two or more distinct personality states
• Distortion or loss of subjective time
• Flashbacks of abuse/trauma
• Frequent panic/anxiety attacks
• Identity confusion
• Mood swings
• Multiple mannerisms, attitudes and beliefs
• Paranoia
• Pseudoseizures or other conversion symptoms
• Psychotic-like symptoms such as hearing voices and other Schneiderian first-rank symptoms
• Self-alteration (feeling as if one's body belongs to someone else)
• Somatic symptoms that vary across identities
• Sudden anger without a justified cause
• Spontaneous trance states
• Suicidal and para-suicidal behaviors (such as self injury)
• Unexplainable phobias

Severe and/or chronic intrusive dissociative symptoms can be very disturbing and may make sufferers question their sanity.

Co-morbid mental illnesses are the rule rather than the exception in all dissociative disorder cases, with 82% of DID patients being diagnosed with at least one DSM Axis I diagnosis in their lifetime. Common Axis I co-morbidities include anxiety disorders such as posttraumatic stress disorder (up to 80%), social phobia (up to 75%), panic disorder (54-70%) and obsessive-compulsive disorder (up to 64%); mood disorders such as major depressive disorder (88-97%); substance-related disorders (50-65%); eating disorders such as bulimia nervosa (19-23.1%); and somatoform disorders (23.1–45.5%). In addition, a majority of those diagnosed with DID meet the criteria for borderline personality disorder, a significant minority meet the criteria for avoidant personality disorder, and other personality disorders are not uncommon. Contrary to what would be expected by the presence of Schneiderian first-rank symptoms, dissociative disorders only rarely appear in co-morbidity with schizophrenia and other psychotic disorders. Studies have shown that DID patients are diagnosed with five to 7.3 co-morbid disorders on average - much higher than other mental illnesses.

Despite research on DID including structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potential and electroencephalography, no convergent neuroimaging findings have been identified regarding DID, making it difficult to hypothesize a biological basis for DID. In addition, many of the studies that do exist were performed from an explicitly trauma-based position, and did not consider the possibility of iatrogenic induction of DID. There is no research to date regarding the neuroimaging and introduction of false memories in DID patients. Studies have shown differences between cerebral blood flow, changes in visual parameters, and support for amnesia between alters. DID patients also appear to show deficiencies in tests of conscious control of attention and memorization (which also showed signs of compartmentalization for implicit memory between alters but no such compartmentalization for verbal memory) and increased and persistent vigilance and startle responses to sound. DID patients may also demonstrate altered neuroanatomy.

The concept of "alters" or "alternate personality" is the distinguishing characteristic of DID. The terms and their meanings are not well-defined though a distinction has been drawn between an "ego state" (behaviors and experiences united by a common principle but possessing permeable boundaries with other such states) and alters (which have a separate autobiographical memory, independent initiative and sense of ownership over their own actions).

Causes

Developmental trauma

Those who accept the validity of DID as a diagnosis attribute it to extremes of stress or disorders of attachment. What may be expressed as posttraumatic stress disorder in adults may become DID when found in children, possibly due to their greater use of imagination as a form of coping. A specific relationship of childhood abuse, disorganized attachment and lack of social support are thought to be a necessary component of DID, along with a rigid parenting style, temperament, genetic predisposition and an inversion of the parent-child relationship. Other suggested explanations include insufficient childhood nurturing combined with the innate ability of children in general to dissociate memories or experiences from consciousness. A high percentage of patients report child abuse and others report an early loss, serious medical illness or other traumatic events. People diagnosed with DID often report that they have experienced severe physical and sexual abuse, especially during early to mid childhood. They also report more historical psychological trauma than those diagnosed with any other mental illness. Several psychiatric rating scales of DID sufferers suggested that DID is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction.

In early childhood, children are still developing a personality structure that allows integrative functioning. Trauma greatly interferes with the development of integrative metacognitive functions and associative pathways between naturally developing ego states, enforcing separation instead of diffuse and inclusive functioning. Repeated activation of trauma-related dissociative states (while the myelin in the hippocampus is still being formed) conditions the brain to function state-dependently and form dissociative identities. Severe sexual, physical, or psychological trauma in childhood by a primary caregiver has been proposed as an explanation for the development of DID. In this theory, awareness, memories and feelings of a harmful action or event caused by the caregiver is pushed into the subconscious and dissociation becomes a coping mechanism for the individual during times of stress. These memories and feelings are later experienced as a separate entity, and if this happens multiple times, multiple alters are created.

Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation - the fact that DID patients report childhood trauma does not mean trauma causes DID - and point to the rareness of the diagnosis before 1980 as well as a failure to find DID as an outcome in longitudinal studies of traumatized children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as "personality state" and "identities", and question the evidence for childhood abuse in patients beyond self-reports, the lack of definition of what would indicate a threshold of abuse sufficient to induce DID and the extremely small number of cases of children diagnosed with DID despite an average age of appearance of the first alter of three years.

Psychiatrist Colin Ross disagrees with Piper and Merskey's conclusion that DID cannot be accurately diagnosed, pointing to internal consistency between different structured dissociative disorder interviews (including the Dissociative Experiences Scale, Dissociative Disorders Interview Schedule and Structured Clinical Interview for Dissociative Disorders) that are in the internal validity range of widely accepted mental illnesses such as schizophrenia and major depressive disorder. In his opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses. He also asserts that Piper and Merskey have cherry-picked data and not incorporated all relevant scientific literature available, such as independent corroborating evidence of trauma in some patients.

Iatrogenesis

It has been suggested that symptoms of DID may be created iatrogenically by therapists using techniques to "recover" memories with suggestible patients. The characteristics of patients diagnosed with DID (hypnotizability, suggestibility, frequent fantasization and mental absorption) contributed to these concerns and concerns regarding the validity of recovered memories. Skeptics believe that a small subset of doctors are responsible for diagnosing the majority of individuals with DID. Psychologist Nicholas Spanos and others skeptical of the condition have suggested that in addition to iatrogenesis, DID may be the result of role-playing rather than separate personalities, though others disagree, pointing to a lack of incentive to manufacture or maintain separate personalities and point to the claimed histories of abuse of these patients. Piper and Merskey list a variety of arguments for the iatrogenic position, including the lack of children diagnosed with DID, the sudden spike in incidence after 1980 in the absence of evidence of greater rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy (particularly involving hypnosis), an increase in the number of alters over time and the changes in the identity of alters (such as those claiming to be animals or mythological creatures).

The iatrogenic position is strongly linked to ideas about false memories. There is little consensus between the iatrogenic and traumagenic positions regarding DID and debates are both passionate and diametrically opposed.

Diagnosis

The diagnosis of dissociative identity disorder is defined by criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-II used the term Hysterical Neurosis, Dissociative Type. The DSM-III grouped the diagnosis with the other four major dissociative disorders, and the DSM-IV-TR categorizes it as dissociative identity disorder. Dissociation is recognized as a symptomatic presentation in response to psychological trauma, extreme emotional stress, and, as noted, in association with emotional dysregulation and borderline personality disorder. The ICD-10 continues to list the condition as multiple personality disorder. The diagnosis has been criticized; researchers Piper and Merskey describe it as a culture-bound and often iatrogenic condition which they believe is in decline.

The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV require that an adult, for non-physiological reasons, be recurrently controlled by multiple discrete identity or personality states while also suffering extensive memory lapses. While otherwise similar, the diagnostic criteria for children requires also ruling out fantasy. Diagnosis is normally performed by a therapist, psychiatrist or psychologist clinically trained in the specific material who may use specially designed interviews (such as the SCID-D) and personality assessment tools to evaluate a person for a dissociative disorder. Subjectivity in terms like personality, ego-state, identity and amnesia grants a certain degree of subjectivity to diagnosis.

The psychiatric history of individuals diagnosed with DID frequently but not always contains multiple previous diagnoses of various mental disorders and treatment failures. It has been suggested that this can be attributed to the large number of co-morbid conditions that often accompany and can mask the underlying diagnosis of DID.

Proposed changes to diagnostic criteria in the DSM-5

The proposed diagnostic criteria for DID in the DSM-5 is:

1. Disruption of identity characterized by two or more distinct personality states (one can be the host) or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others, or reported by the patient.
2. Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.
3. Causes clinically significant distress and impairment in social, occupational, or other important areas of functioning.
4. The disturbance is not a normal part of a broadly accepted cultural or religious practice and is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). NOTE: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

These specifiers are under consideration:

a) With pseudoseizures or other conversion symptoms

b) With somatic symptoms that vary across identities

The proposed Criterion C is intended to "help differentiate normative cultural experiences from psychopathology." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, and not have to diagnose those who report it as having a mental disorder.

Screening

Perhaps due to their perceived rarity, the dissociative disorders (including DID) were not initially included in the Structured Clinical Interview for DSM-IV (SCID), which is designed to make psychiatric diagnoses more rigorous and reliable. Instead, shortly after the publication of the initial SCID a freestanding protocol for dissociative disorders (SCID-D) was published. This interview takes about 30 to 90 minutes depending on the subject's experiences. An alternative diagnostic instrument, the Dissociative Disorders Interview Schedule, also exists but the SCID-D is generally considered superior. The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.

Other questionnaires include the Dissociative Experiences Scale (DES), Perceptual Alterations Scale, Questionnaire on Experiences of Dissociation, Dissociation Questionnaire and the Mini-SCIDD. All are strongly intercorrelated and except the Mini-SCIDD, all incorporate absorption, a normal part of personality involving narrowing or broadening of attention. The DES is a simple, quick, and validated questionnaire that has been widely used to screen for dissociative symptoms, with variations for children and adolescents. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20. The reliability of the DES in non-clinical samples has been questioned.

Differential diagnoses

Due to overlap between symptoms, differential diagnosis between DID and a variety of other conditions (including schizophrenia, psychosis, normal and rapid-cycling bipolar disorder, anxiety disorders, somatization and personality disorders) can be complicated as delusions or auditory hallucinations can be mistaken for speech by other personalities and vice-versa, or sudden behavior changes being attributed to sudden mood fluctuations. Persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotizability and reports from family members or other associates indicating a history of such changes can help distinguish DID from other conditions. A diagnosis of DID takes precedence over any other dissociative disorders. Distinguishing true DID from malingering is a concern when financial or legal gains are an issue, and factitious disorder may also be considered if there patient has a history or pattern help or attention seeking. Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with dissociative disorder not otherwise specified rather than DID due to the lack of internal personalities or alter states. Most individuals who enter an emergency department and are unaware of their names are generally in a psychotic state rather dissociative. Auditory hallucinations are common, but complex visual hallucinations may also occur.

Conditions which may be present with similar symptoms include borderline personality disorder, and the dissociative conditions of dissociative amnesia and dissociative fugue. The clearest distinction is the lack of discrete formed personalities in these conditions. Individuals with schizophrenia will have some form of delusions, hallucinations or thought disorder. The condition may be under-diagnosed due to skepticism and lack of awareness from mental health professionals, made difficult due to the lack of specific and reliable criteria for diagnosing DID as well as a lack of prevalence rates due to the failure to examine systematically selected and representative populations. A specific relationship between DID and borderline personality disorder has been posited several times, with various clinicians noting significant overlap between symptoms and patient behaviors and it has been suggested that DID may arise "from a substrate of borderline traits." Reviews of DID patients and their medical records concluded that the majority of those diagnosed with DID would also meet the criteria for either borderline personality disorder or more generally borderline personality.

Treatment

There is a general lack of consensus in the diagnosis and treatment of DID. Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive behavioral (CBT), insight-oriented therapies, dialectical behavioral therapy (DBT), hypnotherapy and eye movement desensitization and reprocessing (EMDR). Medications can be used for co-morbid disorders and/or targeted symptom relief. Some behavior therapists initially use behavioral treatments such as only responding to a single identity, and then use more traditional therapy once a consistent response is established. Brief treatment due to managed care may be difficult, as individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic alliance. Regular contact (weekly or biweekly) is more common, and treatment generally lasts years - not weeks or months.

Therapy for DID is phase oriented. Different alters may appear based on their greater ability to deal with specific situational stresses or threats. While some patients may initially present with a large number of alters, this number may reduce during treatment - though it is considered important for the therapist to become familiar with at least the more prominent personality states as the "host" personality may not be the "true" identity of the patient. Specific alters may react negatively to therapy, fearing the therapists goal is to eliminate the alter (particularly those associated with illegal or violent activities). A more realistic and appropriate goal of treatment is to integrate adaptive responses to abuse, injury or other threats into the overall personality structure.

The International Society for the Study of Trauma and Dissociation has published guidelines to phase-oriented treatment in adults as well as children and adolescents that are widely used in the field of DID treatment. The first phase of therapy focuses on symptoms and relieving the distressing aspects of the condition, ensuring the safety of the individual, improving the patient's capacity to form and maintain healthy relationships, and improving general daily life functioning. Co-morbid disorders such as substance abuse and eating disorders are addressed in this phase of treatment. The second phase focuses on stepwise exposure to traumatic memories and prevention of re-dissociation. The final phase focuses on reconnecting the identities of disparate alters into a single functioning identity with all its memories and experiences intact. Movement through the phases is often non-linear; patients in the second or third phase of treatment may need to go back to a previous phase to maintain safety and/or process previously unprocessed material.

Prognosis

DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociative symptoms and features of post traumatic stress disorder normally recover with treatment. Those with co-morbid addictions, personality, mood, or eating disorders face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of symptom relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives. Individuals with the condition commonly attempt suicide.

Epidemiology

The DSM does not provide an estimate of incidence for DID and dissociative disorders were excluded from the Epidemiological Catchment Area Project. As a result, there are no national statistics for incidence and prevalence of DID in the United States. Initially DID along with the rest of the dissociative disorders were considered the rarest of psychological conditions, numbering less than 100 by 1944, with only one further case added in the next two decades. In the late 1970s and 80s, the number of diagnoses rose sharply. Accompanying this rise was an increase in the number of alters, rising from only the primary and one alter personality in most cases, to an average of 13 in the mid-1980s (the increase in both number of cases and number of alters within each case are both factors in professional skepticism regarding the diagnosis). A possible explanation for the increase in incidence and prevalence of DID over time is that the condition was misdiagnosed as schizophrenia, bipolar disorder, or other such disorders in the past; another explanation is that an increase in awareness of DID and child sexual abuse has led to earlier, more accurate diagnosis. Others explain the increase as being due to the use of inappropriate therapeutic techniques in highly suggestible individuals, though this is itself controversial. Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:

Figures from the general population show less diversity:

Over-representation in North America

DID is a controversial diagnosis and condition, with much of the literature on DID still being generated and published in North America, to the extent that it was once regarded as a phenomenon confined to that continent though research has appeared discussing the appearance of DID in other countries and cultures. In a 1996 review, Joel Paris offered three possible causes for the sudden increase in people diagnosed with DID:

1. The result of therapist suggestions to suggestible people, much as Charcot's hysterics acted in accordance with his expectations.
2. Psychiatrists' past failure to recognize dissociation being redressed by new training and knowledge.
3. Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: "hysteria".

Paris believes that the first possible cause is the most likely.

In a 2011 publication, Vedat Sar postulated other possible causes for the apparent differences in the prevalence of DID and other dissociative disorders, including different preferences in diagnostic instruments, cultural differences in the interpretation of presenting symptoms, differences in mental health care systems and differences in the frequency of overall mental health treatment seeking behavior around the world.

History

Before the 19th century, people exhibiting symptoms similar to those were believed to be possessed. The first case of DID was thought to be described by Paracelsus in 1646.

An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries, running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings. Hypnosis, which was pioneered in the late 18th century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.

The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100. Epilepsy was seen as a factor in some cases, and discussion of this connection continues into the present era.

By the late 19th century there was a general acceptance that emotionally traumatic experiences could cause long-term disorders which might display a variety of symptoms. These conversion disorders were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivé (1863-?) who suffered a traumatic experience as a 13-year-old when he encountered a viper. Vivé was the subject of countless medical papers and became the most studied case of dissociation in the 19th century.

Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation. One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality.

In the early 20th century interest in dissociation and multiple personalities waned for a number of reasons. After Charcot's death in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet's association with Charcot tarnished his theories of dissociation. Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.

In 1910, Eugen Bleuler introduced the term schizophrenia to replace dementia praecox. A review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States. A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.

Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports. Bleuler also included multiple personality in his category of schizophrenia. It was concluded in the 1980s that DID patients are often misdiagnosed as suffering from schizophrenia.

The public, however, was exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe had a formidable impact. In 1957, with the publication of the book The Three Faces of Eve and the popular movie which followed it, the American public's interest in multiple personality was revived. During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.

Between 1968 and 1980 the term that was used for dissocative identity disorder was "Hysterical neurosis, dissociative type". The APA wrote in the second edition of the DSM: "In the dissociative type, alterations may occur in the patient's state of consciousness or in his identity, to produce such symptoms as amnesia, somnambulism, fugue, and multiple personality." The number of cases sharply increased in the late 1970s and throughout the 80s, and the first scholarly monographs on the topic appeared in 1986.

In 1974 the highly influential book Sybil was published, and later made into a miniseries in 1976 and again in 2007. Describing what Robert Rieber called “the third most famous of multiple personality cases”, it presented a detailed discussion of the problems of treatment of “Sybil”, a pseudonym for Shirley Ardell Mason. Though the book and subsequent films helped popularize the diagnosis, later analysis of the case suggested different interpretations, ranging from Mason’s problems being iatrogenically induced through therapeutic methods used by her psychiatrist, Cornelia B. Wilbur or an inadvertent hoax due in part to the lucrative publishing rights, though this conclusions has itself been challenged. As media attention on DID increased, so too did the controversy surrounding the diagnosis.

With the publication of the DSM-III, which omitted the terms "hysteria" and "neurosis" (and thus the former categories for dissociative disorders), dissociative diagnoses became "orphans" with their own categories with dissociative identity disorder appearing as "multiple personality disorder". In the opinion of McGill University psychiatrist Joel Paris, this inadvertently legitimized them by forcing textbooks, which mimicked the structure of the DSM, to include a separate chapter on them and resulted in an increase in diagnosis of dissociative conditions. Once a rarely occurring spontaneous phenomena (research in 1944 showed only 76 cases), became "an artifact of bad (or naïve) psychotherapy" as patients capable of dissociating were accidentally encouraged to express their symptoms by "overly fascinated" therapists.

"Interpersonality amnesia" was removed as a diagnostic feature from the DSM III in 1987, which may have contributed to the increasing frequency of the diagnosis. There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990. Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995. Scientific publications regarding DID peaked in the mid-1990s then rapidly declined.

In 1994, the fourth edition of the DSM replaced the criteria again and changed the name of the condition from "multiple personality disorder" to the current "dissociative identity disorder" to emphasize the importance of changes to consciousness and identity rather than personality. The inclusion of interpersonality amnesia helped to distinguish DID from dissociative disorder not otherwise specified, but the condition retains an inherent subjectivity due to difficulty in defining terms such as personality, identity, ego-state and even amnesia. The ICD-10 still classifies DID as a "Dissociative disorder" and retains the name "multiple personality disorder" with the classification number of F44.8.81.

A 2006 study compared scholarly research and publications on DID and dissociative amnesia to other mental health conditions, such as anorexia nervosa, alcohol abuse and schizophrenia from 1984 to 2003. The results were found to be unusually distributed, with a very low level of publications in the 1980s followed by a significant rise that peaked in the mid-1990s and subsequently rapidly declined in the decade following. Compared to 25 other diagnosis, the mid-90's "bubble" of publications regarding DID was unique. In the opinion of the authors of the review, the publication results suggest a period of "fashion" that waned, and that the two diagnoses " not command widespread scientific acceptance".

Society and culture

Despite its rareness, DID is portrayed with remarkable frequency in popular culture, producing or appearing in numerous books, films and television shows.

Psychiatrist Colin A. Ross has stated that based on documents obtained through freedom of information legislation, psychiatrists linked to Project MKULTRA claimed to be able to deliberately induce dissociative identity disorder using a variety of aversive techniques.

Surveys of the attitudes of Canadian and American psychiatrists' attitudes towards dissociative disorders completed in 1999 and 2001 found considerable skepticism and disagreement regarding the research base of dissociative disorders in general and DID in specific, as well as whether the inclusion DID in the DSM was appropriate.

Legal issues

Within legal circles, DID has been described as one of the most disputed psychiatric diagnoses and forensic assessments. The number of court cases involving DID has increased substantially since the 1990s and the diagnosis presents a variety of challenges for legal systems. Courts must distinguish individuals who mimic symptoms of DID for legal or social reasons. Within jurisprudence there are three significant problems:

1. Individuals diagnosed with DID may accuse others of abuse but lack objective evidence and base their accusations solely on regular or recovered memories.
2. There are questions regarding the civil and political rights of alters, particularly which alter can legally represent the person, sign a contract or vote.
3. Finally, individuals diagnosed with DID who are accused of crimes may deny culpability due to the crime being committed by a different identity state.

In cases where not guilty by reason of insanity is used as a defence in a court, it is normally accompanied by one of three legal approaches - claiming a specific alter was in control when the crime was committed (and if that alter is considered insane), deciding whether all (or which) alters may be insane, or whether only the dominant personality meets the insanity standard.

There is no agreement within the legal and mental health fields whether an individual can be acquitted due to a diagnosis of DID. It has been argued that any individual with DID is a single person with a serious mental illness and therefore exhibits diminished responsibility and this was first recognized in an American court in 1978 (State v. Milligan). However, public reaction to the result of the case was strongly negative and since that time the few cases claiming insanity have found that the altered consciousness found in DID is either irrelevant or the diagnosis was not admissible evidence. The self-reported nature of the symptoms used to reach a diagnosis makes it difficult to determine their credibility, although objective measuring of brain activation and structural patterns are a promising direction for future scientific research into distinguishing malingered from genuine DID in forensic settings. Forensic experts called on to conduct forensic examinations for DID must use a multidisciplinary approach including multiple screening instruments.

See also

• Complex post-traumatic stress disorder
• Defense mechanisms
• Dissociative disorder not otherwise specified
• Fugue state
• Identity formation
• International Society for the Study of Trauma and Dissociation
• Psychogenic amnesia

Footnotes

1. ^ "The ICD-10 Classification of Mental and Behavioural Disorders" (pdf). World Health Organization.
2. ^ American Psychiatric Association (2000-06). Diagnostic and Statistical Manual of Mental Disorders-IV (Text Revision). Arlington, VA, USA: American Psychiatric Publishing, Inc. pp. 526–529. doi:10.1176/appi.books.9780890423349. ISBN 978-0-89042-024-9. {{cite book}}: Check date values in: |date= (help)
3. Nijenhuis, E (2010). "Trauma-related structural dissociation of the personality" (pdf). Activitas Nervosa Superior. 52 (1): 1–23. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
4. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 15014580 , please use {{cite journal}} with |pmid= 15014580 instead.
5. Goldstein, William N. (1996). Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives. Springer. p. 19. ISBN 978-0-306-45150-8. {{cite book}}: More than one of |author= and |last= specified (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
6. ^ Paris J (1996). "Review-Essay : Dissociative Symptoms, Dissociative Disorders, and Cultural Psychiatry". Transcult Psychiatry. 33 (1): 55–68. doi:10.1177/136346159603300104.
7. ^ Atchison M, McFarlane AC (1994). "A review of dissociation and dissociative disorders". The Australian and New Zealand journal of psychiatry. 28 (4): 591–9. doi:10.3109/00048679409080782. PMID 7794202.
8. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 17716088, please use {{cite journal}} with |pmid= 17716088 instead.
9. Howell, E (2010). "Dissociation and dissociative disorders: commentary and context". Knowing, not-knowing and sort-of-knowing: psychoanalysis and the experience of uncertainty. Karnac Books. pp. 83–98. ISBN 1-85575-657-9. {{cite book}}: Unknown parameter |editors= ignored (|editor= suggested) (help)
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11. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 9989574, please use {{cite journal}} with |pmid= 9989574 instead.
12. ^ Rubin, EH (2005). Adult psychiatry: Blackwell's neurology and psychiatry access series (2nd ed.). John Wiley & Sons. pp. 280. ISBN 1-4051-1769-9. {{cite book}}: Unknown parameter |editors= ignored (|editor= suggested) (help)
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23. Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 15912905 , please use {{cite journal}} with |pmid= 15912905 instead.
24. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 19724751, please use {{cite journal}} with |pmid= 19724751 instead.
25. Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 14683715, please use {{cite journal}} with |pmid= 14683715 instead.
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40. Dissociative identity disorder at the DSM-V showing proposed revision, page found 2011-06-05.
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43. Steinberg, Marlene (1993). Structured clinical interview for DSM-IV dissociative disorders / Marlene Steinberg. Washington, DC: American Psychiatric Press. ISBN 0-88048-562-0.
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58. ^ Sadock 2002, p. 681
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64. Gast U, Rodewald F, Nickel V, Emrich HM (2001). "Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic". J. Nerv. Ment. Dis. 189 (4): 249–57. doi:10.1097/00005053-200104000-00007. PMID 11339321.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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66. Bliss EL, Jeppsen EA (1985). "Prevalence of multiple personality among inpatients and outpatients". The American Journal of Psychiatry. 142 (2): 250–1. PMID 3970252.
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References

• Sadock, Benjamin J. (2002). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams & Wilkins. ISBN 0-7817-3183-6. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: ref duplicates default (link)

External links

• Template:DMOZ
• International Society for the Study of Trauma and Dissociation

Template:Link GA

• Dissociative disorders
• Identity disorders
• Psychiatric diagnosis