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Dissociative Identity Disorder
Key Facts about Dissociative Identity Disorder
1. Dissociative Identity Disorder used to be called Multiple Personality Disorder, but was always classified as a
dissociative disorder; not a personality disorder. [3][5][6]
2. Only around 6% of people with DID make their diagnosis obvious on an ongoing basis (R. P. Kluft, 2009). [1]
3. Dissociative Identity Disorder is a relatively common disorder, affecting around 1-3% of the population [1].
4. Most people with DID have a mix of dissociative and posttraumatic symptoms, as well as non-trauma related
symptoms.[2]
5. Amnesia in people with DID can take many different forms, including amnesia for significant events in the past
OR for events in everyday life. Amnesia is not limited to traumatic or stressful events. [4]:293
DSM-5 Diagnostic Criteria for Dissociative Identity Disorder
The newest guide to diagnosing mental disorders is the DSM-5, released in 2013.[3] It gives the following diagnostic criteria for
Dissociative Identity Disorder:
Code 300.14
"A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as
an experience of possession. The disruption of marked discontinuity in sense of self and sense of agency, accompanied by
related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These
Key Facts about
signs and symptoms may be observed by others or reported by the individual.
Dissociative Identity
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are
Disorder
inconsistent with ordinary forgetting.
DSM-5 Diagnostic
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
Criteria for Dissociative
functioning.
Identity Disorder
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are
Understanding the
not better explained by imaginary playmates or other fantasy play.
DSM criteria for DID
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during
alcohol intoxication) or another medical condition (e.g., complex partial seizures)." [3]:292
Understanding the DSM criteria for DID
Healthy Multiplicity
ICD Diagnostic Criteria
ICD 11 draft Dissociative Identity
The key characteristic of Dissociative Identity Disorder is the presence of at least two distinct personality states, (or in some
cultures, an experience of "possession"); amnesia is the next most important characteristic.[3]:292 The alternate personality
states are often referred to as "alters" or alternate identities,[4]:193 although many other terms may be used including
Apparently Normal Part of the personality (ANP), and Emotional Part of the personality (EP).[1] Alters are only overt (obvious) in
a small minority of people with DID in clinical situations. A change introduced in the DSM-5 is that it is possible to diagnose DID
without directly observing the alternate personality states by identifying two clusters of symptoms, described in the DSM-5 as:
Sudden alterations or discontinuities in sense of self and sense of agency (Criteria A),
and recurrent dissociative amnesias (Criteria B).[3]:292
Disorder
ICD 10 Diagnostic
Criteria
Diagnostic Tests and
Interviews
Treatment
Psychotherapy
Medication and DID
References
Healthy Multiplicity
Healthy multiplicity is achieved when a person has multiple senses of identity, but does not have clinically significant distress or
impairment as a result of their dissociative identities. A person who meets all the diagnostic criteria for Dissociative Identity
Disorder except Criteria C (distress or impaired life) may be referred to as a healthy multiple, and does not have any
dissociative disorder since all of them require distress or impaired functioning.
ICD Diagnostic Criteria
The last edition of the International Classification of Diseases, the diagnostic guide published by the World Health Organization
is the ICD-10, published in 1992.[2] The draft ICD-11 criteria for Dissociative Identity Disorder classifies it as a Mixed Dissociative
Disorder, and proposes this definition:
ICD 11 draft - Dissociative Identity Disorder
Code 7B32.2
"Dissociative identity disorder is characterized by the presence of two or more insufficiently integrated conscious and selfconscious subsystems of the personality. Each of these subsystems has its own pattern of conceiving, perceiving, and relating to
self, the body, and the environment. They can manifest in a sequence, or in parallel. The disorder may include cognitive,
behavioral, sensory and motor dissociative symptoms. In some cases, one major dissociative identity predominantly controls
the individual's behavioral and mental actions, but is recurrently intruded and influenced by the actions of one or more other
dissociative identities. In other cases, two or more dissociative identities recurrently influence each other, and at least two of
these take executive control for substantial periods of time. The symptoms are not better explained by another mental and
behavioral disorder, are not due to the direct effects of a substance or medication, and are not due to a neurological condition
or other disorder or disease, or to fatigue or hypnogogic or hypnopompic states. The symptoms are of sufficient severity to
produce significant impairment in personal, family, social, educational, occupational or other important areas of functioning."
[6]
Last updated November 2014.
Differences between the ICD-10 and Draft ICD-11 for DID
Several significant changes have been made, including recognizing each alter identity/dissociative part of the personality as a
"subsystem of the personality" rather than a complete personality.
ICD 10 Diagnostic Criteria
Code F44.81
Dissociative Identity Disorder is still referred to as Multiple personality disorder, classified within code F44.8. The diagnostic
criteria are:
"A. The existence of two or more distinct personalities within the individual, only one being evident at a time.
B. Each personality has its own memories, preferences and behaviour patterns, and at some time (and recurrently) takes full
control of the individuals behaviour.
C. Inability to recall important personal information, too extensive to be explained by ordinary forgetfulness.
D. Not due to organic mental disorders (F0) (e.g. in epileptic disorders) or psychoactive substance-related disorders (F1) (e.g.
intoxication or withdrawal).
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during
alcohol intoxication) or another medical condition (e.g., complex partial seizures)."[5]:123
Diagnostic Tests and Interviews
The Dissociative Experiences Scale is a self-assessment screening tool that is useful for identifying people who experience a high
degree of dissociation. A definite diagnosis should only be made by an qualified clinician. This can be done using a clinical
interview based on the Dissociative Experiences Scale, or by using one of the two clinical interviews developed for dissociative
disorders: [1]:126-127[11]:21, [12], [14]
Dissociative Disorders Interview Schedule (DDIS), developed by Dr Colin Ross et al.[13]
Structured Clinical Interview for Dissociative Disorders - Revised - SCID-D, a semi-structured clinical interview developed by Dr
Marlene Steinberg. [12], [14]
Another self-report tool, the Multidimensional Inventory of Dissociation (MID; Dell, 2006a), also exists.[1]:126
Treatment
The treatment guidelines were first produced over 20 years ago, and the currently version are free to download from the
International Society for the Study of Trauma and Dissociation.[7] The treatment guidelines for Dissociative Identity Disorder
also cover similar forms of Dissociative Disorder Not Otherwise Specified (DDNOS), which is now known as Other Specified
Dissociative Disorder. [1]
Research shows that treatment based on the treatment guidelines, which focused primarily on outpatient psychotherapy,
improves symptoms, increases functioning and reduce the rates of hospitalization.[7], [9]:169 Poor outcomes were found when
treatment did not follow the guidelines, for example treatment which did not directly engage alter identities and seek to reduce
amnesia,[9]:169 or when treatment was focused on "memory recovery". [9]:180 Harm was far more likely to occur when DID was
not treated at all. [9]:169 Treating Dissociative Identity Disorder did not only consistently improve dissociative symptoms, it also
improved patients' general distress and depression.[9]:175
Psychotherapy
Psychotherapy (talking therapy) is the primary method of treatment, which follows the basic principles of psychotherapy with
the additional of techniques which address dissociative symptoms. Treating Dissociative Identity Disorder is not primarily based
around uncovering trauma memories or trauma exposure techniques. A recent study that compared experts in the treatment of
Dissociative Disorders to community clinicans found that experts spent more time on techniques for the containment of trauma
memories than uncovering them.[8]:4 Experts also spent more time on grounding and safety interventions.[8]:4
The goal of treatment is integrated functioning, which means a workable form of integration or harmony among identities.[1]
Some people mistakenly believe that the goal is to have a single identity rather than different separate alter identities, this is
known as final fusion. This is a goal for some people, but resolution is more common, this is a "co-operative arrangement"
between the identities.
See also: Healthy Multiplicity
Progress through the three recommended treatment stages is explained:
Medication and DID
Although psychotropic (psychiatric) medication is not a primary treatment for complex dissociative disorders, most DID patients
do take some form of medication. This typically targets the comorbid conditions, including PTSD, mood disorders (e.g.,
depression), and any obsessive-compulsive symptoms.[1] The use of anti-depressants is particularly common. People with DID
or other complex posttraumatic conditions may only partially respond to medication, in DID there is the further complication of
potential amnesia for whether other alters have refused to take medication or taken too much. The DID treatment guidelines for
adults state that alters may report different responses to the same medication, possibly due to physiological differences,
physical symptoms which have a psychological cause (somatoform symptoms), and/or the alters' experience of separateness.[1]
References
1. International Society for the Study of Trauma and Dissociation. (2011). Guidelines For Treating Dissociative Identity Disorder In
Adults, Third Revision: Summary Version. Journal of Trauma & Dissociation,12(2), 188-212. DOI: 10.1080/15299732.2011.537248.
2. World Health Organization. (2014). Classification of Diseases. Retrieved November 16, 2014, from
http://www.who.int/classifications/icd/revision/en/
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.:
American Psychiatric Association. ISBN 0890425558.
4. Black, Donald W. (2014) (coauthors: Grant, Jon E.). DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition. American Psychiatric Pub. ISBN 9781585624652.
5. World Health Organization. (1992). The ICD-10 Classification of Mental and Behavioural Disorders Diagnostic criteria for research.
Retrieved November 17, 2014, from http://www.who.int/classifications/icd/en/GRNBOOK.pdf
6. World Health Organization. (November 15, 2014). ICD-11 Beta Draft (Joint Linearization for Mortality and Morbidity Statistics).
7. International Society for the Study of Trauma and Dissociation. Adults Treatment Guidelines (Forward). Retrieved November 17,
2014, from http://www.isst-d.org/default.asp?contentID=49
8. Myrick, A. C., Chasson, G. S., Lanius, R. A., Leventhal, B., & Brand, B. L. (2014). Treatment of Complex Dissociative Disorders: A
Comparison of Interventions Reported by Community Therapists Versus those Recommended by Experts. Journal of Trauma &
Dissociation, (16)1:51-67 doi:10.1080/15299732.2014.949020
9. Brand, B. L., Loewenstein, R. J., & Spiegel, D. (2014). Dispelling myths about dissociative identity disorder treatment: An empirically
based approach. Psychiatry, 77(2), 169-189
10. Carlson, E.B. & Putnam, F.W. (1993). An update on the Dissociative Experience Scale. Dissociation 6(1), p. 16-27. Note: Dissociative
Experiences Scale-II included in Appendix.
11. Bernstein, E.M. & Putnam, F.W. (1986). Development, reliability and validity of a dissociation scale. Journal of Nervous & Mental
Diseases. 174 p.727-735. Note: Dissociative Experiences Scale-II included in Appendix but with Q25 missing.
12. Ross, C.A., Heber, S., Norton, G.R., Anderson, D., Anderson, G. & Barchet, P. (1989). The Dissociative Disorders Interview Schedule: A
structured interview. Dissociation, 2(3). p.169-189.
13. Steinberg M. (1994). Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R). Washington, DC, American
Psychiatric Press. ISBN 088048562.
14. Steinberg M. (1994). Interviewers Guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) (Revised).
Washington, DC, American Psychiatric Press. ISBN 1585623490.
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