case study on dissociative identity disorder

Dissociative Identity Disorder Case Study: A Deep Dive

Have you ever wondered what it's like to live with more than one identity inhabiting your mind? As you explore the intricate case of a 55-year-old woman grappling with Dissociative Identity Disorder (DID), bipolar disorder, and substance use disorder, you'll encounter the complexity of human psychology laid bare.

This case study isn't just a recount of symptoms and treatments; it's a journey into the fragmented reality of an individual whose life is a mosaic of distinct personalities, each with their own history and way of interacting with the world. You'll scrutinize the triggers that provoke shifts between these personalities and the memory gaps that add layers of mystery to an already enigmatic condition.

Your understanding of DID will expand as you're introduced to the challenges faced by both the patient and the therapists committed to her recovery. What awaits is a narrative that blurs the lines between self and other, questioning the very nature of identity.

Key Takeaways

• Dissociative Identity Disorder (DID) involves fragmentation of one's identity into distinct personalities, resulting in disconnection between thoughts, identity, consciousness, and memory.
• DID often coexists with dissociative amnesia, and triggers can lead to switching between personality states.
• Severe trauma, especially during formative years, can contribute to the development of DID, as childhood neglect disrupts the development of a cohesive sense of self.
• Understanding and integrating the various alter personalities is vital for healing and managing triggers in DID treatment.

Understanding DID

To grasp the complexity of Dissociative Identity Disorder (DID), it's essential to recognize that it involves a fragmentation of one's identity into distinct personalities, each with their own perceptions and ways of interacting with the world. These alternate personality states aren't mere moods; they're profound shifts in your sense of self, memories, and consciousness.

The term dissociation refers to the disconnection between thoughts, identity, consciousness, and memory. DID is an extreme form of dissociation, where each personality may have its own name, history, and characteristics. Unsurprisingly, DID often coexists with dissociative amnesia, which means you might be unable to recall personal information, especially that related to traumatic events.

Understanding DID isn't just about the diagnosis; it's about recognizing the triggers that lead to the switching between personality states. You may find that certain situations, people, or feelings prompt the emergence of an alternate personality, particularly if they're associated with past trauma. It's not a choice; it's a coping mechanism that your mind has developed, often in response to severe abuse.

Case Background

Delving into the case background, we encounter a 55-year-old woman whose struggle with DID is compounded by substance use and bipolar disorder. Her fragmented personality showcases multiple exhibited personalities alongside a primary identity that veers between periods of control and overshadowing by alternate personality states. This complexity isn't unique to her, as DID, once known as multiple personality disorder, often manifests with a host of dissociative disorders, each with its own nuances and challenges.

Her violent behavior and the prevalence of suicide attempts in her history mirror the self-injurious patterns commonly seen in DID cases. It's important to note that the exact cause of DID remains elusive, but it's widely suggested that severe trauma, such as physical and sexual abuse, especially when experienced during formative years, can lay the groundwork for the disorder. Childhood neglect, in particular, is a significant factor that can disrupt a child's ability to develop a cohesive sense of self.

Understanding and managing triggers is paramount in her treatment, as they can provoke the emergence of different personality states. Ongoing research is vital in shedding light on these triggers, aiming to provide more effective strategies for those grappling with the complexities of DID.

Personality Manifestations

You'll notice that in DID, individuals exhibit various alter personality traits that are distinct and unique.

It's crucial to understand the triggers that cause identity switching, as these are central to managing the disorder.

Recognizing these cues can help you anticipate and prepare for the changes that come with each switch.

Alter Personality Traits

Individuals with Dissociative Identity Disorder (DID) may exhibit a range of alter personalities, each with distinct characteristics and memories that reflect their unique responses to traumatic experiences. These distinct identities alternately take control, demonstrating how DID fragments consciousness into a single person's multiple selves.

Typically, each alter has its own role, purpose, and view of the world, often starkly different from the others within the same individual. It's like having two or more distinct people sharing one body.

Understanding and integrating these personalities is vital in your journey towards healing. Current research strives to unpack the complexities of these traits, aiming to improve your life and how you cope with the profound challenges DID presents.

Identity Switching Triggers

When discussing traumatic events or facing intense emotions, people with Dissociative Identity Disorder may experience a sudden switch to an alternate identity. These identity switching triggers are deeply rooted in the person's history, often connected to instances of emotional abuse or sexual abuse. It's imperative that you understand the key stress factors that can prompt these switches:

• Confrontations that provoke past traumas
• Sensory stimuli reminiscent of the original trauma
• Unexpected life stressors that overwhelm coping mechanisms
• Internal conflicts among alternate identities
• Therapeutic interventions that probe into traumatic memories

Managing these triggers requires careful navigation, especially with professional guidance. It's crucial for you to work with a therapist to identify and mitigate these triggers, thereby reducing the frequency and intensity of involuntary identity switches in dissociative identity disorder.

Triggers and Memory Gaps

You may find that certain topics or experiences can unexpectedly lead to dissociation if you're living with Dissociative Identity Disorder (DID). It's crucial to identify these triggers and work with a therapist to understand how they contribute to memory lapses.

Learning to manage these episodes can help you gain more control over your life and reduce the disruption caused by unexpected dissociative states.

Identifying Common Triggers

Recognizing the triggers that can precipitate memory gaps and personality switches is a key component in the management of dissociative identity disorder (DID). These triggers are often related to past trauma, which is a core aspect of DID. To enhance your mental health, it's crucial to identify what sets off these episodes.

Here's what you should look out for:

• Stressful events that overwhelm your usual coping mechanisms.
• Reminders of past trauma , such as specific anniversaries, sounds, or places.
• Intense emotional situations that echo previous experiences.
• Substance abuse , which can destabilize mood and cognitive function.
• Encounters that may resemble past situations involving borderline personality disorder or other mental health conditions.

Understanding Memory Lapses

Building on the importance of identifying common triggers, it's equally crucial to understand how these triggers can lead to memory lapses in individuals with dissociative identity disorder. Triggers often activate dissociative states where you might experience significant memory gaps. These aren't just momentary lapses; they can correspond with a switch between different identities, each with a distinct history and sense of self.

As you grapple with dissociative identity disorder, recognizing and managing these triggers becomes a central part of your journey.

For patients with dissociative conditions, including depersonalization-derealization disorder, understanding post-event effects and the necessity to avoid known triggers is key. Active research continues to unearth how these memory lapses occur and how to effectively address them, aiming to improve your quality of life.

Treatment Approaches

Addressing Dissociative Identity Disorder (DID) requires a comprehensive treatment plan that often starts with psychotherapy to integrate the multiple identities. As you navigate this complex condition, which is detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), you'll find that treatment is multifaceted. It's not just about merging identities, but also improving your overall functioning and quality of life.

Here are some key components of treatment approaches for DID:

• Psychotherapy: The cornerstone of DID treatment, facilitating communication and integration of identities.
• Medication: While no drugs specifically treat DID, they can help with co-occurring symptoms like depression or anxiety.
• Support Networks: The role of family and friends in providing emotional support can't be overstated.
• Education: Learning about DID, including triggers and post-traumatic stress disorder (PTSD) symptoms, is vital.
• Coping Strategies: Developing skills to manage daily life and avoid triggers that exacerbate the disorder.

Challenges Faced

Navigating the complexities of DID, you'll encounter significant challenges, such as managing violent behavior and controlling substance use that can complicate treatment. Dissociative Identity Disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, presents a unique set of hurdles that require careful, tailored approaches.

Identifying and avoiding triggers for dissociation isn't straightforward. Each personality may have different triggers, and what soothes one might distress another. Anxiety symptoms can escalate, complicating the overall management of the disorder.

Coordinating care among multiple personalities demands specialized expertise, and without it, treatment can be fragmented and less effective. Furthermore, the stigma and misunderstanding surrounding DID create barriers in both personal relationships and interactions with healthcare professionals.

Balancing the needs and emotions of different personalities can overwhelm you, and without proper support, the risk of suicide attempts increases. It's crucial to address each personality's concerns while maintaining a cohesive treatment plan.

Here's a condensed view of the challenges faced:

Personal Impact

Living with Dissociative Identity Disorder (DID) can profoundly disrupt your sense of self and ability to navigate daily life. Once known as multiple personality disorder, DID isn't a single multidimensional experience; it's a complex condition that affects you in various ways. It's not akin to the temporary effects of a substance; it's an ongoing battle with identity and consciousness.

Here's how DID can personally impact you:

• Your relationships may struggle due to the presence of different identities, causing confusion and strain with loved ones.
• You might experience intense emotional distress, grappling with internal conflicts that can be overwhelming.
• The disorder can affect your work life, making it challenging to maintain consistent employment.
• Stigma and misunderstanding can lead to feelings of isolation, as society often misinterprets the complexities of DID.
• Daily functioning can be unpredictable, as different identities may emerge with distinct memories, behaviors, and needs.

Your personal impact from DID is multi-layered, often requiring professional support to manage. Understanding and acceptance from those around you can make a significant difference in how you cope with the condition.

Therapeutic Outcomes

When considering therapeutic outcomes for Dissociative Identity Disorder, integrating the various identities into a cohesive self is the cornerstone of successful treatment. You'll find that specialized therapies, particularly cognitive behavioral therapy (CBT), are at the forefront of managing this complex mental illness. They've proven effective in not just reducing symptoms but also in enhancing your day-to-day functioning.

Medications play a supportive role; they're not the main act but assist in controlling DID-related depression or anxiety. This medical support, when teamed with therapy, can significantly boost your therapeutic outcomes. Yet, it's the support from your circle—family and friends—that often becomes the unsung hero in your recovery journey. Their understanding and support can make a world of difference.

Your journey through DID treatment hinges on a comprehensive evaluation—understanding your unique symptoms and history is vital. This is where the Diagnostic and Statistical Manual of Mental Disorders (DSM) comes in, providing a framework for better understanding and categorizing your experiences.

Responding to psychotherapy and other treatments is a personal process; what works for one mightn't work for another. But rest assured, the goal is always the same: to help you lead a more integrated, functional life.

Frequently Asked Questions What Is a Famous Case Study of Dissociative Identity Disorder?

You're likely thinking of the case of Shirley Ardell Mason, also known as Sybil, which is a well-known study of Dissociative Identity Disorder that brought widespread attention to the condition.

What Have 95% of Those With Dissociative Identity Disorder Had?

You've faced severe trauma; 95% of those with dissociative identity disorder have suffered significant physical and sexual abuse, highlighting the profound impact such early life experiences have on mental health.

What Youtuber Has 40 Personalities?

You're wondering about a YouTuber with 40 personalities? That's DissociaDID, who shares their life with Dissociative Identity Disorder, aiming to educate and connect with others about mental health.

Are DID Patients Aware of Other Personalities?

You might not always be aware of other personalities if you have DID. Your awareness can vary and may change with therapy, stress, or triggers. It's different for each person.

You've journeyed through the shadowed corridors of a fragmented mind, witnessing the battle scars of a psyche splintered into disparate selves. Your eyes have opened to the complexities of DID, the struggle for unity, and the hope etched into every treatment plan.

Remember, this odyssey isn't just a clinical case; it's a mosaic of human resilience. As you step back into the light, carry the understanding that behind every diagnosis, there beats a heart yearning for wholeness.

Daniel Logan is a renowned author and mental health expert who specializes in psychology and mental health topics. Daniel holds a degree in psychology from the University of California, Los Angeles (UCLA). With years of experience in the field, he has become a trusted voice in the industry, sharing insights and knowledge on a variety of mental health issues.

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• March 15, 2024 | VOL. 77, NO. 1 CURRENT ISSUE pp.1-42

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Three Cases of Dissociative Identity Disorder and Co-Occurring Borderline Personality Disorder Treated with Dynamic Deconstructive Psychotherapy

• Susan M. Chlebowski , M.D. ,
• Robert J. Gregory , M.D.

SUNY Upstate Medical University, Syracuse, NY.

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E-mail Address: [email protected]

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

Introduction

Dissociative Identity Disorder (DID) is a relatively common disorder, especially in clinical populations. Johnson and colleagues found the prevalence to be 1.5% in a population of 658 adults in a community-based longitudinal study ( Johnson, Cohen, Kasen, & Brook, 2006 ). Foote and colleagues (2006) noted the prevalence of DID to be 6% in a study of inner city, psychiatric outpatients. Among adult psychiatric inpatients, estimates of prevalence have varied from 0.9 to 5% ( Gast, Rodewald, Nickel, & Emrich, 2001 ; Rifkin, Ghisalbert, Dimatou, Jin, & Sethi, 1998 ; Ross, 1991 ).

Figure 1. DISSOCIATIVE EXPERIENCES SCALE SCORES OF 3 PATIENTS WITH DISSOCIATIVE IDENTITY DISORDER

The conceptualization and treatment of DID has been rife with controversy, reflecting in part a dearth of empirical research. A PsychINFO search using the terms dissociative identity disorder and clinical trials indicated no published randomized controlled trials. Various treatment models have been applied to clients with DID, including psychodynamic psychotherapy, cognitive behavioral therapy (CBT), hypnosis, group therapy and family therapy. However, there is little empirical support for any model. In 1986, Putnam and colleagues published the results of a questionnaire given to 92 clinicians treating 100 cases of DID. Thirty six percent of the therapists asked to speak with specific alters, 32% awaited for alters to announce themselves, and 20% used hypnosis to elicit alters. Employing a survey of clinicians treating 305 clients with DID, Putnam and Lowenstein (1993) reported that individual therapy with hypnosis was the most common form of treatment. The average client was seen twice a week for an average of 3.8 years.

Many therapists utilize techniques that include speaking directly with the different alters. ( Caul, 1984 ; Congdon, Hain, & Stevenson, 1961 ; Fine, 1991 ; Kluft, 1987 ; Putnam, 1989 ; Ross et al., 1990 ; Ross and Gahan, 1988 ). Other therapists warn against attending to alters ( Gruenewald, 1971 ; Horton & Miller, 1972 ). There is concern that any acknowledgement of alters can result in “mutual shaping” of present or additional personalities. ( Greaves, 1980 ; Spanos, 1985; Sutcliffe & Jones, 1962 ; Taylor and Martin, 1944 ).

Although hypnosis is a commonly used modality, evidence supporting its use is based primarily on case reports and a single case series ( Coons, 1986 ). When using hypnosis, the therapist attempts to uncover and resolve traumatic experiences linked to specific alters. Coons (1986) reported on the outcomes of 20 clients treated with hypnosis and psychodynamic therapy. Based on global impressions by the treating clinicians, 5 of 20 clients with DID were reported to have “complete integration” over a 3-year period of treatment.

Another approach with preliminary empirical support is cognitive analytic therapy (CAT). In CAT practice, descriptions of dysfunctional relationship patterns and of transitions between them are worked out by therapist and client at the start of therapy and are used by both throughout its course ( Ryle & Fawkes, 2007 ). Employing a single-case experimental design, Kellet (2005) utilized the dissociative experiences scale (DES) to measure the effectiveness of CAT during 16 months with one client. The client received the standard CAT design of 24 sessions with four follow-up sessions. The client developed insight, had reduced fragmentation, and improved self-manageability, but did not establish integration.

The model with the largest empirical basis has been Kluft’s (1999) individualized and multi-staged treatment. It involves making contact and agreement among alters to work towards integration, accessing and processing trauma with occasional use of hypnosis, learning new coping skills, and eventually fusion among the alters and the self. Using this model, Kluft (1984) describes treatment of 123 DID clients over a decade of observation. Of the clients, 83 (67%) achieved fusion, including 25 who sustained fusion over at least a 2-year-follow-up period without any residual or recurrent dissociative symptoms. Kluft noted that individuals with borderline personality traits were less likely to achieve stable fusion. A major limitation of his study was the lack of valid outcome measures or formalized assessment of adherence to the treatment protocol.

Dissociative symptoms commonly co-occur with borderline personality disorder (BPD) and the prevalence of DID among outpatients with borderline personality disorder (BPD) was 24% in two separate studies that employed structured diagnostic interviews ( Korzekwa, Dell, Links, Thabane, & Fougere, 2009 ; Sar et al., 2003 ). Two treatment models targeting borderline personality disorder have been shown to be effective for reducing dissociative phenomena in randomized controlled trials. Koons and colleagues (2001) randomized 20 female clients who had BPD to either dialectical behavior therapy (DBT) or to treatment as usual. At 6 months, participants receiving DBT had a greater reduction in DES scores than those receiving usual care. However, in a shorter 12-week randomized controlled trial, 20 participants receiving DBT demonstrated no improvement in DES scores ( Simpson et al., 2004 ).

The other treatment modality shown effective for dissociative phenomena with BPD is dynamic deconstructive psychotherapy (DDP). Gregory and colleagues (2008) randomized 30 participants with borderline personality disorder and co-occurring alcohol use disorders to either DDP or to optimized community care. Over 12 months of treatment, DES scores were significantly reduced among those receiving DDP, but not among those receiving optimized community care.

Although DBT and DDP have shown promise in reducing dissociative symptoms among clients with BPD, it is unclear whether they would be effective in treating DID. To our knowledge there are no reported cases of any treatment modality for DID complicated by co-occurring BPD employing validated, quantifiable outcome measures. The present observational study attempts to fill that gap in the literature by describing three cases of co-occurring DID and BPD treated with 12 months of DDP, using the DES as an outcome measure.

Participants

Participants include three consecutive cases of DID who had been provided treatment with DDP. All of them were young adult women who had been diagnosed with co-occurring BPD. They were administered the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986 ) at baseline, 6 months, and 12 months into treatment with DDP. The DSM-IV diagnoses of DID and BPD were assigned clinically in each case by the treating therapist. Identifying information has been removed or modified within the case reports to protect the privacy of the participants.

Dissociative Experience Scale

The DES is a 28-item self-report measure assessing a wide array of dissociative phenomena, and it has become the most commonly used and extensively researched scale for measuring the severity of dissociation. Internal consistency has ranged from .83 to .93 and test-retest reliability from .79 to .96 for 4-to-8 week periods ( Carlson et al., 1993 ). There are no differences in scores associated with gender, race, religion, education, and income.

Clients rate their endorsement to each item on a continuum from 0% to 100%, and the mean score is calculated across items. The average DES score in clients with DID has ranged from 41 to 58 across studies, as compared to a median score of 11 for adults without mental disorders ( Bernstein & Putnam, 1986 ; Ross et al., 1990 ). Steinberg, Rounsaville, and Cicchetti ( 1991 ), comparing the DES to diagnosis from structured interviews, found a cutoff score of 15 to 20 yielded good sensitivity and specificity for DID, whereas Ross, Joshi, and Currie (1991) used a cutoff score of 30 in their epidemiological study.

Treatment Intervention

Dynamic Deconstructive Psychotherapy structure is manual based and time limited, involving weekly individual therapy sessions over 12 to 18 months. In a 12-month randomized controlled trial with 30-month follow up, DDP significantly improved interpersonal functioning and reduced self-harm, suicide attempts, alcohol and drug misuse, depression, and dissociation among clients with co-occurring BPD and alcohol use disorders ( Gregory et al., 2008 ; Gregory, Delucia-Deranja, & Mogle, 2010 ). Adherence to DDP techniques correlate strongly with positive outcomes ( r = .64), supporting the effectiveness and specificity of DDP interventions ( Goldman & Gregory, 2009 ).

Dynamic Deconstructive Psychotherapy theory combines the translational neuroscience of emotion processing with object relations theory and deconstruction philosophy ( Gregory & Remen, 2008 ). Through therapy, the individual attempts to remediate the connection between self and one’s experiences and to deconstruct attributions that interfere with authentic and fulfilling relationships.

The practice of DDP targets three purported neurocognitive functions: association , attribution , and alterity. Association is the ability to verbalize coherent narratives of interpersonal episodes, including identification and acknowledgement of specific emotions within each episode. Association techniques involve facilitating discussion of a recent interpersonal episode, helping the client to form a complete narrative sequence and to identify and label specific emotions within the episode.

Attribution is the ability to form complex and integrated attributions of self and others. Attributions of clients with BPD are often distorted and polarized, described in black and white terms ( Gregory, 2007 ). Attribution techniques involve deconstructing distorted, polarized attributions by exploring alternative meanings and motives within narratives.

Alterity is the ability to form realistic and differentiated attributions of self and others. Included within this function are self-awareness, empathic capacity, mentalization, individuation, and self-other differentiation. Alterity techniques are experiential within the client-therapist relationship; they attempt to disrupt the client’s stereotyped expectations by providing acceptance or challenge at key times.

Within the DDP model, DID is conceived primarily as an adaptation to severe trauma and as an end point along a continuum with other dissociative phenomena. Dissociation provides a mechanism for diminishing the emotional impact of trauma by splitting off awareness of feelings, perceptions, and memories from consciousness. However, once dissociation becomes established as a coping mechanism, even minor stresses can trigger it.

Given that clients with DID are often highly hypnotizable and may, therefore, be very suggestible ( Braun, 1984 ), the concern within DDP theory is that alters may become reified as they are individually named and characterized. A DDP therapist explicitly refrains from hypnosis and refrains from exploring the various alters or calling them by name; but insists on addressing the client by his/her legal name. These aspects of DDP differ from expert consensus treatment guidelines of DID, which emphasize negotiation and cooperation between alters, including the occasional use of hypnosis for calming and exploration ( International Society for the Study of Trauma and Dissociation, 2011 ). Also unlike the consensus guidelines, DDP explicitly avoids work on early trauma until later stages of therapy given the difficulty clients with BPD have in adaptively processing intense emotional experiences ( Ebner-Priemer et al., 2008 ) and instead emphasizes narration of recent interpersonal encounters.

The DDP therapist reframes alters as “different parts of you that need to be integrated” while not favoring one aspect of the self over another. This aspect of DDP is largely consistent with the expert consensus DID guidelines emphasizing awareness and resolution of conflict between competing identities, rather than suppressing or ignoring them ( International Society for the Study of Trauma and Dissociation, 2011 ). DDP theory and technique are summarized by Gregory and Remen (2008) and within the training manual (at http://www.upstate.edu/ddp ).

For the present study, the therapists included the founder of DDP (RG; cases 2 and 3) and a senior psychiatry resident (SC; case 1). Training for the senior resident involved several didactic sessions in DDP, reading the training manual, and ongoing weekly case supervision by the founder to ensure treatment fidelity.

Ms. A. was a 33-year-old Caucasian female with a history of chronic major depression, severe dissociation, and narcissistic and borderline personality disorders. She started DDP with a psychiatric resident trainee after several years of recurrent psychiatric admissions for depression, suicidal attempts, and self-mutilation. She would whip herself with chains and used torture devices with religious/medieval themes. She had twice required cardiac resuscitation after overdoses.

Ms. A. also described multiple dissociative symptoms that occurred on a frequent basis. These included flashbacks of traumatic experiences, psychogenic amnesia of important events, derealization, depersonalization, and lapses in time. In addition, the patient described having three separate alters, each having a different name, age, and characteristics. On admission her DES score was 57.

Ms. A. stated her childhood was saddened by her father leaving home when she was about 3 years old; she spent most of her childhood awaiting his return. She vividly recalls feeling alone and spending hours in a rocking in a chair staring at a wall.

Her mother remarried a man who sexually abused Ms. A.’s younger brother and older sister and physically abused Ms. A. When the children revealed the abuse to their mother, she sought counseling at their church, which recommended therapy and that he remain in the home. Ms. A. felt betrayed by her mother for allowing the terror in the home to continue. Ms. A. could not recall feeling loved by her mother, who was a nurse and busy portraying herself a caring individual for others.

Ms. A. did well in school despite having chronic dissociative symptoms, she described as “spacing out” and feeling detached from the world. She enjoyed writing, and she pursued her interest in literature.

Ms. A. became pregnant during her senior year of high school, married, and had a second child. She had difficulties recalling most of her married life, but remembered her husband as being demanding and unloving. Eventually, her husband left her for her best friend.

Initially Ms. A. took on raising the two children on her own, but she was unable to work or even to talk on the telephone due to anxiety. Because of her prolonged periods of dissociation, she was unable to provide adequate and safe care for her children; Child Protective Services eventually removed them from her custody. They went to live with their father in another state. Ms. A. lost contact with her children because they refused to communicate with her.

Ms. A. engaged well in treatment with DDP, attending weekly sessions and developing a therapeutic alliance over the first few months. Much of her early treatment focused on her relationship with her mother, with whom she was living. The predominant theme was, “Do I have a right to be angry?”

She was angry at her mother for her behaviors and attitudes; her mother sympathized with Ms. A.’s ex-husband, insisted that Ms. A. use bed sheets and clothing stained with blood from Ms. A.’s prior cutting episodes, and discouraged her from attending psychotherapy.

At 6 months of therapy, Ms. A. had developed a strongly positive and somewhat dependent transference with the therapist, and she was much better at identifying and articulating feelings of anger, guilt, and shame. She also felt much less need to punish herself, and self-mutilating episodes became less frequent and less severe. Her DES score had decreased from 57 at baseline to 29 at 6 months. However, during therapist vacations, feelings of abandonment would surface in Ms. A., and these sometimes resulted in an exacerbation of self-mutilation and/or severe depression needing hospitalization.

During the final 6 months of therapy, Ms. A. focused a great deal on the preset planned termination of treatment. Vacations and the pending termination were reminders of the limitations of the therapist as an all-caring idealized object. On the one hand, Ms. A. felt as if she had a more integrated self, and she was beginning to expand her functional capacity through the formation of friendships and returning to school part-time. On the other hand, she felt abandoned by the therapist, and this was accompanied with exacerbations of depression, as Ms. A. redirected the anger towards her therapist onto herself. Ms. A. expressed worries about the future and she devalued treatment and the therapist’s role. The therapist struggled to remain empathic with Ms. A.’s worries (without giving false reassurance) and to tolerate the devaluation without becoming defensive.

By the end of treatment, Ms. A. appeared to have a more balanced view of her treatment and of herself. She could express anger with less internal hatred. Depression and suicide ideation markedly improved and 12-month DES score was 12. At termination, she gave the therapist a drawing of a Celtic knot to symbolize the integration of her disconnected self. She was transferred to the care of another therapist; the exact nature of her treatment and course is unknown. However, a chance encounter with the DDP therapist 5 years later revealed that Ms. A. was generally doing well and participating in part-time college coursework.

Ms. B. was a married Caucasian female in her 30s with a long history of severe psychopathology. She delineated five alters, each with a separate name, gender, and age. She was unable to control unexpectedly switching between alters. Ms. B. also described frequent disruptive and embarrassing time lapses. On two occasions, these lapses occurred while she was in the changing room of a Department store: she would become aware of her surroundings after the store had closed and locked its doors.

In addition to dissociative symptoms, the client met criteria for multiple Axis I and II disorders, including BPD, Bipolar I, alcohol and drug dependence, post traumatic stress disorder, obsessive compulsive disorder, and anorexia nervosa, bingeing/purging type. She had a history of six psychiatric hospitalizations beginning in her early twenties; she was treated for suicide attempts, manic episodes, and/or psychosis.

Over the course of her illness, Ms. B. had tried multiple classes of psychotropic medications none successes in treatment, but she has some improvement with mood stabilizers and antipsychotic medications. She had been treated for 5 years in twice-weekly supportive psychotherapy, which had involved a progressively pathological and regressive client-therapist relationship, including cuddling and playing with blocks on the floor. As the client regressed, she also became intrusively demanding of her therapist’s time, which eventually led to the therapist terminating treatment and subsequent deterioration in the client’s condition.

Ms. B. began to see demons in her house, and develop paranoid delusions necessitating psychiatric hospitalization. Following hospitalization, the client was referred for a trial of DDP. At that time, her DES score was 62. Initial sessions focused on establishing clear parameters of treatment, boundary limitations within the client-therapist relationship, and psycho-education regarding the importance of avoiding boundary violations. The client repeatedly brought up interactions with her prior therapist, including her feeling abandoned by the therapist. She was able to work through conflicts regarding agency, i.e. if she or her therapist was to blame for various incidents. As the client gradually worked through her issues she had with her prior therapist, the focus shifted to her marital relationship. Her husband was extremely physically and emotionally abusive. He had prostituted her to his friends and acquaintances. Episodes of physical abuse would be followed by increased psychiatric symptoms, including dissociation. The DDP therapist helped the client identify, label, and acknowledge her emotions in interactions with her husband, and to work through her conflict of agency in that relationship, i.e. whether or not she provoked him to attack her. As Ms. B. worked this through, she decided to terminate the relationship with her husband. She temporarily lived with her parents and eventually lived independently. There was a mourning process involving de-idealization of her husband and of her parents, who pressured her to return to her husband.

Her symptoms of Axis I disorders steadily improved during the course of treatment, despite diminishing dosages of antipsychotic and mood stabilizer medications. Her symptoms of dissociation also improved and her DES score decreased to 45 by 6 months of treatment and to 35 by 12 months. Ms. B. described time lapses as less frequent and of shorter duration, and she began to sense an increased ability to control them. Shifts in personality style became less frequent and pronounced, and Ms. B. no longer described herself as having independent personalities, but rather described “parts of herself” that emerged at different times. She also described herself as “waking up” and feeling “more whole.”

As termination approached, the last phase of weekly treatment was difficult and involved working through feelings of abandonment. After 18 months of weekly sessions, monthly maintenance treatment, which was primarily supportive in nature, was initiated. Despite discontinuing all medications against advice 6 months after termination of weekly DDP, Ms. B. displayed gradual improvement in symptoms at 8-year post-treatment, however, she continued monthly supportive psychotherapy sessions.

During the follow-up period, Ms. B. decided to pursue a professional degree while on social security disability, which supported her efforts through Vocational and Educational Services for Individuals with Disabilities. She successfully completed her courses, came off disability, and has worked full time for the last 3 years of her follow-up period in a responsible professional position.

Ms. C. was a divorced African American woman in her 30s, having a history of alcohol and cocaine dependence. She had moved to the area to “get clean” and leave negative influences. She heard about the study for co-occurring BPD and alcohol use disorders ( Gregory et al., 2008 ), and subsequently enrolled and was randomized to DDP.

Ms. C. described lifelong difficulties with sudden shifts in mood and personality combined with impulsive behaviors, including misuse of alcohol, cocaine, and cannabis. Significant dissociative symptoms included frequent episodes of derealization, feelings of spaciness, fugue episodes, and three distinct personalities, each with a specific name. One of her alters was called “Sunlight.” Sunlight had been the primary alter in Ms. C.’s life for the past few years. Sunlight enjoyed dominating and manipulating men as a drug dealer and prostitute. Unlike Ms. C., Sunlight felt no emotional pain and saw no need for treatment.

Ms. C. was diagnosed with cocaine, alcohol and cannabis dependence, DID, and BPD at evaluation. An 18-month course of DDP therapy was planned. Her initial DES score was 41. Throughout treatment, the therapist addressed the client by her legal name, and reframed the different personalities as different being parts of Ms. C. that were poorly integrated. The focus in early treatment was an exploration of a series of tumultuous relationships with boyfriends. These men had histories of imprisonment and tended to be manipulative or threatening. Her relational pattern was initially to idealize the men. This was followed by disappointment, anger, and fear. She would then engage in manipulating or controlling them. In therapy, the client was able to identify, label, and acknowledge conflicting feelings towards them and to describe a core conflict between her desire to be taken care of by a strong man versus her desire to be independent and in control.

By 6 months in treatment, dissociative episodes were much improved; DES score was 34. Ms. C. was maintaining abstinence and she was able to avoid harmful relationships with men. She began to develop female friendships for the first time in her life and to pursue educational courses leading up to a professional degree.

By 9 months, Ms. C. began to take responsibility for her life but was felt overwhelmed by responsibilities. She became less committed to treatment and recovery, and she began to have increased cravings for substances along with drug dreams. She would speak glowingly about times in the past when she felt in control and without emotional pain in the role of Sunlight. Much of the remaining 6 months of treatment involved bringing Ms. C.’s ambivalence about recovery to consciousness and helping her to mourn the loss of grandiose fantasies. Ms. C. also had to mourn the loss of the therapy relationship. She left treatment 3 months before the scheduled termination so that she “wouldn’t have to say goodbye.” As part of the BPD and alcohol use disorder study, Ms. C. met with the research assistant for follow-up 30 months after enrollment ( Gregory et al., 2010 ). She remained abstinent during the follow-up period despite lack of further treatment, finished her course work for a professional degree, and had been working fulltime during the last 12 months of the follow-up period.

The three cases of DID with co-occurring BPD appeared to respond well to time-limited treatment with DDP. Average DES scores decreased from 53 to 25 over 12 months, indicating an average reduction of 54%. Long-term follow-up for Cases 2 and 3 indicated further improvement in symptoms and function occurred after termination of weekly DDP treatment. These findings are consistent with a randomized controlled trial of DDP for disorders that demonstrated significant improvement in DES scores over time (individuals with BPD and alcohol use Gregory et al., 2008 ).

A theoretical principal of DDP is that individuals with BPD have deficits in association, which involves a dis -association between emotional experience and verbal symbolic capacity ( Gregory & Remen, 2008 ). Individuals are often unable to verbally describe, label, and sequence specific emotional experiences. Association deficits are manifested by incoherent narratives of emotionally charged interpersonal episodes and there is difficulty identifying and appropriately expressing emotions within such episodes.

Dissociation has been linked in prior studies to aberrant processing of emotional experiences. Deficits in the ability to identify and express emotions (as assessed by the Toronto Alexithymia Scale [TAS]), have been noted in traumatized populations, and have been linked to dissociative symptoms, as measured by the DES ( Frewen, Pain, Dozois, & Lanius, 2006 ; McLean, Toner, Jackson, Desrocher, & Stuckless, 2006 ). Clients with DID have been noted to have a slowed response time to negative emotions on the Flanker test ( Dorahy, Middleton, & Irwin, 2005 ). In large, population-based studies ( Elzinga, Bermond, & van Dyck, 2002 ; Maaranen et al., 2005 ; Sayar, Kose, Grabe, & Topbas, 2005), the TAS and DES scores have been correlated with one another even when dissociative symptoms are severe enough to be pathological ( Grabe, Rainermann, Spitzer, Gansicke, & Freyberger, 2000 ; Maaranen et al., 2005 ).

Dynamic Deconstructive Psychotherapy specifically targets association deficits by helping clients to develop coherent narratives of recent interpersonal episodes and to identify, label, and acknowledge emotions within such episodes. Given that deficits in emotion processing have been linked to dissociative symptoms, targeting these deficits should theoretically be helpful for dissociation. This hypothesis was supported by recent research demonstrating a strong and statistically significant correlation (r = .79) between the use of association techniques, as assessed by independent raters, and improvement in DES scores ( Goldman & Gregory, 2010 ). It is, therefore, likely that the use of association techniques was a critical component of treatment response among the reported three cases of DID.

Since DBT also targets association deficits through helping clients to identify emotions associated with maladaptive behaviors, it is perhaps not surprising that this modality has been shown to be helpful in reducing dissociative symptoms ( Koons et al., 2001 ). Whether DBT can be helpful for DID per se, remains to be seen.

Limitations of the present case series include the observational nature of the study, exclusive reliance on clinical diagnoses, and restriction of the study sample to clients with co-occurring BPD. It is unclear whether DDP would be effective for DID clients who are free from this severe personality pathology. The small number of cases also limits the ability to generalize findings. Large controlled trials are needed to better evaluate the efficacy of DDP and other treatment modalities for individuals who suffer from DID.

Conclusions

Dissociative Identity Disorder is a common and under-researched disorder. Borderline Personality Disorders frequently co-occurs with DID and has been noted to worsen its course. DDP is a treatment modality previously found effective for dissociative symptoms of BPD. The active component of DDP for dissociative symptoms may be the use of association techniques, whereby verbal symbolic capacity is linked to emotional experiences within narratives. The three cases presented in this report suggest that DDP can be an effective treatment for clients suffering from DID complicated by co-occurring BPD.

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• A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults 26 December 2023 | Journal of Trauma & Dissociation, Vol. 25, No. 2
• Dissociative Identity Disorder Journal of Nervous & Mental Disease, Vol. 212, No. 3
• An In-Depth Comparative Analysis of Psychotherapy and Pharmacotherapy for Dissociative Identity Disorder 26 November 2023 | Journal of Education, Humanities and Social Sciences, Vol. 22
• Complex trauma, dissociation and Borderline Personality Disorder: Working with integration failures European Journal of Trauma & Dissociation, Vol. 1, No. 1
• Robert J. Gregory , M.D. ,
• Shilpa Sachdeva , M.D.
• Frontiers in Psychiatry, Vol. 7
• Journal of Trauma & Dissociation, Vol. 15, No. 1
• From the Neuropsychiatric to the Analytic Harvard Review of Psychiatry, Vol. 21, No. 1

• Dissociative Identity Disorder
• Borderline Personality Disorder
• psychodynamic psychotherapy
• hypnotherapy
• dissociation
• dissociative disorders
• psychotherapy
• individual psychotherapy
• analytical psychotherapy

Dissociative Identity Disorder Cases: Famous and Amazing

There are many famous dissociative identity disorder (DID) cases, probably because people are so fascinated by the disorder. While DID is rare, detailed reports of DID have existed since the 18th century. Famous cases of dissociative identity disorder have been featured on the Oprah Winfrey show, in books and have been seen in criminal trials. (See Real Dissociative Identity Disorder Stories and Videos and Celebrities and Famous People with DID )

A Dissociative Identity Disorder Case in Court: Billy Milligan

In 1977, Billy Milligan was arrested for kidnapping, robbing and raping three women around Ohio State University. After being arrested, he saw a psychiatrist who diagnosed him with DID (See how DID is diagnosed ). It was argued in court that Milligan wasn't guilty as, at the time of the crimes, two other personalities were in control -- Ragen, a Yugoslavian man and Adalana, a lesbian ( Understanding Dissociative Identity Disorder Alters ).

The jury agreed with the defense and Milligan became the first person ever to be found not guilty due to dissociative identity disorder . Milligan was confined to a mental hospital until 1988 when psychiatrists felt that all the personalities had melded together.

An upcoming film, The Crowded Room , will be based on his famous case of dissociative identity disorder.

Famous Cases of DID: Kim Noble

Kim Noble was born in 1960 and, from a young age, was physically abused. As a teenager, she suffered many mental problems and overdosed several times.

It wasn't until her 20s that other personalities began to appear. "Julie" was a very destructive personality that ran Noble's van into a bunch of parked cars. "Hayley," another personality, was involved in a pedophile ring.

In 1995, Noble received a DID diagnosis and has been getting psychiatric help ever since. It's not known how many personalities Noble has as she goes through four or five personalities a day, but it is thought to be around 100. "Patricia" is Noble's most dominant personality and she is a calm and confident woman.

Noble (as Patricia) and her daughter appeared on The Oprah Winfrey Show in 2010. In 2012, she published a book about her experiences: All of Me: How I Learned to Live with the Many Personalities Sharing My Body.

A Dissociative Disorder Case Study

In 2005, a dissociative identity disorder case study of a woman named "Kathy" (not her real name) was published in Journal of the Islamic Medical Association of North America.

Kathy's traumas began when she was three. At that age, she would have terrible nightmares during which her parents would often entertain leaving the child to cry for hours before falling asleep only to awake a few hours later frightened and screaming.

At age four, Kathy found her father in bed with a five-year-old neighbor. At that time, her father convinced her to join in on the sexual activity. Kathy felt guilty and cried for several hours only stopping once she began to attribute what had happened to an alternate personality, Pat. Kathy would insist on being called Pat during the abuse the father committed for the next five years.

At age nine, Kathy's mother discovered Kathy and her father in bed together. Her mother insisted on the child sleeping in her bed every night thereafter leading to a sexual relationship with the child. Kathy could not accept this and created another identity, Vera, who continued the relationship for another five years.

At age 14, Kathy was raped by her father's best friend and began calling herself Debbie. At that time, she became very depressed and mute and was admitted to a hospital (read why some go to dissociative identity (DID) treatment centers ).

According to the case study, "she showed a mixture of depression, dissociation and trance-like symptoms, with irritability and extensive manipulation which caused confusion and frustration among the hospital staff."

At age 18, Kathy became very attached to her boyfriend but her parents forbid her to see him. Kathy then ran away from home to a new town. However, she could not find a job and her need of money drove her to prostitution. She began to call herself Nancy at this point.

The alternate personality Debbie rejected Nancy and forced her to overdose on sleeping pills. It was then that Kathy was admitted to a psychiatric hospital and given the diagnosis of multiple personality disorder (as it was known at the time). (More on the history of dissociative identity disorder here.)

Kathy is now 29, married, and continues to struggle with mental health problems including dissociative episodes.

article references

APA Reference Tracy, N. (2022, January 4). Dissociative Identity Disorder Cases: Famous and Amazing, HealthyPlace. Retrieved on 2024, April 26 from https://www.healthyplace.com/abuse/dissociative-identity-disorder/dissociative-identity-disorder-cases-famous-and-amazing

Medically reviewed by Harry Croft, MD

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The Misunderstood: A Discussion on Dissociative Identity Disorder & Multiple Personality Disorder

• Isabel Sommer University of Cincinnati

In this presentation, I explore the misunderstood life of people with Dissociative Identity Disorder and Multiple Personality Disorder through a presentation and discussion of what reality is for these people. Multiple Personality Disorder and Dissociative Identity Disorder are widely misunderstood, making life for those diagnosed with these particularly harder. The media tends to depict these people as incapable of function or dangerous, which majority of the time is not the case. Because of the stigmas surrounding mental health, I will shed light on what life is like for those people who live with these disorders.

Some major points of my research include that the stigma of Dissociative Identity Disorder (and Multiple Personality Disorder) is generally formed by the public media's interpretation and dramatizing of the disorders. These media tend to frame the people diagnosed with these disorders as incapable of daily function or dangerous. People diagnosed may find complications with job and career placement, housing, and other stabilizing factors for the general person.

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Dissociative identity disorder.

Paroma Mitra ; Ankit Jain .

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Last Update: May 16, 2023 .

• Continuing Education Activity

Dissociative identity disorder (DID) is a rare psychiatric disorder diagnosed in about 1.5% of the global population. This disorder is often misdiagnosed and often requires multiple assessments for an accurate diagnosis. Patients often present with self-injurious behavior and suicide attempts. This activity reviews the evaluation and treatment of dissociative identity disorder and explains the role of an interprofessional team in caring for patients diagnosed with dissociative identity disorder (DID). This activity also reviews the association between DID and suicidal behavior.

• Describe the constellation of behavioral symptoms that lead to a diagnosis of dissociative identity disorder.
• Review risk factors for the development of a diagnosis of dissociative identity disorder.
• Explain the different modalities of evidence-based treatment for dissociative identity disorder.
• Outline some interprofessional strategies that can improve patient outcomes in patients with dissociative identity disorder.
• Introduction

Dissociative identity disorder (DID) is a rare disorder associated with severe behavioral health symptoms. DID was previously known as Multiple Personality Disorder until 1994. Approximately 1.5% of the population internationally has been diagnosed with dissociative identity disorder. [1] Patients with this diagnosis often have several emergency presentations, often with self-injurious behavior and even substance use. [2]

Of note, DID has been observed and described in several countries and associated with terms such as "outer world possession" and "possession by demons." [3]  Several case reports have been described with those terms; however, trauma and its association came with DID much later.

Dissociative identity disorder is typically associated with severe childhood trauma and abuse. [4] Dalenberg and his team have detailed the role of trauma in the development of dissociative disorder and dismissed the previous model, which was based on fantasy and often associated with suggestibility, cognitive distortions, and fantasy. However, newer research tends to describe a combination of both severe traumas (which may be in any form physical/emotional/sexual)as well as some effects of cognitive suggestion. Stress experienced by an individual secondary to trauma has been seen to contribute to the formation of an accurate understanding of the trauma being unreal, even posttraumatic dissociation such as leaving one's body, etc., and poor sleep. However, in the fantasy theory-it has been seen that people with high levels of vulnerability, predisposition of psychological symptoms, media influences, and likely social isolation and vulnerability. [5]

Several prominent psychologists, such as Kluft, have broken down the theory behind DID-in-sum. The theory describes predisposing factors for dissociation, which include an ability to dissociate, overwhelming traumatic experiences that distort reality, creation of alters with specific names and identities, and lack of external stability, which leads to the child's self-soothing to tolerate these stressors. These four factors must be present for DID to develop. [6]

• Epidemiology

Dissociative disorders show a prevalence of 1% to 5% in the international population. Severe dissociative identity disorder is present in 1% to 1.5% of this population. Patients may spend up to 5 to 12.5 years in treatment before being diagnosed with dissociative identity disorder. [7] Patients with DID come with increased rates of non-suicidal self-injurious behavior and suicide attempts. [8]

• Pathophysiology

The DID person, per the International Society for the Study of Trauma and Dissociation,  is described as a person who experiences separate identities that function independently and are autonomous of each other. The International Society describes alternate identities or "alters" as independent identities with distinct behaviors and memories distinct from others and may even differ in language and expressions used. Signs of a switch to an altered state include trance-like behavior, eye blinking, eye-rolling, and changes in posture. 

The major hypothesis by Putnam et al. is that "alternate identities result from the inability of many traumatized children to develop a unified sense of self that is maintained across various behavioral states, particularly if the traumatic exposure first occurs before the age of 5."  [9]  The theories have been studied by groups in the inpatient unit services in the 1990s.

• History and Physical

The way to diagnose dissociative identity disorder is via detailed history taken by both psychiatric practitioners and experienced psychologists. Often, persons with DID are misdiagnosed with other personality disorders, most commonly borderline personality disorder, as elements of dissociation are prominently seen and even amnesia. Longitudinal assessments over long periods and careful history-taking are often required to complete diagnostic evaluations. History is often gathered from multiple sources as well. Neurological examinations are often required to rule out autoimmune encephalitis, often requiring electroencephalograms, lumbar punctures, and brain imaging.

Dissociative Disorders are classically characterized as disrupting normal consciousness/memory/identity and behavior. The disorders are classically broken down into "positive " and "negative " symptoms -positive symptoms are often associated with "new personalities, derealization," and negative symptoms are symptoms such as autism and paralysis. [10] Dissociative identity disorder is part of the larger dissociative disorders spectrum; however, it has more specific criteria outlined by the Diagnostic And Statistical Manual Edition-5.

The Diagnostic and Statistical Manual (DSM-5)criteria for DID include at least two or more distinct personalities. Each personality varies in behavior, sense of consciousness, memory, and perception of the outside world. Persons with DID experience amnesia, distinct gaps in memory, and recollections of daily and traumatic events. They cannot be directly related to substance use or part of cultural norms or practices. Importantly, these symptoms must cause a notable lack of daily functioning. [11] [10]

As explained above, a detailed history from multiple sources and multiple longitudinal assessments over time is of the essence. However, some evaluation tools have been developed to diagnose DID. Some of these are below:

• Dissociative Experiences Scale - a 28-item self-report instrument whose items primarily tap the absorption of outside information, use of imagination depersonalization, derealization, and amnesia. [12]
• Dissociation Questionnaire - 63 questions that measure identity confusion and fragmentation, loss of control, amnesia, and absorption.
• Difficulties in Emotion Regulation Scale (DERS) - 36-question subjective questions around challenges in goal-directed work, impulsivity, emotional responses to situations, ability to self-regulate emotions, etc. [13]
• Treatment / Management

Some treatment approaches for dissociative identity disorder include basic structures from work with personality disorders in a three-pronged approach:

• Establishing safety, stabilization, and symptom reduction;
• Confronting, working through, and integrating traumatic memories
• Identity integration and rehabilitation. [14]

The first step focuses on the safety of patients with DID, as many present with suicidal ideation and self-injurious behavior. [8]  It is important to mitigate that risk. The second phase focuses on working with traumatic memories and includes tolerating, processing, and integrating past trauma. This may focus on continuing to re-access traumatic memories with different alternate identities and may help share memories. The third and final treatment phase focuses on the patient’s relationship to self as a whole and to the rest of the world. Through all the phases of treatment, a strong therapeutic alliance and trust are encouraged

The most common approach is via psychodynamic psychotherapy steps, broken down above. Recent approaches include trauma-focused cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). [15]  There are no controlled clinical trials for CBT. The reason DBT skills are used is essentially secondary to some of the overlapping symptoms between borderline personality disorder and DID. Even with varying therapy approaches, some core treatment features include more education, emotional regulation, managing stressors, and daily functioning.

Another mode of treatment is the use of hypnosis as therapy. According to the literature, DID patients are more hypnotizable than other clinical populations. [16]  There have been some studies as recent as 2009 that have shown efficacy in the use of hypnosis to treat DID. [17]  Many DID patients are considered autohypnotic. Some techniques include accessing alternate identities not present in the session, an intervention that can facilitate the emergence of identities critical to the therapeutic process. [6]

Another mode of treatment has been the use of Eye Movement Desensitization and Reprocessing ( EMDR ). The guidelines, however, advocate for EMDR to be used as part of integrative treatment. EMDR processing is recommended only when the patient is generally stable and has adequate coping skills.EMDR interventions for symptom reduction and containment, ego strengthening, work with alternate identities, and, when appropriate, the negotiation of consent and preparation of alternate identities. [18]

Psychopharmacology is not the primary treatment for DID. Medications may be used to target certain symptoms reported. The most commonly used medications include medications for mood disorders and PTSD (post-traumatic stress disorder). [19]  The challenges of using psychopharmacological medications remain as different alters may report different symptoms. Some alters may report compliance, and some may not. The literature review has shown that many medications have been used for DID, including antipsychotic medications, mood stabilizers, and even stimulants; however, no medication has been effective in the treatment of DID. [20]

• Differential Diagnosis

As mentioned above, the most common differential diagnosis includes borderline personality disorder, histrionic personality disorder, and even primary psychotic disorders such as schizophrenia and schizoaffective disorders. As mentioned, patients with DID often present with symptoms of dissociation and amnesia, which are also seen in patients with borderline personality disorder. Often, patients' symptoms are considered symptoms of psychosis as alters as mistaken as hallucinations, which often precipitate the use of antipsychotic medications. Given that trauma is a focus, post traumatic stress disorder is also a differential diagnosis.

The most common differential diagnosis is borderline personality disorder. [21]  Borderline personality disorder is also associated with extensive trauma, which often presents with micropsychotic and dissociative symptoms.

• Pertinent Studies and Ongoing Trials

There have been case studies and case reports formerly reported in the '90s and early 2000s. Some more treatment interventions have been described in naturalistic and longitudinal studies that continue to inform outcomes. [7]

Unfortunately, Dissociative identity disorder is a medical condition often diagnosed later in life. Often, patients are misdiagnosed with other diagnoses as described above and treated with medications and even therapies that may not directly address DID. Once in treatment, this tends to be lifelong as DID patients continue to require reality-based and grounding interventions. Safety planning with DID patients is lifelong. The prognosis without treatment and correct diagnosis is poor.

• Complications

The patients remain at increased risk of self-injurious behavior given the presence of alters as well as latent trauma. [22]  There have been newer research studies that have described suicidal ideation, especially during dissociation, which describes decreased pain tolerance and more emotional dysregulation. Most treatment interventions advocate for safety planning and reality testing before the use of more advanced psychotherapy techniques

Inpatient hospitalizations and day treatment programs may also be recommended for patients who struggle with thoughts of self-injurious behavior, poor impulse control, or acute mood dysregulation. Medications may be added for mood stabilization.

• Deterrence and Patient Education

Patient education must focus on informing patients on the correct diagnosis when it is determined. Family members are encouraged to be educated about the nature of this illness, including the presence of alters, as well as safety and grounding techniques. Another vital aspect continues to maintain a strong therapeutic alliance with the treatment team and engage in maintaining safety techniques.

Education may be done with multiple alters that do not communicate with each other, and this must be recognized. On the other hand, DID patients often do not want their diagnosis shared publicly, and their privacy must be respected.

• Enhancing Healthcare Team Outcomes

Dissociative identity disorder requires treatment by an interprofessional healthcare team - this will often consist of medical specialists such as a psychiatrist, mid-level practitioners, nursing staff, specialized therapists, trauma counselors, peer counselors, and therapists who all communicate and collaborate. A psychiatrist and primary care physician complete the team. Maintaining a strong therapeutic alliance with the patient and involved family members continues to be of utmost importance. DID patients require frequent check-ins and follow-up appointments and an almost daily focus on safety planning and reality-based interventions.

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Disclosure: Paroma Mitra declares no relevant financial relationships with ineligible companies.

Disclosure: Ankit Jain declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Mitra P, Jain A. Dissociative Identity Disorder. [Updated 2023 May 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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