Beginner's Guide to Dissociative Identity Disorder

Formerly known as multiple personality disorder, dissociative identity disorder is seen as the most severe of 3 dissociative disorders recognized by the DSM-5-which involve problems relating to memory, identity, emotion, perception, behavior, and sense of self. Since it was first identified in 1882, to its popularization in the media in the 1970s when the movie Sybil was released, until today, this disorder has baffled many and remains controversial and even an enigma to much of the psychiatric community. So, what is dissociative identity disorder? Where does it come from, and what is available as far as treatment for this disorder today?

What is dissociative Identity disorder?

Dissociative identity disorder, or DID, is a disorder of dissociation which is a coping mechanism the brain employs in severe episodes of trauma, in which the individual may feel detached from reality, present, or even themselves. When this coping mechanism is used often enough, a dissociative disorder may present in one of three ways. These are dissociative amnesia-in which the person affected suffers from chronic loss of memory of events or time frames, depersonalization/ derealization disorder-in which the person struggles with persistent difficulty in separating from themselves and reality, and dissociative identity disorder-which involves a combination of these and, to them, adds the development of numerous personalities. 

Dissociative identity disorder has been diagnosed in approximately 1.5% of the population, but, today, its validity is still debated among the psychiatric community. In fact, this disorder is excluded in numerous accredited psychology program's curriculums. This leaves it an enigma to many, and not all psychologists are prepared to identify or treat it for this reason. 

What's going on in their brains?

Researchers have begun to examine the neurological basis of DID in an effort to provide stronger physical evidence towards its validity, and have found it. When compared to the standard brain's anatomy, patients with dissociative identity disorder show less volume in the hippocampus-which is most highly associated with learning and memory and located in the temporal lobe the amygdala-which is also located in the temporal lobe and is responsible for the 4 f's (feeding, fleeing, fighting, and mating), the structures in the parietal lobe-which are most highly involved in the perception and personal awareness, and the structure of the frontal lobe-which deal with movement, executive functioning (which includes fear learning), and expressive language.

Moreover, these individuals appear to have larger white matter tracts-which communicate information between different parts of the somatosensory cortex. This cortex is responsible for receiving and processing sensory information, and include the basal ganglia, which specializes in motor control, and the precuneus, that assists in many of the brain's functions, including pain response, memory, information's integration relating to environmental perception.

When combined, these neuroanatomical differences lead the individual to the dissociation and neurotic defense mechanisms associated with this disorder.

So, where does this disorder come from?

Similar to C-PTSD, dissociative identity disorder usually originates from prolonged exposure to childhood trauma. Dissociation is a form of escapism often employed by children in traumatic situations and is the base of all the dissociative disorders. Its believed that children rely on dissociation more often than adults because they have little responsibility to keep them attached and little autonomy to change the situation they find themselves in. The prolonged exposure to a traumatic event leaves the child with a severe form of post-traumatic stress, and in this case, a reliance on a coping mechanism to alleviate this stress.

Although it was first diagnosed in 1882, records indicate that before this, DID was mistaken as possession, and appeared far earlier than that. It was believed that the individual was taken over by another person or spirit because someone with DID has an average of 15 personalities or alters that can vary in everything from interests, to accents, to body mass. The first few have usually appeared by 5 years old, making it diagnosable as early as then, later, more are added in response to new stressors the life presents. 

There are four personalities consistently seen in those with dissociative identity disorder. 

The first is the child. This personality type stems from the coping mechanism that is regression. Anna Freud first discovered and defined regression as the tendency for the ego to revert to an earlier stage of development in response to stressful situations, as an attempt to return the individual to a time they felt safer. This personality usually possesses child-like qualities throughout the patient's life, like playfulness and helplessness, and is a young age. 

Along with the child, we often see develop is the protector. This alter typically forms during childhood and in response to the experience that caused it. The protector is a parent-like alter that helps the child to feel safer while experiencing the traumatic event and remains available to them throughout their life. 

Next, there is the persecutor/ punisher. The persecutor/ punisher personality develops in response to the individual's self-conscience shame surrounding the traumatic event. Children often assume that adults are right, so when they abuse that power and them-emotionally, physically, or sexually they feel they deserved to be made felt that way, so the punisher personality develops to continue to punish them. 

Lastly, there's a pattern of one developed later in life This one appears around sexual maturity, so during the teenage years. It's an identity that's formed to handle the added stress that this brings and is its main focus. 

How do they move between personalities?

The transition in between identities for a person with dissociative identity disorder is called switching. A switch can be either consensual, forced, or triggered.  A consensual switch may be planned ahead of time-like a more educated personality taking over when the person has a test scheduled. A forced switch is where a stronger alter might push out in front of a less dominant one for various reasons. Triggered switches are unintentional and generated by triggers which include stress, drug use, strong emotions, sensory information memories, or the change in seasons. These triggers can be positive or negative-like a trip to the zoo bringing forward the child or a PTSD related memory giving control to the protector.

There are two types of switches. The quick switch is more entertaining and often employed in media depictions of this disorder for that reason. This type requires only a moment in between identities and is more rare-most often occurring during triggered switches. Slow switches are typically consensual, often overnight or during hour to several time periods that involve the co-conscious of two or more alters slowly blending and retreating. These can be planned or unexpected, in response to a lengthy state of dissociation and depersonalization in the individual.

For those not very close to the individual, switching is not easily noticed. There are physical signs that a person is switching; however, these are much more subtle in most than the movies make it appear. Physical or outward signs of switching include:

• muscle twitching
• slow and heavy blinking
• clearing the throat
• change in the pitch of their voice
• change in vocabulary
• change in temperament
• different functional abilities or skills
• lack of eye contact
• change in handwriting
• appearing "spaced out" 
• adjusting clothing
• change in posture.

An individual may be able to sense a switch coming on or while its occurring through several inward signs of switching. These include:

• memory loss
• confusion
• auditory or visual disturbances
• feeling "out of body" or in a trance-like state
• flashbacks

How do we treat DID?

Unfortunately, treatment of dissociative identity is believed to have a success rate of approximately 20%, which is less than that of most disorders. 

Psychotherapy is the treatment method used most often to treat this disorder, which is talk therapy that may also include other, more specialized methods. Some examples of these are exposure therapy-which is when the patient is exposed to their trigger in a safe environment, hypnosis-which is a state of consciousness where the individual loses voluntary control over his/ actions, and EMDR-which stands for eye movement desensitization and reprocessing and is a type of therapy that asks the patient to recall the traumatic even while performing a series of eye movements. The goal of each of these is to desensitize the patient to his/her triggers to better prepare them to face these in their natural environment.

Another treatment often used in tandem with therapy is medication. There are no medications specifically for dissociative identity disorder; however, the addition of antianxiety and antidepressant medications have been proven to alleviate some of the everyday hardship and stress it puts on the individual, and anti psychotics can be helpful in preventing dissociation as well.