Dissociative identity disorder (DID), formerly known as multiple personality disorder or colloquially as split personality disorder, is a rare mental health condition that is characterized by identity and reality disruption. Individuals with DID will exhibit two or more distinct personality states and recurrent periods of memory loss. The fragmentation of identity and disconnection with reality that typifies DID is most commonly the result of extreme and pervasive childhood abuse.1
What Is Dissociative Identity Disorder (DID)?
DID is a dissociative disorder that involves a disconnection from reality and discontinuity between one’s behaviors, thoughts, and memories. Dissociation is defined as a disconnection from self or one’s surroundings, and is part of the symptom criteria for PTSD and other trauma related disorders. These disorders are commonly unhealthy coping mechanisms that stem from trauma, which leads to maladaptive escaping from one’s reality or avoidance of traumatic memories. It is estimated that 1.5% of US and global populations experience DID.1,2
DID was once termed multiple personality disorder in prior versions of the DSM, due to the distinct personality states characteristic of the disorder. The personalities often have different traits, thoughts, behaviors, preferences, speech, food, and dress. These changes are often ego-dystonic, or inconsistent with the individual’s core identity, causing significant distress. This disorder is also commonly referred to colloquially as split personality disorder, due to the “splitting” of personalities and apparent lack of awareness or memory in between personality shifts or splits. Some individuals refer to their other personalities as “alters” furthering a distinction of them as separate distinct personas. The DSM-4 chose to rename multiple personality disorder to re-conceptualize the disorder as a lack of a singular, unified identity, rather than multiple, discrete, personalities.1
Dissociative Identity Disorder Signs & Symptoms
The subjective experience of dissociation that leads to the switching of personality states varies by person. Each individual has differing levels of awareness and insight into this process, and varying levels of acceptance and feelings about their disorder. However, commonly reported symptoms of this “switching” stage are dizziness, fatigue, feelings of co-awareness of two or more personality states, and a sensation of spinning or zoning out.
The loss of volitional control over this process can make some people feel helpless, embarrassed, and out of control. It is important to note that these states of shifting or switching are not always readily apparent or noticeable to others. The often-dramatic shifting of personality states commonly portrayed in the mass media are not accurate of most people’s experiences, and unfortunately contribute to a stigmatization of the disorder.3,4
Family and loved ones may observe startling and sudden changes in behavior of the person with DID. An individual with DID may deny doing or saying things that were clearly witnessed by the loved one. Certain triggers or stressors in their environment may become apparent. For example, the loved one may identify that certain environmental or social cues initiate the shift in personality state. The individual with DID may have little or no insight into these triggers or shifting states. It may be difficult for families to parse through the signs and symptoms of their loved ones, as most people with DID have multiple diagnoses that impact their mood, behaviors, thoughts, and cognitions. Those with DID may also feel shame about their experiences, and be reticent to discuss their disassociate symptoms or history of trauma.4,5
Symptoms and signs of DID may include:
- Memory loss
- Changes in affect and mood
- Lack of agency or control
- Changes in behavior
- Perceptual distortions
- Loss of time
- Headaches/Somatic symptoms
- Suicidal ideation and behaviors
“For people who have never experienced DID, the symptoms can seem so bizarre that people are either very frightened, or believe that the individual with DID must be faking it. How could someone go from behaving like an adult male to talking and behaving like a little girl? It doesn’t match people’s preconceptions regarding stable identities and is too much for most to fathom.” – Dr. Robert Gregory, MD.16
Alters in Dissociative Identity Disorder
Alternate identities, or “alters” as they are frequently referenced, may manifest in a variety of ways. One of the most common forms of DID alters, and often the first and easiest to identify in therapy, are child alters. They present as young children, with varying levels of communication skills, and will represent the person when they were young, often when they experienced their childhood abuse. They may express fear and act as if they are still in danger. Alters may also have different genders, different preferences, different dress, etc. More interestingly, there is evidence of psychobiological differences, such as changes in vision, medication responses, known allergies, handedness, to name a few.6,7
The number of alternate identities or personality states an individual with DID can endorse may vary from two to over 100, with an average being about 10. Alters are also known to take nonhuman forms, such as animals, fantasy creatures, or hybrids of different creatures. These alters may also act as protectors–examples include dragons, fairies, or distressful alternate personalities, such as demons.7
According to Dr. Gregory, “No one can truly get rid of an alter, because alters are ultimately parts of one’s self. Even very healthy individuals have parts of themselves that can be dangerous if the right triggers or circumstances come along. The only difference in DID is that those parts can be dissociated from the rest of the self, so that they can form separate identities or part-selves. The goal of treatment is to acknowledge and accept the alters as parts of oneself so that they can be reintegrated into the self-structure.”16
What Causes Dissociative Identity Disorder?
The most common etiology of DID is severe, chronic childhood abuse. Traumatic experiences may be too much for a person to process, and thus it becomes compartmentalized in different personality states. There is also evidence that traumatizing medical and health experiences during childhood may also cause DID.8 Other researchers hypothesize that DID may be caused by suggestibility in therapy, and subsequently produces false or repressed trauma memories. This phenomenon of suggestibility is no longer an accepted theory for the etiology of DID.2
Common Co-Occurring Conditions
The prevalence of present or lifetime PTSD among individuals with DID is estimated to be between 46.7% and 79.2%.5 Additionally, 70% of people with DID have attempted suicide, and it is not uncommon for them to have multiple attempts.1Borderline and avoidant personality disorder commonly present as comorbid with DID. Mood disorders, conversion disorder, somatic symptom disorder, substance use disorders, eating disorders, and sleep disorders are also common comorbidities with DID.1
DID may occur comorbidly with:
- Post-traumatic stress disorder (PTSD)
- Substance use disorder
- Suicidal behaviors
- Personality disorders (avoidant and borderline)
- Conversion disorder
- Somatic symptom disorder
- Eating disorders
- Obsessive-compulsive disorder
- Sleep disorders
Dissociative Identity Disorder Diagnosis
Receiving a diagnosis of DID is notoriously difficult, and it often goes misdiagnosed or undiagnosed. Comorbidities often complicate the clinical presentation of individuals with DID–it is estimated that between five and seven other mental health conditions commonly accompany this disorder. Additionally, its relative rarity makes it less likely that providers and clinicians are experienced in diagnosing and treating DID.
The DSM-5 reported that women over-represented the outpatient clinical setting, while males with DID often minimize their symptoms and trauma histories, leading to misdiagnosis. Cultures with prevalent religious themes are more likely to result in personality states in which demonic possessions are used to explain alternate identities.1
The current diagnostic criteria for DID includes a disruption in identity by two or more personality states which cause distortions in sense of self, changes in behaviors, among others. Gaps in remote memory (life events or childhood trauma events) and dependable memory (what happened today or skills) may also be indicative of the condition. These symptoms cannot be better explained by another medical condition, cultural practice, or intoxication from substances.1
To be diagnosed with DID, a person must experience:
- Disturbances in identity as evidenced by two or more distinct personality states–change in sense of one’s self, agency, mood, affect, behaviors, memory, perceptions, consciousness, thoughts, and sensory-motor functioning.
- Gaps in memory that are not part of normal forgetfulness
- Symptoms that cause clinically significant distress and impairment in functioning
- Symptoms that are not part of cultural or religious practices
- Symptoms that are not caused by the use of substances or a medical condition1
Dissociative Identity Disorder Treatments
The first step in properly treating DID is receiving a comprehensive diagnosis. This will likely require that the clinician or provider is specifically trained in DID to properly assess symptoms, perform differential diagnosis, and provide psychoeducation to the client. Self-report from the client during intake may be challenging, due to changing personality states and frequent episodes of amnesia.
The best practices for effectively treating DID may include a combination of medication and therapy. The primary form of treatment is psychotherapy; a specialized focus on dissociation may be foundational for treatment success, particularly since there are no medications that specifically target dissociative symptoms. Given the high prevalence of suicidality in DID, inpatient treatment may be indicated for the individual’s safety, and to treat high acuity of symptoms related to DID and other comorbid disorders.9
Currently, there are no medications prescribed to specifically treat DID. Individuals with DID are often prescribed medications for other comorbid mood disorders, sleep disturbances, dissociative disorders, and anxiety symptoms. Stabilizing these symptoms can help improve the individual with DID’s overall mental health and adaptive functioning.4Commonly prescribed medications for those with DID include anti-depressant, anti-anxiety, and antipsychotic medications.4,10
At present, there are no evidence-based therapy guidelines for the treatment of DID. This is mostly due to a lack of controlled, systematic research on DID. However, in therapy, the clinician or provider will create a treatment plan with the individual based on their personal needs.
The ultimate goal of therapy may differ, depending on the conceptualization of DID. However, relieving distress, improving quality of life, and teaching adaptive functioning are always vital parts of therapeutic treatment. Finding a clinician that is skilled at treating DID or other dissociative disorders is an important first step to getting efficacious treatment.
The International Society for the Study of Trauma and Dissociation (ISSTD) reports that therapy modalities should be delivered in stages of treatment–phase one aiming for symptom stabilization and reduction in suicidal or homicidal ideation; phase two is trauma processing; and phase three is integration of identity and self-concept. Still, many clinicians believe this approach can be re-traumatizing, particularly when trauma memories are identified and confronted. When treatment for DID is not done well, it can be destabilizing for the individual. The frequency of sessions and length of treatment may vary, but generally treatment for DID lasts around three years, which is significantly longer than treatment for most disorders.8
Therapy options for DID include:8,9,11,12,13
- Cognitive behavioral therapy (CBT): CBT is helpful in the treatment of negative thoughts, depression, and anxiety related symptoms.
- Cognitive Processing Therapy (CPT): CPT is an evidenced based treatment for PTSD and may be helpful in treating trauma-related symptoms of DID.
- Dialectical behavioral therapy (DBT): This therapy works in a staged approach, which is also the suggested treatment guidelines for DID. DBT also prioritizes reducing suicidality, self-harm, and improving emotion regulation and distress tolerance.
- Psychodynamic therapy: This treatment focuses on early childhood experiences, attachment, and relational issues. The relationship between the patient and therapist is important and leveraged to identify and repair maladaptive relationship patterns.
- Schema therapy: This therapy has components of CBT, experiential, and interpersonal modalities. Schema therapy places focus on reframing experiences of early childhood trauma, cognitions and beliefs.
Hypnosis, or hypnotherapy, was one of the earliest forms of treatment for DID, as research indicates success with this technique. This therapy works to resolve trauma associated with one’s different personality states. Nevertheless, hypnotherapy is not widely regarded as an evidenced-based treatment for trauma or dissociative disorders. There is also significant concern about suggestibility within this treatment framework. Some studies supported findings that individuals with DID may be more prone to hypnotic suggestibility. Contrarily, it is possible that those with higher suggestibility are more prone to develop DID. More research is needed on the efficacy of hypnosis and hypnotherapies in the treatment of DID. 10,14
Healthy Coping When Living with DID
While living with DID can be challenging, there are ways to cope with your symptoms. Healthy coping mechanisms can help you experience relief when in instances of distress.
Here are some healthy coping skills for living with DID:
- Utilizing social support: Having healthy, positive relationships brings joy to one’s life and support when needed. Knowing how to ask your loved ones for help is an adaptive coping skill.
- Creating a crisis plan: It is helpful to create a plan (i.e., identifying protective factors, social supports, and coping skills) with your provider as part of a treatment plan. This should include critical information and a step-by-step plan for situations such as feeling suicidal, relapse prevention, or other crisis situations.
- Abstaining from substances and alcohol: Using substances can often be an avoidance coping strategy that delays and complicates healing. It is typically contraindicated when taking psychotropic medications.
- Being kind to yourself: Having compassion for yourself and your experiences can help with feelings of guilt, shame, or other negative emotions.
- Practicing self-care: Caring for your body by maintaining a good diet and exercise routine can improve overall wellness. It is also vital to know when to rest, relax, and decompress from stress.
- Meditating: Meditation can help with grounding or bringing one to the present. It also can mitigate stress and emotional distress.
- Practicing mindfulness: Mindfulness techniques can help those with dissociation better predict and control their states through better self-awareness. It can also help with emotion regulation.15
How to Help a Loved One With DID
Given that DID is associated with chronic and severe trauma, it is important to utilize a trauma-informed approach when a loved one has been diagnosed with DID. You should not re-traumatize the person (i.e., avoiding them, blaming them, rushing them, shaming them), and recognize the effect the trauma has on their behaviors, thoughts, and emotions. This can be done by validating a person’s experiences; using reflexive listening statements (stating back to them what they say to you); refraining from offering unsolicited advice; and listening genuinely and intently. Be patient and give them time to open up and process their experiences.
Here are some additional tips for supporting a loved one with DID:
- Help with medication and treatment plan adherence
- Model good mental health behaviors
- Be patient and kind
- Assist them with gaps in memory
- Learn to identify and understand dissociative triggers
- Don’t tease, shame or play games/tricks with the other personality states
- Learn what helps to ground the individual and help them with their effective coping strategies
Outlook for Dissociative Identity Disorder
Left untreated, DID will most likely last a lifetime. It is common for an individual to be symptomatic for years before receiving a proper diagnosis and treatment, with the average age of diagnosis being between 29 and 35 years of age.9 With effective treatment, DID and its symptoms can improve and achieve remission. Some individuals who have experienced remission reported that a new trauma or stressor has resulted in symptom re-emergence. Fortunately, others may go on to have lives free of dissociation and with an integrated, unitary identity.
DID is a notoriously controversial disorder and is vastly understudied, which has contributed to a lack of consensus regarding its conceptualization and fostered misdiagnosis and stigmatization. This may lead those suffering from DID to experience feelings of shame and avoidance of treatment. However, with effective treatment and symptom maintenance, a person can find relief and possibly remission from this invasive condition.