Dissociative Identity Disorder (DID)

Primer

Dissociative Identity Disorder (DID) (also previously known as multiple personality disorder), is a mental disorder characterized by at least two distinct and relatively enduring personality states. Individuals with DID may report they have suddenly become depersonalized observers of their “own” speech and actions, and feel powerless to stop it. They may also report perceptions of voices (e.g. - a child's voice, crying, the voice of a spiritual being).

Controversy

DID remains a controversial diagnosis despite its inclusion in the DSM-5. It is highly comorbid with other psychiatric disorders including psychotic disorders, personality disorders, substance use disorders, and posttraumatic stress disorder (PTSD).[1]

DSM-5 Diagnostic Criteria

Criterion A

Disruption of identity characterized by 2 or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

Criterion B

Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

Criterion C

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion D

The disturbance is not a normal part of a broadly accepted cultural or religious practice.

Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
Criterion E

The symptoms are not attributable to the physiological effects of a substance (e.g. - blackouts or chaotic behaviour during alcohol intoxication) or another medical condition (e.g. - complex partial seizures).

Scales

Psychometric Scales for Dissociative Disorders

Name Rater Description Download
Dissociative Experiences Scale (DES) Patient The scale is a 28-item self-report questionnaire measuring dissociation in normal and clinical populations. The mean of all item scores ranges from 0 to 100 and is called the DES score. There are two versions of the DES, there is the original DES, and the second version, the DES-II.[2] See also the DES Taxon Calculator to help differentiate between pathological and normal dissociation. DES Download

Pathophysiology

Dissociative identity disorder is associated with overwhelming experiences, traumatic events, and/or abuse occurring in childhood. The full disorder may first manifest at al most any age (from earliest childhood to late life). Prevalence of childhood abuse and neglect is about 90% in Western countries.

Investigations

Treatment

A trauma-informed phase-based psychotherapy approach is recommended by international guidelines, which focuses on:[3][4]

  1. Establishing safety, stabilization, and symptom reduction
  2. Confronting, working through, and integrating traumatic memories
  3. Identity integration and rehabilitation

Differential Diagnosis

  • Other specified dissociative disorder
  • Major depressive disorder
  • Bipolar disorders
  • Posttraumatic stress disorder (some traumatized individuals have both posttraumatic stress disorder (PTSD) and dissociative identity disorder)
  • Psychotic disorders (dissociative identity disorder may be confused with schizophrenia or other psychotic disorders - individuals with DID do not have delusional phenomena)
  • Substance/medication-induced disorders
  • Personality disorders
  • Conversion disorder
  • Seizure disorders
  • Factitious disorder and malingering

Guidelines

Dissociative Identity Disorder Guidelines

Guideline Location Year PDF Website
International Society for the Study of Trauma and Dissociation International 2011 Link Link

Resources

For Patients
For Providers
Articles
Research

References

1) Piper, A., & Merskey, H. (2004). The persistence of folly: A critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. The Canadian Journal of Psychiatry, 49(9), 592-600.
2) Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of nervous and mental disease.
3) The International Society for the Study of Trauma & Dissociation Guidelines for Treating Dissociative Identity Disorder in Adults (2011)
4) Pollock, B. E., Macfie, J., & Elledge, L. C. (2017). Evidence for phase-based psychotherapy as a treatment for dissociative identity disorder comorbid with major depressive disorder and alcohol dependence. Journal of Trauma & Dissociation, 18(4), 595-609.