People with dissociative identity disorders (DID) may adopt as many as 100 new identities, all simultaneously coexisting, although the average number is closer to 15. In some cases, the identities are complete, each with its own behavior, tone of voice, and physical gestures. But in many cases, only a few characteristics are distinct, because the identities are only partially independent, so it is not true that there are “multiple” complete personalities.
DSM-5 criteria for DID include amnesia, as in dissociative amnesia. In dissociative identity disorders (DID), however, identity has also fragmented. How many personalities live inside one body is relatively unimportant, whether there are 3, 4, or even 100 of them. Again, the defining feature of this disorder is that certain aspects of the person’s identity are dissociated.
Diagnostic Criteria for Dissociative Identity Disorders.
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 signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
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).
Life circumstances that encourage the development of DID seem quite clear in at least one respect. Almost every patient presenting with this disorder reports to their mental health professional being horribly, often unspeakably, abused as a child.
Imagine you are a child in a situation like this. What can you do? You’re too young to run away. You’re too young to call the authorities. Although the pain may be unbearable, you have no way of knowing it is unusual or wrong. But you can do one thing. You can escape into a fantasy world; you can be somebody else. If the escape blunts the physical and emotional pain just for a minute or makes the next hour bearable, chances are you’ll escape again. Your mind learns there is no limit to the identities that can be created as needed. Fifteen? Twenty-five? A hundred? You do whatever it takes to get through life.
Investigators have corroborated the existence of at least some early sexual abuse in 12 patients with DID. Abuse is not the only cause of trauma. Individual experience and personality factors also contributed to dissociative experiences. The behavior and emotions that make up dissociative disorders seem related to otherwise normal tendencies present in all of us to some extent. It is quite common for otherwise normal individuals to escape in some way from emotional or physical pain.
The life stress or trauma is in the present rather than the past, as in the case of the overwrought mother who suffered from dissociative amnesia. Many patients are escaping from legal difficulties or severe stress at home or on the job. But sophisticated statistical analyses indicate that “normal” dissociative reactions differ substantially from the pathological experiences.
Individuals who experience dissociative amnesia or a fugue state usually get better on their own and remember what they have forgotten. The episodes are so clearly related to current life stress that prevention of future episodes usually involves therapeutic resolution of the distressing situations and increasing the strength of personal coping mechanisms.
When necessary, therapy focuses on recalling what happened during the amnesic or fugue states, often with the help of friends or family who know what happened, so that patients can confront the information and integrate it into their conscious experience. For more difficult cases, therapists use hypnosis or benzodiazepines (minor tranquilizers), with their suggestions that it is okay to remember the events.
For DID, however, the process is not so easy. With the person’s very identity shattered into many elements, reintegrating the personality might seem hopeless. The strategies that therapists use today in treating DID are based on accumulated clinical wisdom, as well as on procedures that have been successful with PTSD.
The fundamental goal is to identify cues or triggers that provoke memories of trauma, dissociation, or both, and to neutralize them. More important, the patient must confront and relive the early trauma and gain control over the horrible events, at least as they recur in the patient’s mind. To instill this sense of control, the therapist must skillfully, and slowly, help the patient visualize and relive aspects of the trauma until it is simply a terrible memory instead of a current event.