Dissociative Identity Disorder: Symptoms, Causes, and Treatment

Introduction to Dissociative Identity Disorder

Dissociative Identity Disorder (DID), also referred to as multiple personality disorder, is a condition in which an individual's identity dissociates, or fragments, creating additional identities that exist independently of each other within the same person (Gale 2001). Each personality is distinctly separate from the others in specific ways, such as tone of voice, mannerisms, vocabulary, and posture (Gale 2001). Most people with DID exhibit only one or two personalities; however, there are cases in which an individual will have more than a hundred identities (Gale 2001). Whether one or a hundred, the criteria for diagnosis remain the same (Gale 2001).

Until the publication of the DSM-IV, this disorder was referred to as multiple personality disorder. That name was abandoned for several reasons, one being a concern for psychiatric explicitness — it was thought that the name should reflect the dissociative aspect of the disorder rather than focus on multiplicity of personality alone (Gale 2001).

Persons suffering from DID usually have a primary personality referred to as the host. Although this is generally not the individual's original personality, but rather one developed over time, it is typically this personality that seeks psychiatric help (Gale 2001). The other personalities are referred to as "alters," and the transition phase between alters is called the "switch" (Gale 2001).

Alters vary not only in number but also in gender — men may have female alters, and women may have male alters (Gale 2001). Among the most striking aspects of the disorder are the physical changes that occur during a switch between alters, such as differences in voice and posture (Gale 2001). A 1986 study found that in 37% of patients, "alters even demonstrated different handedness from the host" (Gale 2001). DID sufferers average approximately fifteen identities, and the disorder is nine times more common in females than in males. The usual age of onset is early childhood, generally around four years of age (Gale 2001). If left untreated, the disorder can last a lifetime, as new identities may accumulate over time as the person encounters new situations and circumstances (Gale 2001).

Two well-known cases have drawn wide public attention to DID. A woman with 22 personalities was depicted in the 1957 film and book The Three Faces of Eve. Twenty years later, in 1977, that woman — identified as Caroline Sizemore — described her own experiences in a book titled I'm Eve. Separately, the story of "Sybil" (a pseudonym) was published in 1973, describing a patient with sixteen distinct personalities that emerged over forty years. Both cases offer insight into the unconscious mind, the interrelationship between remembering and forgetting, and the nature of personality development. Scientists monitoring these cases were able to record unique patterns of brainwave activity corresponding to each distinct personality (Gale 2001).

DSM-IV Diagnostic Criteria and Symptom Profile

The DSM-IV lists four criteria for diagnosing Dissociative Identity Disorder. The first is the presence of two or more distinct identities or personality states. Second, at least two of these personalities must regularly take control of the person's behavior. Third, the person must exhibit aspects of amnesia — that is, he or she forgets routine personal information. Fourth, the condition must not have been caused by direct physiological effects, such as drug abuse or head trauma (Gale 2001).

Symptoms of Dissociative Identity Disorder include the following (Psychology 2002):

• Multiple personalities — on average ten, though there can be as few as two and as many as 100
• Distinct personalities exhibiting different behavior and even different physical characteristics
• Episodes of amnesia or time loss (e.g., not remembering people or places)
• Depression or suicidal ideation
• Self-mutilation
• Visual or auditory hallucinations in approximately one-third of patients
• The average age for the development of alters is 5.9 years
• Depressive symptoms
• Inability to focus in school (in childhood)
• Conduct problems (in childhood)

To receive a clinical diagnosis of DID, the following criteria must be identified (Psychology 2002):

• The presence of at least two distinct personalities with their own relatively enduring pattern of sensing, thinking about, and relating to self and environment
• At least two of these personalities assume control of behavior repeatedly
• Extensive inability to recall major personal information that cannot be attributed to ordinary forgetfulness
• The behavior is not caused directly by substance abuse or a general medical condition

A diagnosis is reached through a mental status examination supplemented by questions concerning dissociative symptoms, such as episodes of amnesia, fugue, depersonalization, derealization, identity confusion, identity alteration, age regressions, autohypnotic experiences, and auditory hallucinations (Psychology 2002). Screening tools — including the Dissociative Experience Scale, the Dissociative Questionnaire, and the Questionnaire of Experiences of Dissociation — as well as psychological tests such as the Rorschach and hypnotherapy have all been used to establish a diagnosis (Psychology 2002).

Causes, Comorbidities, and Attachment Theory

People suffering from DID generally have other severe disorders as well, including depression, substance abuse, borderline personality disorder, and eating disorders (Gale 2001). In almost every documented case of DID, there is a history of horrific physical or sexual child abuse — and in some instances, torture (Gale 2001). One study found that 97 out of 100 patients had suffered child abuse (Gale 2001). It is believed that young children, faced with a routine of torture and neglect, create a fantasy world in order to escape the brutality. In this way, DID is considered similar to post-traumatic stress disorder (PTSD). Recent psychiatric thinking suggests the two disorders may be linked, with some researchers beginning to view DID as a severe subtype of PTSD (Gale 2001).

According to a Minnesota study, specific associations were found between early experience and antisocial behavior, anxiety, depression, and dissociative symptomatology (Sroufe 2003). The premise in attachment theory is that "the need for human contact, reassurance, and comforting in the face of illness, injury, and threat is a normal response throughout the life span" (Sroufe 2003). This need is especially prominent early in development, when physical and emotional survival depends on the caregiving relationship (Sroufe 2003). The development of an infant–caregiver attachment is considered an essential adaptation of the human species, grounded in evolutionary history: humans, like other primates, are born vulnerable and remain so for years (Sroufe 2003). The attachment system is believed to have evolved to ensure that infants and caregivers remain in physical proximity, guaranteeing infant protection — thus the caregiver serves as a safe haven (Sroufe 2003). All infants with sufficient access to adults become attached to their caregivers regardless of the quality of treatment, even in the face of maltreatment and severe punishment (Sroufe 2003).

Recent findings indicate a coherent pattern: self-reported anger is higher in insecure females, who are likely to develop a tendency to use dissociation as a coping style (Pini 2003). One study examined the relationships among dissociative experiences, anger proneness, and attachment styles in young adult females (Pini 2003). The results confirm the importance of psychological intervention by educational agencies and mental health services in helping young adults integrate anger experiences into their gendered self-schema, as a means of preventing emotional disturbances (Pini 2003).