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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) one of the essential features of Dissociative Identity Disorder is full dissociation (switching), between distinct personality states. These dissociated states routinely control behavior, and are often limited to state dependent memory. This disorder is thought to be trauma based and caused by pathological levels of stress during the earliest years of childhood, prior to the age where a unitary sense of self forms. During infancy behavior is organized as a set of "discrete behavioral states" which link and group together in sequences over time. The original trauma in those with DID is usually a failure of secure attachment with a primary caregiver which impedes linkage. The last couple of years (2011-2012) have recorded tremendous insights into the study of DID and complex trauma, but controversy does still exist. The ISST-D reports prevalence rates of .01 to 1% in the general population. Studies have indicated a prevalence rate of .5 to 1.0% in psychiatric settings. Dissociative disorders, including DID are often mistaken for various disorders by those that are not trained or educated in trauma psychology.

Symptoms & Diagnosis

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria is located in section 300.14 (dissociative disorders). The criteria requires that an adult, for non-physiological reasons, be recurrently controlled by at least two alternating discrete identity states while also suffering extensive memory lapses. While otherwise similar, the diagnostic criteria for children also requires ruling out fantasy. Diagnosis should be performed by health care professionals trained to administer the SCID-D, use other personality tools and to diagnose trauma and dissociative disorders.

DSM IV Criteria

The Diagnostic and Statistical Manual of Mental Disorders presents the minimum criteria acceptable for a diagnosis of dissociative identity disorder.

• The presence of two or more distinct identities or personality states
• At least two of these identities or personality states recurrently take control of the person's behavior
• Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness
• The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

Proposed changes: DSM-5

The DSM 5 committee gives credit to the following article

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

• Disruption of identity characterized by two or more distinct personality states (one of course can be the host, since this is also a dissociated state in those with DID) 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.
• Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.
• Causes clinically significant distress and impairment in social, occupational, or other important areas of functioning.
• The disturbance is not a normal part of a broadly accepted cultural, religious practice, or part of the normal fantasy play of children.
• The disturbance 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).

The proposed revision will also include specifiers for "prominent non-epileptic seizures and/or other sensory-motor (functional neurologic) symptoms" due to the high number of DID patients with conversion or somatoform symptoms that may require clarification or special treatment. 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.

Passive Symptoms - Beyond Amnesia

P. Dell concludes, after a 5 year process, that 10 well documented dissociative symptoms of DID have been reported in 8 to 32 empirical studies. however the DSM 5 will only include the minimum criteria necessary to make a diagnosis. The task of the DSM relative to any given Dx is to delineate a minimum set of symptoms which can be used to distinguish those who have a Dx from those who do not - in other words, a symptom set that will allow diagnosis to be accomplished reliably.

Passive Symptoms commonly reported in those with DID include: amnesia, conversion, auditory hallucinations, chronic depersonalization, trance, self alteration, derealization, awareness of alters, identity confusion, flashbacks and psychotic-like (not to be confused with psychotic) dissociative symptoms: auditory hallucinations, visual hallucinations and Schneiderian first-rank symptoms which include made actions, voices arguing, voices commenting, made feelings, thought withdrawal, through insertion, made impulses.

States of Dissociative Identity Disorder

Sinason states: "What happens when the toxic nature of what is poured into the undeveloped vulnerable brain of a small child is so poisonous that it is too much to manage? Little children, who have had poured into them all the human pain and hate adults could not manage, somehow grow up. Legions of warriors are lost to society through suicide, psychiatric hospitals, addiction and prison. What happens to them, especially when those that hurt them are attachment figures?" In some children, the result of such abuse is DID. Rarely is this disorder caught during childhood when a youngster is still living with their abuser(s).

Those who have been diagnosed and have educated themselves about DID, usually understand that alters are dissociated states, but they still report that it feels as if these parts are separate people. "Alters have “their own identities, involving a center of initiative and experience, they have a characteristic self representation, which may be different from how the patient is generally seen or perceived, have their own autobiographic memory, and distinguish what they understand to be their own actions and experiences from those done and experienced by other alters, and they have a sense of ownership of their own experiences, actions, and thoughts, and may lack a sense of ownership of and a sense of responsibility for the action, experiences, and thoughts of other alters."

The most common alters that present are the host, child, abuser, protectors, differently gendered, animal, managers, inner-self helpers, parts that inflict self-harm, even attempting or committing suicide, and parts that are thought to be dead. "Dead parts" are interesting since parts cannot be killed, these parts are instead moved far from consciousness where their abuser cannot find them, thus all other parts in the system think them dead, but they can later be brought out again and worked with. Any part, including the hosts, separate from the other parts will experience major deficits in self-awareness and functioning. All dissociated parts together make up a system; if a system becomes "integrated," (no part is lost) then a fully cognizant and functioning human being will finally exist. Remember, as explained above, we do not begin life as a unified self, it is something that happens naturally, over time, during a normal childhood; something those with DID never experienced - but can now as adults with correct treatment. Also, the normal self is made up of ego states, it is not one part.

The Two Major Forms of Pathological Dissociation:

1. Amnesia or Full Dissociation - Dissociative symptoms fully dissociated from consciousness so the host has no awareness of the time at all.

2. Intrusions or Partial Dissociation: Intrusion is two fold, a) criterion B PTSD symptoms (intrusive memories, dreams, flashbacks) and b) passive influence (non-psychotic forms of Schneiderian first-rank symptoms). What those with DID commonly report as co-consciousness is another dissociative part is partially dissociated from consciousness so the host is aware of the alien intrusions into his or her executive function and sense of self. Dell and many others make it clear that other than amnesia, all other symptoms are partial dissociation.

Etiology

It is generally accepted that the main etiology of DID is the interaction of severe trauma starting very early in childhood along with prolonged trauma experienced throughout other important developmental periods of childhood. To survive some children separate many of their feelings and memories from their usual level of conscious awareness.

Multiple Self-States

"Current research in neurobiology, cognitive psychology, and developmental psychology indicates that the brain, the mind, and the self are normally multiple. Neurobiologists increasingly understand the brain as organized into neural systems that to some degree function independently of one another. Such parallel and multitrack processing help to explain dissociative phenomena on a neurological level. What is important for psychological health is the degree of dissociation between self-states, or , to put it more positively, the degree to which we experience our multiple self-states as contextually interrelated and part of what comprises the sum of who we are."

Children are not born with a sense of a unified identity

It has been shown that "symptom patterns in dissociative identity disorder are typical of the normal human response to severe, chronic childhood trauma and have ecological validity for the human race in general."

The Merck Manual: Children are not born with a sense of a unified identity; it develops from many sources and experiences. In overwhelmed children, many parts of what should have blended together remain separate. Chronic and severe abuse (physical, sexual, or emotional) and neglect during childhood are frequently reported by and documented in patients with dissociative identity disorder. Some patients have not been abused but have experienced an important early loss,such as death of a parent, serious medical illness, or other overwhelmingly stressful events. In contrast to most children who achieve cohesive, complex appreciation of themselves and others, severely mistreated children may go through phases in which different perceptions, memories, and emotions of their life experiences are kept segregated. Such children may over time develop an increasing ability to escape the mistreatment by “going away” or retreating into their own mind. Each developmental phase or traumatic experience may be used to generate a different self-state.

Screening and Treatment

DID is Frequently Misdiagnosed

Due to lack of trauma based education by some health care professionals, a client with DID might have previous diagnoses of various mental disorders and treatment failures. A diagnosis of DID takes precedence over any other diagnosis - treating DID as a whole has been proven to show improvement in patients, rather than attempting to fix the problems of just one dissociated part. Due to shared symptoms, differential diagnosis between DID and a variety of other conditions including schizophrenia, psychosis, bipolar disorder, anxiety disorders, somatization, borderline personality disorder, dissociative amnesia and dissociative fugue can be complicated. It is imperative to get the right diagnosis so a patient receives correct treatment and as with any disorder, distinguishing DID from malingering and factitious disorder.

Screening

Screening is to be done by a healthcare professional trained in diagnosing trauma and dissociative disorders. A freestanding protocol for dissociative disorders, the SCID-D is available. This interview takes about 30 to 90 minutes depending on the subject's experiences. An alternative diagnostic instrument, the dissociative disorders interview schedule, can be used as well, 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-SCID-D. All are strongly inter-correlated and except the mini-SCID-D, 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.

Treatment

Virtually all we have to direct us on how to treat DID is the admonitions of those who are articulate, highly experienced clinical specialists - this means Putnam, Kluft, Howell, Boone, Brand, etc. They are all basically saying the same thing, which Howell summarizes nicely: get destabilizing symptoms under control; promote and support integration, and reduce/eliminate the effects of trauma; and train life effectiveness and optimization skills (self-management, relationship success, cognitive effectiveness, etc.). Howell refers to this as a three stage model.

The International Society for the Study of Trauma and Dissociation has published guidelines for phase-oriented treatment in adults as well as children and adolescents that are widely used in the field of DID treatment. Coping with Trauma-Related Dissociation is a self-help book that follows the ISST-D guidelines; the authors explain that "patients with a dissociative disorder appear to benefit from treatment that specifically focuses on dissociative pathology."

• 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.

Steele, van der Hart, Nijenhuis in their book, The Haunted Self, as well as a variety of research publications have also proposed 3 phases of therapy for those with structural dissociation. (ASD to DID)

• Phase I - Overcoming the phobia of attachment and attachment loss
• Phase II - Overcoming the phobia of dissociated parts
• Phase III - Integration of the personality and overcoming the phobias of daily life

Brief treatment due to managed care may be difficult, as individuals with DID may 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. Others explain treatment methods as an eclectic mix of psychotherapy techniques, including cognitive behavioral (CBT), insight-oriented therapies, dialectical behavioral therapy (DBT), hypnotherapy and in some cases eye movement desensitization and reprocessing (EMDR). Medications can be used for co-morbid disorders and/or targeted symptom relief.

Prognosis

DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociative symptoms and features of posttraumatic 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 dissociative disorders, including DID, frequently have histories of failed suicide attempts and self-harm. B. Brand's 2012 review reported "treatment for dissociative disorders is associated with decreased symptoms of dissociation, depression, posttraumatic stress disorder, distress, and suicidality."

Models of Dissociative Identity Disorder

Structural Dissociation Model

Steele, K., van der Hart, O., Nijenhuis, E. suggest a distinction between "apparently normal parts" (ANP) and "emotional parts". ANP, the part in executive control and who is responsible for daily functioning is often exhausted and depressed. The part avoids trauma memory and often has amnesia for many if not all childhood traumatic events. If those events were grouped close together, entire blocks of early life will be absent from ANP's memory. ANP avoids the affect and information held by EP, including nightmares, dreams, somnambulism, intrusive thoughts, flashbacks and some somatoform symptoms. ANP is not only avoidant of the list above, but is actually phobic of trauma memory, related emotions, cognitions and sensory memory that goes with it. ANP actively or passively suppress triggers to the point that it can become automatic.

"Emotional parts" (EP) are needed for survival situations involving Fight or Flight, total submission, reflexes, vivid traumatic memories and strong, painful emotions. EP remains fixated in traumatic experiences, which it often reenacts. It is focused on a narrow range of cues that were relevant to the trauma. “Action systems” direct EP.

To sum this up: "Traumatized individuals fail to sufficiently integrate current reality -- normal life -- as EP. As ANP they have failed to integrate the trauma, either partially or fully, and tend to be more or less engaged in normal life."

Summary of Categories of Structural Dissociation.

• Primary Structural Dissociation (PSD) PSD - Involves one EP and one ANP such as found in simple acute stress disorder and PTSD. The ANP is detached and numb, characterized by partial or complete amnesia of the trauma. EP is usually limited in scope compared to ANP and is hyper-amnesic and re-experiences trauma.
• Secondary Structural Dissociation. (SSD) - Includes trauma based DDNOS-1, complex PTSD and borderline personality disorder. This is characterized by dividedness of two or more defensive subsystems. For example, there may be different EP's who are devoted to flight, fight, freeze, total submission and so on.
• Tertiary Structural Dissociation (TSD) - This is Dissociative Identity Disorder. Two or more ANP perform aspects of daily living, such as work, child-rearing. There must also be 2 or more EP.

Traumatic Model

DID is increasingly understood as a complex and chronic posttraumatic psychopathology closely related to severe, particularly early, child abuse. It has been shown that "symptom patterns in dissociative identity disorder are typical of the normal human response to severe, chronic childhood trauma and have ecological validity for the human race in general." The Trauma Model of Dissociative Identity Disorder explains how pathological levels of stress during the earliest years of childhood, prior to the interconnecting of self states, disrupt the normal integrative processes of consciousness. In fact, current research has shown that "infant attachment disorganization is in itself a dissociative process, and predisposes the individual to respond with pathological dissociation to later traumas and life stressors." The bulk of research on the subject shows it is important to understand that trauma theory alone does not explain DID, one must also consider disorganized attachment (DA) which explains how trauma hampers linkage (ability to link and integrate experiences) of self states. The theory states that an infants behavior is organized as a set of discrete behavioral states such as sleep which link and group together in sequences over time. Trauma, such as a failure of secure attachment with a primary caregiver, impedes this linkage - interfering with the development of integrative metacognitive functions and associative pathways between naturally developing ego states, enforcing separation instead of diffuse and inclusive functioning. It is believed by many top researchers, in the field of trauma, that 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. The bulk of research on the subject indicates that stress and lack of social support, experienced in infancy, continues throughout the early years in those with DID - from a primary caregiver. Children have an innate ability to cope via dissociation and are often able to dissociate memories and experiences from consciousness. These memories and feelings are later experienced as a separate entity, and if this happens multiple times, multiple parts may be created. Putnuam's reported that the part of self that is host is not "the original part." According to the trauma model a persons sense of self is "built up and synthesized over time. E. Howell adds to this that "the usually presenting part is, by definition, a part in relation to and in relationship with other parts in the total organization of the personality. People do not start out in life unified, but developmentally accomplish the joining and harmonious functioning of different behavior and mental states." As adults, those with dissociative identity disorder have observable disorganized attachment patterns. Neuroscientific research in recent years has uncovered fascinating points regarding adult (implicit and explicit) memory and attention in those with DID. "The evidence linking attachment in infancy and attachment-related traumas to later dissociative symptoms, and that linking concurrent states of mind with dissociative symptoms, converge to form a compelling picture." Integration is a confusing term, since we know we do not begin life integrated. Watkins defines it thus: Integration means making the barriers between various alters more permeable, increasing communication and cooperation, then returning the various sub-personalities to the status of "covert" ego-states which cannot be contacted except under hypnosis. We feel it is unnecessary to fuse them into a unity since this is not a part of the "normal" personality.

Dell's 2006 study comparing three models for DID

1. DSM IV's Classic model
2. Subjective/phenmenological model
3. Sociocognitive model

Dell concludes that the DSM model is limited to an alter disorder and that the sociocognitive model copies the media's representation of multiple personality disorder, not understanding the "15 subjective dissociative symptoms of DID that are invisible and thus can't be copied by the general public thereby in his view, destroying all argument that the sociocognitive group has. Dell's subjective/phenomenological model is "deduced from a novel of empirically supported pathological dissociation, which fully explains the empirical literature on DID where as the DSM IV model of DID can account for little of that literature."

Sociocognitive Model

This model does not support the trauma or the structural dissociation models, instead this model claims that DID does not come from childhood trauma. Piper and Merskey describe it as a culture-bound and often iatrogenic condition which they believe is in decline. In a 2011 review, Boysen concluded: "Despite continuing research on the related concepts of trauma and dissociation, childhood DID itself appears to be an extremely rare phenomenon that few researchers have studied in depth. Nearly all of the research that does exist on childhood DID is from the 1980s and 1990s and does not resolve the ongoing controversies surrounding the disorder." Those who support the iatrogenic position report their reasoning is that characteristics of patients diagnosed with DID (hypnotizability, suggestibility, frequent fantasization and mental absorption) contributed to these concerns regarding the validity of recovered memories. Some of these researchers believe that a small subset of doctors are responsible for diagnosing the majority of individuals with DID. Psychologist N. 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. 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. One of Piper and Merskey's challenges to the trauma model argues 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 argue the 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.

"A 2012 review of the literature concludes that a sociocognitive model better accounts for the extant data. We further propose a perspective on dissociation based on a recently established link between a labile sleep–wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality. We conclude that this perspective may help to reconcile the posttraumatic and sociocognitive models of dissociation and dissociative disorders."

Current Controversy

"Dissociative identity disorder (DID) remains a controversial diagnosis mainly due to conflicting views on its etiology.

• DID is caused by childhood trauma.
• DID is caused by iatrogenesis," due to certain psychotherapeutic practices and/or by social influence.

It appears to be mutually accepted that in adults DID can be induced through poor therapeutic practices, such as leading and hypnosis. E. Howell points out however, that during Kluft's many studies he observed that the parts created through "experimental hypnosis are highly limited, do not have a center of subjectivity, initiative and personal history, and they don't last."

The main debate appears to be if early childhood abuse can cause DID: C. Ross points out the errors of logic and scholarship that the quite vocal disbelievers of trauma based disorders, Piper and Merskey, have made in their publications concerning DID. Ross also 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 DES and the SCID-D that are both in the internal validity range of widely accepted mental illnesses such as schizophrenia and major depressive disorder. In Ross's opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses. Ross 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.

The arguments go back and forth from one point of view to the other.

• The position of the sociogognitive camp is that initially DID was infrequently diagnosed, numbering less than 100 by 1944, with only one further case added in the following two decades, but then the late 1970s and 80s were marked with a number of cases. Accompanying this rise was an increase in the count of dissociated parts per case, rising from only a primary and one other dissociated part; with most cases averaging 13 parts by the mid-1980s. This group also proposes that this increase was a result of iatrogenic procedures. In addition, they argue that the failure of some health care professionals to recognize dissociation is now redressed by new training and knowledge so that they can claim that the dissociative phenomena itself is increasing. Researchers who support this view report that the rise in dissociative disorders only represents a new form of an old and protean entity: hysteria. A 2012 review of the literature proposed a perspective on dissociation based on a recently established link between a labile sleep–wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality.

• Proponents of the trauma model report that the increase in incidence and prevalence of DID over time is that the condition was misdiagnosed as 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. V. Sar postulated other possible causes for apparent variance in the prevalence of DID, including preferences in diagnostic instruments, cultural distinctions in the interpretation of presenting symptoms and differences in mental health care systems and in the frequency of overall mental health treatment seeking behavior around the world. Dell's in-depth 2006 study concluded that given the sociocognitive model claims that the public copies the media's representation of what is more commonly known as multiple personality disorder, and not understanding the "15 subjective dissociative symptoms of DID that are invisible, these criteia cannot be copied by the general public - thereby in his view, destroying all argument that the sociocognitive group has. Reinders et. al. concluded in their 2012 study: "The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e.g., iatrogenic) origin."

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. The ISST-D reports prevalence rates of .01 to 1% in the general population. Studies have indicated a prevalence rate of .5 to 1.0% in psychiatric settings. A 2011 review by V. Sar reported that: "Screening studies using diagnostic tools designed to assess dissociative disorders yielded lifetime prevalence rates around 10% in clinical populations and in the community. Special populations such as psychiatric emergency ward applicants, drug addicts, and women in prostitution demonstrated the highest rates."

Figures from the general population show less diversity:

History

Before the 19th century, people exhibiting symptoms similar to those with DID 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, (30 May 1859 – 24 February 1947) was a pioneering French psychologist, philosopher and psychotherapist in the field of dissociation and traumatic memory. Janet was one of the first people to draw a connection between events in the subject's past life and his or her present day trauma, and coined the words ‘dissociation’ and ‘subconscious’.

Janet developed theories of dissociation which have been revived in the structural dissociation model. It was as far back as 1907 when Janet refereed to a division of the personality or of consciousness by noting that dissociation involved divisions among systems of ideas and function that personality is a structure comprised of various systems. Carl Jung studied with Janet in Paris in 1902, and was much influenced by him, for example equating what he called a complex with Janet's idée fixe subconsciente. Jung's view of the mind as "consisting of an indefinite, because unknown, number of complexes or fragmentary personalities" built upon what Janet in Psychological Automatism called 'simultaneous psychological existences'.

One of the first individuals diagnosed with "multiple personalities" and 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. 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 setting the study of dissociation backward. 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.

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. In 1957, with the publication of the book The Three Faces of Eve and the popular movie which followed it - a reportedly true accountof a woman (Chris Sizmore) who had "multiple personalities", peaks the American public's interest in multiple personality again.

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 what is known today as DID 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 book Sybil was published, and later made into a miniseries in 1976 and again in 2007.

Describing what R. 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. 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" (MPD). 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 MPD to the current DID to emphasize the importance of changes to consciousness and identity and note that no person can have more than one personality. What occurs is dissociated parts of the one personality. The inclusion of interpersonality amnesia helped to distinguish DID from dissociative disorder not otherwise specified. The ICD-10 still classifies DID as a "Dissociative disorder" and retains the name MPD 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".

The DSM-II used the term Hysterical Neurosis, Dissociative Type. The DSM-III grouped the diagnosis with the other four major dissociative disorders using the term MPD. The name was changed to DID in the DSM IV for two reasons.

• First, to emphasize the main problem was not a multitude of personalities, but rather a lack of a single, unified identity.

• Second, a patient with DID switches between identities and behavior patterns is the personality.

It is for this reason the DSM-IV-TR referred to "distinct identities or personality states" and not personalities. The changes also included the addition of amnesia as a symptom, which was not included in the DSM-III-R, because despite being a core symptom of the condition, patients may fail to report amnesic episodes. Amnesia was listed as a criteria when it became clear that the risk of false negative diagnoses was low because amnesia was central to DID.

Society and culture

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

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 defense 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 symptoms used to reach a diagnosis makes it difficult to determine legal measures, however 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

• Posttraumatic stress disorder
• Complex post-traumatic stress disorder
• Defense mechanisms
• Dissociation (psychology)
• Dissociative disorder not otherwise specified
• Dissociative Experiences Scale
• Fugue state
• Identity formation
• International Society for the Study of Trauma and Dissociation
• Psychogenic amnesia
• Trauma model of mental disorders

Footnotes

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External links

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

Template:Link GA

• Dissociative disorders
• Identity disorders
• Psychiatric diagnosis