As individuals, one of the major factors that make us unique and different from each other is our personality. Personality can be described as a pattern of unique characteristics that influence traits like behaviors, thoughts, emotions, and interactions. (Comer, 2015, p. 200) By consistently portraying certain characteristics, like behaviors and emotions, actions become fairly predictable as people obtain an understanding of a person's personality. However, when a person has a dissociative disorder, characteristics and traits are not as easy to predict. Dissociative Identity Disorder (DID) is a type of dissociative disorder where an individual develops multiple personalities. The most common personality that a person with DID portrays is known as the host personality. The other, less commonly portrayed, personalities are known as alternate personalities. These personalities interact with each other in three possible ways. In a mutually amnesic relationship, the subpersonalities are unaware of each other. In contrast, a mutually cognizant relationship is one where each subpersonality is aware of the other personalities. Lastly, in a one-way amnesic relationship, the most common relationship, some personalities are aware of the others while some are not.(Comer, 2015, p. 201) The fascinating aspect about the various personalities a person can display is that each personality is unique. These personalities can differ in behavior, emotion, sexual orientation, and even gender. As the number of people diagnosed with the disorder has increased over the years, numerous symptoms and treatment methods have been discovered. Throughout this research paper, the DSM-V criteria as well as the multiple symptoms and treatment of the disorder will be discussed comprehensively.
DSM-V Criteria
The DSM-V is an important tool when it comes to diagnosing mental disorders. This book can be used as a manual to further understand descriptions, symptoms and various other facts about a particular mental disorder. In the DSM-V, there are five criteria that can be used for the diagnosis of dissociative identity disorder. Criteria one states that DID is a “Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession.” (DSM-V, 2013, p. 292) This criteria refers to the fact that the multiple personalities that a person exhibits are all completely different from each other. Each personality has its own memories and views itself and the world differently. Because of this, people who are aware of their altered personalities lose a sense of self and become depersonalized observers as they switch from the host personality to an altered personality. As people make this switch, they begin to feel a change in their physical structure. (DSM-V, 2013, p. 292) This change can make the body feel different as people may switch to a personality where they are younger, stronger, or even the opposite gender.
Despite how much is known about the disorder, little is known about the causes of DID. Today, experimenters have found a strong correlation between a patient’s history and the development of the disorder. More specifically, traumatic events during a patient’s childhood have been found to be greatly associated with the development of DID. In the United States and Canada, physical and sexual abuse are some of the more common traumas found in the history of patients with DID. For example, in the DSM-V (2013), studies have shown that roughly 90% of patients who were clinically diagnosed with DID in the United States, Canada, and Europe had a history of either physical or sexual abuse. People who have gone through such traumatic events can display symptoms of DID anywhere between early childhood and late adulthood. However, it is more common for symptoms of DID to appear in later life rather than earlier life. Children who do develop DID are at a higher risk of developing problems with memory and concentration. (DSM-V, 2013, p. 294)
The second criteria for DID states that patients struggle with “recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.” (DSM-V, 2013, p. 292) These recurrent gaps are primarily caused by dissociative amnesia. As stated by the DSM-V, dissociative amnesia is displayed in three possible ways. First, the patient has difficulty remembering important life events like getting married or the loss of a loved one. Second, the patient can experience lapses in dependable memory. Such memories can include skills like how to ride a bike, use a computer, or read. Lastly, people with DID can experience time loss as they are completely unaware of certain actions or tasks they have done in the past. People with the disorder only become aware of their time loss by finding evidence of things that they did during the time they cannot recollect. For example, they may find clothing in their closet that they do not remember buying or they may find sticky notes in their handwriting that they do not recall writing. These episodes of loss in memory and time are due to the various alter personalities that someone with DID has. (DSM-V, 2013, p. 294) As mentioned before, each altered personality has its own set of memories, emotions, and behaviors and perceives itself as a unique individual. When a person switches back to their host personality, they are unable to remember what the other personalities have experienced.
Despite these facts, the levels of dissociative amnesia and the attitudes toward it are different for each person. For example, people who are mutually cognizant may notice a loss of memory and time as they are aware of the other personalities. However, people who are mutually amnesic may not be aware of such losses in memory and time as they are unaware of the other personalities. Such people may have others inform them about their amnesia as they are unable to remember things themselves. (DSM-V, 2013, p. 294). As mentioned in the DSM-V, this amnesia cannot be categorized as “ordinary” loss in memory as people may have difficulty recollecting information like their own name, or who their children and close friends are. People who struggle with such severe memory loss are prone to high levels of distress.
As mentioned in the DSM-V, the third criteria states that “symptoms [of DID] cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (DSM-V, 2013, p.292) This criteria refers to the fact that DID is a disorder that will cause some form of anxiety or pain towards the person with the disorder. This criteria is extremely important as it can help reduce the rate of false positive diagnoses to people who claim to have DID but are not going through any kind of distress. Due to the high level of pain or suffering that patients with the disorder go through, there is a significantly high suicide rate among people with DID. It is noted that over 70% of people with DID have attempted suicide at least once in their life. These attempts are frequently accompanied by behaviors of self harm. (DSM-V, 2013, p. 295) The risk of suicide is extremely complicated to understand when working with people who have DID. The reason for this being that one identity may be suicidal while the other identities are not. When therapists attempt to evaluate which identity is suicidal, they attempt to fully comprehend each identities thoughts and emotions in order to single out the suicidal identity. However, this task is extremely difficult as suicidal identities may not display any symptoms. What also makes this task increasingly difficult is the fact that all personalities belong to the same body. Discovering areas of self injury will not be helpful as it will not give an indication of which identity inflicted the pain.
For criterias four and five, the DSM-V excludes symptoms brought up by cultural, religious, or physiological settings as symptoms of DID. Criteria four specifically states that the disturbance caused by DID “is not a normal part of a broadly accepted cultural or religious practice.” (DSM-V, 2013, p. 292) For example, a spiritual leader portraying a religious figure for a cultural ceremony should not be categorized as a form of DID. These practices are culturally accepted as they do not affect the individual and the people around the individual in a negative way. However, people who actually have the disorder go through great levels of distress and can struggle to maintain a proper relationship with friends, family members, coworkers, etc. Despite the fact that such cultural practice cannot be categorized as DID, an individual's cultural background may have a strong influence on whether a person develops the disorder or not. In the past, therapists have encountered patients with DID who have had unexplained symptoms like paralysis and seizures that are common in certain cultural settings. (DSM-V, 2013, p. 295) For example, if a person with DID came from a cultural setting that has experienced some kind of catastrophic event, like war, they may show unique post traumatic symptoms that DID patients from other regions of the world may not show. However, if more people with DID from the same cultural setting were examined, such unique symptoms would not be as uncommon.
Lastly, criteria five simply states that symptoms of DID “are not attributable to the physiological effects of a substance or another medical condition.” (DSM-V, 2013, p. 292) Consuming too much alcohol is a good example to help comprehend this criteria. Having too much to drink and forgetting the events of the previous night does not fall into the second criteria of dissociative amnesia. Also, acting like a completely different person due to the consumption of alcohol does not fall into the first criteria of having multiple personalities. Overall, these symptoms only occur during the consumption of alcohol and do not occur at random as it does for people with DID.
Primary Symptoms
As stated in the previous section, people with DID struggle with memory loss and tend to have a history of traumatic events. However, these are not the only primary symptoms that people with the disorder may experience as perceptual disturbances are extremely common. A common perceptual disturbance that is classified in Schneiderian’s first-rank symptoms (FRS) is pseudo hallucinations. FRS was originally used to diagnose patients with schizophrenia. However, over time, it was eminent that symptoms categorized in FRS were more common in patients with DID. The pseudo hallucinations that people with DID experience tend to be auditory as people may hear voices arguing or making comments on their thoughts. These voices are classified as pseudo hallucinations as they are heard internally in the patient's mind rather than from the external environment. Only about 20% of patients with DID claim to have heard voices outside of their head. These auditory hallucinations may represent the various altered personalities fighting for control of the body. (McDavid, 1994) The auditory hallucinations that people with DID experience should not be confused with that of schizophrenia patients. As mentioned, DID patients tend to hear voices inside their mind while people with schizophrenia are more likely to hear voices from the external environment. When comparing the frequency of auditory hallucinations between the two disorders, a study by Dorahy et. al (2009) found that people with DID were more likely to hear more than two voices before the age of eighteen.
As people with depersonalization/derealization disorder get an “out of body” feeling, it is extremely common for patients with DID to share these symptoms. More specifically, depersonalization is a type of dissociation that causes someone to lose their sense of self. This loss may lead individuals to feel as if they are watching themselves from a distance as symptoms of disconnection or detachment from the body are common. (Simeon, 2004, p. 344) A good way to understand this would be to think about watching movies. When we watch a movie that we can connect to, we tend to perceive ourselves as the protagonist. However, as much as we want the protagonist to do certain things throughout the film, we have no control over what decisions the character will make. As everyone experiences depersonalization at least once in their life, the duration of the symptom varies between individuals without a psychological disorder and individuals with a psychological disorder like DID. For people without a psychological disorder, depersonalization does not last very long and can occur in situations like a time of severe stress or while in a foreign surrounding. (Simeon, 2006, p. 3) Such short lasting experiences of depersonalization have an estimated annual prevalence of 23%. On the other hand, people with psychological disorders, like DID, feel depersonalized for longer periods of time. For DID patients, depersonalization may be used as a defense mechanism to distance themselves from overwhelming circumstances like childhood traumas or war. (Simeon, 2004, p. 344) This depersonalization leads to the production of new identities in order to avoid thoughts of previous events. According to the DSM-V (2013), Individuals with DID often time report feeling like depersonalized observers as they have no control over their own speech and actions. This is due to the host personality not being in control at the time as one of the altered personalities has complete control over functioning of the body.
Treatment and Prognosis Statements
When attempting to treat patients with DID, therapists ultimately try to help patients recognize the nature of their disorder, recover gaps in memory, and fuze the various personalities into one. As it is easy for patients with DID to fall into a hypnotic state, a common treatment method is hypnosis. Therapists use hypnosis to allow the various personalities to come out. As each personality presents itself, therapists try to bond with each personality and attempt to educate each one about their disorder. (Comer, 2015, p. 209) This can be done in various ways with some examples including video footage of actions that other personalities have committed or by bringing in family members and having them inform the patients about previous actions and behaviors. Before the hypnosis procedure can be conducted, the patient's previous experience with hypnosis, the quality of that experience, and the patient's current feelings about hypnosis must all be investigated. According to McDavid (1994) hypnosis is a very safe treatment method. However, if hypnosis is used despite the patient's negative experience with the treatment method, it is possible for the patient to become extremely distraught. If the patient is comfortable undergoing hypnosis, then the treatment method can also be used to recover gaps in memory. More specifically, hypnosis can be used to relieve anxiety to allow the patient to retrieve historical information. Helping patients remember previous significant events, especially traumatic ones, can lead to a faster recovery in memory.
As patients begin to regain memory, they may become distressed causing the present personality to retreat and allow a more calm personality to emerge. In order to successfully integrate personalities and prevent retreating, cognitive behavioral therapy (CBT) can be used. This form of therapy teaches patients various relaxation exercises and ways to gain control over cognitive distortions. (Gillig, 2009) When such exercises are taught, patients are better able to control their emotions and reduce the amount of switching that occurs. This will allow patients to integrate all personalities into one complete personality. Despite such positive effects, therapy must be maintained even after treatment in order to prevent later dissociation. (Comer, 2015, p. 209)