Dissociative identity disorder

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Dissociative Identity Disorder
Dissociative identity disorder.jpg
Classification and external resources
ICD-10 F44.8
ICD-9 300.14
eMedicine article/916186
MeSH D009105

Dissociative identity disorder (DID), previously known as multiple personality disorder (MPD),[1] is a mental disorder on the dissociative spectrum characterized by at least two distinct and relatively enduring identities or dissociated personality states that alternately control a person's behavior, and is accompanied by memory impairment for important information not explained by ordinary forgetfulness. These symptoms are not accounted for by substance abuse, seizures, other medical conditions, nor by imaginative play in children.[2] Diagnosis is often difficult as there is considerable comorbidity with other mental disorders. Malingering should be considered if there is possible financial or forensic gain, as well as factitious disorder if help-seeking behavior is prominent.[2][3][4][5]

DID is considered by some in the psychiatric community to be a controversial disorder.[3] Research on effectiveness of treatment has been concerned primarily with clinical approaches and case studies. Dissociative symptoms range from common lapses in attention, becoming distracted by something else, and daydreaming, to pathological dissociative disorders.[6]

Although neither epidemiological surveys nor longitudinal studies have been done, it is thought DID rarely resolves spontaneously. Symptoms are said to vary over time.[6] In general, the prognosis is poor, especially for those with co-morbid disorders. There are few systematic data on the prevalence of DID.[4] The International Society for the Study of Trauma and Dissociation states that the prevalence is between 1 and 3% in the general population, and between 1 and 5% in inpatient groups in Europe and North America.[5] DID is diagnosed more frequently in North America than in the rest of the world, and is diagnosed three to nine times more often in females than in males.[4][7][8] The prevalence of DID increased greatly in the latter half of the 20th century, along with the number of identities (often referred to as "alters") claimed by patients (increasing from an average of two or three to approximately 16).[7] DID is also controversial within the legal system[3] where it has been used as a rarely successful form of the insanity defense.[9][10] The 1990s showed a parallel increase in the number of court cases involving the diagnosis.[11]

Dissociative disorders including DID have been attributed to disruptions in memory caused by trauma and other forms of stress, but research on this hypothesis has been characterized by poor methodology. So far, scientific studies, usually focusing on memory, have been few and the results have been inconclusive.[12] An alternative hypothesis for the etiology of DID is as a by-product of techniques employed by some therapists, especially those using hypnosis, and disagreement between the two positions is characterized by intense debate.[3][13] DID became a popular diagnosis in the 1970s, 80s and 90s but it is unclear if the actual incidence of the disorder increased, if it was more recognized by clinicians, or if sociocultural factors caused an increase in iatrogenic presentations. The unusual number of diagnoses after 1980, clustered around a small number of clinicians and the suggestibility characteristic of those with DID, support the hypothesis that DID is therapist-induced.[14] The unusual clustering of diagnoses has also been explained as due to a lack of awareness and training among clinicians to recognize cases of DID.[15]


Dissociation, the term that underlies the dissociative disorders including DID, lacks a precise, empirical and generally agreed upon definition.[7][16][17] A large number of diverse experiences have been termed dissociative, ranging from normal failures in attention to the breakdowns in memory processes characterized by the dissociative disorders. Thus it is unknown if there is a common root underlying all dissociative experiences, or if the range of mild to severe symptoms are a result of different etiologies and biological structures.[7] Other terms used in the literature, including personality, personality state, identity, ego state and amnesia, also have no agreed upon definitions.[14][16] Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones.[16] The most widely used model of dissociation conceptualizes DID as at one extreme of a continuum of dissociation, with flow at the other end, though this model is being challenged.[17]


Signs and symptoms[edit]

According to the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM), DID includes "the presence of two or more distinct identities or personality states" that alternate control of the individual's behavior, accompanied by the inability to recall personal information beyond what is expected through normal forgetfulness.[2] In each individual, the clinical presentation varies and the level of functioning can change from severely impaired to adequate.[15][20] The symptoms of dissociative amnesia, dissociative fugue and depersonalization disorder are subsumed under the DID diagnosis and are not diagnosed separately. Individuals with DID may experience distress from both the symptoms of DID (intrusive thoughts or emotions) as well as the consequences of the accompanying symptoms (dissociation rendering them unable to remember specific information).[21] The majority of patients with DID report childhood sexual and/or physical abuse, though the accuracy of these reports is controversial.[6] Identities may be unaware of each other and compartmentalize knowledge and memories, resulting in chaotic personal lives.[20] Individuals with DID may be reluctant to discuss symptoms due to associations with abuse, shame and fear.[6] DID patients may also frequently and intensely experience time disturbances.[22]

The number of alters varies widely, with most patients identifying fewer than ten, though as many as 4,500 have been reported. The average number of alters has increased over the past few decades, from two or three to now an average of approximately 16. However it is unclear whether this is due to an actual increase in alters, or simply that the psychiatric community has become more accepting of a high number of alters.[7] The primary identity, which often has the patient's given name, tends to be "passive, dependent, guilty and depressed" with other personalities or "alters" being more active, aggressive or hostile, and often containing more complete memories. Most identities are of ordinary people, though fictional, mythical, celebrity and animal alters have also been reported.[7]

Co-morbid disorders[edit]

Most dissociative disorder cases have co-morbid mental disorders, with an average of 8 axis I and 4.5 axis II DSM diagnoses.[7] The psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures.[23] The most common presenting complaint of DID is depression, with headaches being a common neurological symptom. Co-morbid disorders can include substance abuse, eating disorders, anxiety, posttraumatic stress disorder (PTSD) and personality disorders.[24] A majority of those diagnosed with DID meet the criteria for DSM axis II personality disorders such as borderline personality disorder;[18] a significant minority meet the criteria for avoidant personality disorder and other personality disorders.[25] Further, data supports a high level of psychotic symptoms in DID, and that both individuals diagnosed with schizophrenia and DID have histories of trauma.[26] Individuals diagnosed with DID also demonstrate the highest hypnotizability of any clinical population.[21] The large number of symptoms presented by individuals diagnosed with DID has led to some clinicians to suggest that, rather than being a separate disorder, diagnosis of DID is actually an indication of the severity of the other disorders diagnosed in the patient.[7]

Borderline personality disorder[edit]

The DSM-IV-TR states that acts of self-mutilation, impulsivity and rapid changes in interpersonal relationships "may warrant a concurrent diagnosis of Borderline Personality Disorder".[2] Steven Lynn and colleagues have suggested that the significant overlap between BPD and DID may be a contributing factor to the development of iatrogenic DID, in that hidden alters suggested by therapists who propose a diagnosis of DID provides an explanation to patients for the behavioral instability, self-mutilation, unpredictable mood changes and actions they experience.[27] In 1993 a group of researchers reviewed both DID and borderline personality disorder (BPD), concluding that DID was an epiphenomenon of BPD, with no tests or clinical description capable of distinguishing between the two. Their conclusions about the empirical proof of DID were echoed by a second group, who still believed the diagnosis existed, but while the knowledge to date did not justify DID as a separate diagnosis, it also did not disprove its existence.[18] Reviews of medical records and psychological tests indicated that the majority of DID patients could be diagnosed with BPD instead, though about a third could not be, suggesting DID does exist but may be over-diagnosed.[18] Between 50–66% of patients also meet the criteria for BPD, and nearly 75% of patients with BPD also meet the criteria for DID with considerable overlap between the two conditions in terms of personality traits, cognitive and day-to-day functioning, and ratings by clinicians. Both groups also report higher than general population rates of physical and sexual abuse, and patients with BPD also score highly on measures of dissociation.[7] Even using strict diagnostic criteria, it can be difficult to distinguish between dissociative disorders and BPD (as well as bipolar disorder and schizophrenia),[16] though the presence comorbid anxiety disorders may help.[28]


The cause of DID is unknown and widely debated, with debate occurring between supporters of different hypotheses: that DID is a reaction to trauma; that DID is produced iatrogenically by inappropriate psychotherapeutic techniques that cause a patient to enact the role of a patient with DID; and newer hypotheses involving memory processing that allows for the possibility that trauma-causing dissociation can occur after childhood in DID, as it does in PTSD. It has been suggested that all the trauma-based and stress-related disorders be placed in one category that would include both DID and PTSD.[29] Disturbed and altered sleep has also been suggested as having a role in dissociative disorders in general and specifically in DID, alterations in environments also largely effecting the DID patient.[30]

Research is needed to determine the prevalence of the disorder in those who have never been in therapy, and the prevalence rates across cultures. These central issues relating to the epidemiology of DID remain largely unaddressed despite several decades of research.[31] The debates over the causes of DID also extend to disagreements over how the disorder is assessed and treated.[7]

Developmental trauma[edit]

People diagnosed with DID often report that they have experienced severe physical and sexual abuse, especially during early to mid-childhood,[32] (although the accuracy of these reports has been disputed[2]) and others report an early loss, serious medical illness or other traumatic event.[20] They also report more historical psychological trauma than those diagnosed with any other mental illness.[not in citation given][33] Severe sexual, physical, or psychological trauma in childhood has been proposed as an explanation for its development; awareness, memories and emotions of harmful actions or events caused by the trauma are removed from consciousness, and alternate personalities or subpersonalities form with differing memories, emotions and behavior.[34] DID is attributed to extremes of stress or disorders of attachment. What may be expressed as post-traumatic stress disorder in adults may become DID when occurring in children, possibly due to their greater use of imagination as a form of coping.[18][21] Possibly due to developmental changes and a more coherent sense of self past the age of six, the experience of extreme trauma may result in different, though also complex, dissociative symptoms and identity disturbances.[21] A specific relationship between childhood abuse, disorganized attachment, and lack of social support are thought to be a necessary component of DID.[18] Other suggested explanations include insufficient childhood nurturing combined with the innate ability of children in general to dissociate memories or experiences from consciousness.[20]

Delinking early trauma from the etiology of dissociation has been explicitly rejected by those supporting the early trauma model. However, a 2012 review article supports the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states.[35] Giesbrecht et al. have suggested there is no actual empirical evidence linking early trauma to dissociation, and instead suggest that problems with neuropsychological functioning, such as increased distractibility in response to certain emotions and contexts, account for dissociative features.[36] A middle position hypothesizes that trauma, in some situations, alters neuronal mechanisms related to memory. Evidence is increasing that dissociative disorders are related both to a trauma history and to "specific neural mechanisms".[21] It has also been suggested that there may be a genuine but more modest link between trauma and DID, with early trauma causing increased fantasy-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of DID.[27]

The suggestion that DID was the result of childhood trauma increased the appeal of the diagnosis among clinicians, patients and the public as it validated the idea that child abuse had lifelong, serious effects. There is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption.[37]


The prevailing post-traumatic model of dissociation and dissociative disorders is contested.[27] It has been hypothesized that symptoms of DID may be created by therapists using techniques to "recover" memories (such as the use of hypnosis to "access" alter identities, facilitate age regression or retrieve memories) on suggestible individuals.[13][14][15][31][38] Referred to as the "sociocognitive model" (SCM), it proposes that DID is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes,[31] with unwitting therapists providing cues through improper therapeutic techniques. This behavior is enhanced by media portrayals of DID.[27]

Proponents of the SCM note that the bizarre dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of DID who, through the process of eliciting, conversing with and identifying alters, shape, or possibly create the diagnosis. While proponents note that DID is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are skeptical of the traumatic etiology suggested by proponents.[39] The characteristics of people diagnosed with DID (hypnotizability, suggestibility, frequent fantasization and mental absorption) contributed to these concerns and those regarding the validity of recovered memories of trauma.[40] Skeptics note that a small subset of doctors are responsible for diagnosing the majority of individuals with DID.[13][14][37] Psychologist Nicholas Spanos and others have suggested that in addition to iatrogenesis, DID may be the result of role-playing rather than alternative identities, though others disagree, pointing to a lack of incentive to manufacture or maintain separate identities and point to the claimed histories of abuse.[41] Other arguments for the iatrogenic position, include the lack of children diagnosed with DID, the sudden spike in incidence after 1980 (although DID was not a diagnosis until DSM-IV, published in 1994), the absence of evidence of increased rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities (such as those claiming to be animals or mythological creatures) and an increase in the number of alternate identities over time[27][14] (as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy.[27]) These various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably borderline personality disorder, which is commonly co-morbid with DID.[27] In addition, presentations can vary across cultures, such as Indian patients who only switch alters after a period of sleep — which is commonly how DID is presented by the media within that country.[27]

The iatrogenic position is strongly linked to the false memory syndrome hypothesis, coined by the False Memory Syndrome Foundation in reaction to memories recovered by a range of controversial therapies whose effectiveness is unproven. Such a memory could be used to make a false allegation of child sexual abuse. However, false memory syndrome itself has not been sufficiently proven in any clinical studies and is not recognized as a psychiatric disorder by any major, peer-reviewed scientific organization.[42] There is little consensus between the iatrogenic and traumagenic positions regarding DID.[3] Proponents of the iatrogenic position suggest a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position[31] though it has also been claimed that higher rates of diagnosis in specific countries like the United States, may be due to greater awareness of DID. Lower rates in other countries may be due to an artificially low recognition of the diagnosis.[15]



The initial theoretical description of DID was that dissociative symptoms were a means of coping with extreme stress (particularly childhood sexual and physical abuse), but this belief has been challenged by the data of multiple research studies.[27] Proponents of the traumagenic hypothesis claim the high correlation of child sexual and physical abuse reported by adults with DID corroborates the link between trauma and DID.[7][27] However, the DID-maltreatment link has been questioned for several reasons. The studies reporting the links often rely on self-report rather than independent corroborations, and these results may be worsened by selection and referral bias.[7][27] Most studies of trauma and dissociation are cross-sectional rather than longitudinal, which means researchers can not attribute causation, and studies avoiding recall bias have failed to corroborate such a causal link.[7][27] In addition, studies rarely control for the many disorders comorbid with DID, or family maladjustment (which is itself highly correlated with DID).[7][27] The popular association of DID with childhood abuse is relatively recent, occurring only after the publication of Sybil in 1973. Most previous examples of "multiples" such as Chris Costner Sizemore, whose life was depicted in the book and film The Three Faces of Eve, disclosed no history of child abuse.[39]



The diagnosis has been criticized as proponents of the iatrogenic or sociocognitive hypothesis believe it as a culture-bound and often iatrogenic condition.[7][14][38] The social cues involved in diagnosis may be instrumental in shaping patient behavior or attribution, such that symptoms within one context may be linked to DID, while in another time or place the diagnosis could have been something other than DID.[37] Other researchers disagree and argue that the existence of the condition and its inclusion in the DSM is supported by multiple lines of reliable evidence, with diagnostic criteria allowing it to be clearly discriminated from conditions it is often mistaken for (schizophrenia, borderline personality disorder, and seizure disorder).[15] That a large proportion of cases are diagnosed by specific clinicians, and that symptoms be created in nonclinical research subjects given appropriate cueing has been suggested as evidence that a small number of clinicians who specialize in DID are responsible for the iatrogenic creation of alters.[7]


Perhaps due to their perceived rarity, the dissociative disorders (including DID) were not initially included in the Structured Clinical Interview for DSM-IV (SCID), which is designed to make psychiatric diagnoses more rigorous and reliable.[16] Instead, shortly after the publication of the initial SCID a freestanding protocol for dissociative disorders (SCID-D)[44] was published.[16] This interview takes about 30 to 90 minutes depending on the subject's experiences.[45] An alternative diagnostic instrument, the Dissociative Disorders Interview Schedule, also exists but the SCID-D is generally considered superior.[16] The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.[46]

Other questionnaires include the Dissociative Experiences Scale (DES), Perceptual Alterations Scale, Questionnaire on Experiences of Dissociation, Dissociation Questionnaire and the Mini-SCIDD. All are strongly intercorrelated and except the Mini-SCIDD, all incorporate absorption, a normal part of personality involving narrowing or broadening of attention.[16] The DES[47] is a simple, quick, and validated[48] questionnaire that has been widely used to screen for dissociative symptoms, with variations for children and adolescents. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20.[49] The reliability of the DES in non-clinical samples has been questioned.[50]

Differential diagnoses[edit]

People with DID are diagnosed with five to seven comorbid disorders on average—much higher than other mental illnesses.[18] Due to overlapping symptoms, differential diagnosis includes schizophrenia, normal and rapid-cycling bipolar disorder, epilepsy, borderline personality disorder and Asperger syndrome.[51] Delusions or auditory hallucinations can be mistaken for speech by other personalities.[21] Persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotizability and reports from family members or other associates indicating a history of such changes can help distinguish DID from other conditions. A diagnosis of DID takes precedence over any other dissociative disorders. Distinguishing DID from malingering is a concern when financial or legal gains are an issue, and factitious disorder may also be considered if there patient has a history of help or attention seeking. Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with dissociative disorder not otherwise specified rather than DID due to the lack of identities or personality states.[2] Most individuals who enter an emergency department and are unaware of their names are generally in a psychotic state. Although auditory hallucinations are common in DID, complex visual hallucinations may also occur.[18] Those with DID generally have adequate reality testing; they may have positive Schneiderian symptoms of schizophrenia but lack the negative symptoms.[15] They perceive any voices heard as coming from inside their heads (patients with schizophrenia experience them as external).[7] In addition, individuals with psychosis are much less susceptible to hypnosis than those with DID.[21] Difficulties in differential diagnosis are increased in children.[31]


History of the DSM diagnosis[edit]

The DSM-II used the term Hysterical Neurosis, Dissociative Type. It described the possible occurrence of alterations in the patient's state of consciousness or identity, and included the symptoms of "amnesia, somnambulism, fugue, and multiple personality."[53] The DSM-III grouped the diagnosis with the other four major dissociative disorders using the term "multiple personality disorder". The DSM-IV made more changes to DID than any other dissociative disorder,[15] and renamed it DID.[2] The name was changed for two reasons. First, the change emphasizes the main problem is not a multitude of personalities, but rather a lack of a single, unified identity[15] and an emphasis on "the identities as centers of information processing".[21] Second, the term "personality" is used to refer to "characteristic patterns of thoughts, feelings, moods and behaviors of the whole individual", while for a patient with DID, the switches between identities and behavior patterns is the personality.[15] It is for this reason the DSM-IV-TR referred to "distinct identities or personality states" instead of personalities. The diagnostic criteria also changed to indicate that while the patient may name and personalize alters, they lack an independent, objective existence.[15] The changes also included the addition of amnesia as a symptom, which was not included in the DSM-III-R because despite being a core symptom of the condition, patients may experience "amnesia for the amnesia" and fail to report it.[21] Amnesia was replaced when it became clear that the risk of false negative diagnoses was low because amnesia was central to DID.[15]


The DSM-IV-TR criteria for DID have been criticized for failing to capture the clinical complexity of DID, lacking usefulness in diagnosing individuals with DID (for instance, by focusing on the two least frequent and most subtle symptoms of DID) producing a high rate of false negatives and an excessive number of DDNOS diagnoses, for excluding possession (seen as a cross-cultural form of DID), and for including only two "core" symptoms of DID (amnesia and self-alteration) while failing to discuss hallucinations, trance-like states, somatoform, depersonalization and derealization symptoms. Arguments have been made for allowing diagnosis through the presence of some, but not all of the characteristics of DID rather than the current exclusive focus on the two least common and noticeable features.[21] The DSM-V-TR criteria has also been criticized for being tautological, using imprecise and undefined language and for the use of instruments that give a false sense of validity and empirical certainty to the diagnosis.

The DSM-5 updated the definition of DID in 2013, summarizing the changes as:[54]



DID is considered controversial by some members of the psychiatric community.[7] The primary dispute is between those who believe DID is caused by traumatic stresses forcing the mind to split into multiple identities, each with a separate set of memories,[12][16] and the belief that the symptoms of DID are produced artificially by certain psychotherapeutic practices or patients playing a role they believe appropriate for a patient suffering from DID.[13][15][38][40][41][55] The debate between the two positions is characterized by intense disagreement.[3][13][14][15][38][41] Psychiatrist Joel Best notes that the idea that a personality is capable of splitting into independent alters is an unproven assertion that is at odds with research in cognitive psychology.[37]



Despite research on DID including structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potential and electroencephalography, no convergent neuroimaging findings have been identified regarding DID, making it difficult to hypothesize a biological basis for DID. In addition, many of the studies that do exist were performed from an explicitly trauma-based position, and did not consider the possibility of iatrogenic induction of DID. There is no research to date regarding the neuroimaging and introduction of false memories in DID patients,[3] though there is evidence of changes in visual parameters[57] and support for amnesia between alters.[3][16] DID patients also appear to show deficiencies in tests of conscious control of attention and memorization (which also showed signs of compartmentalization for implicit memory between alters but no such compartmentalization for verbal memory) and increased and persistent vigilance and startle responses to sound. DID patients may also demonstrate altered neuroanatomy.[18] Experimental tests of memory suggest that patients with DID may have improved memory for certain tasks, which has been used to criticize the hypothesis that DID is a means of forgetting or suppressing memory. Patients also show experimental evidence of being more fantasy-prone, which in turn is related to a tendency to over-report false memories of painful events.[27]


There is a general lack of consensus in the diagnosis and treatment of DID[3] and research on treatment effectiveness focuses mainly on clinical approaches described in case studies. General treatment guidelines exist that suggest a phased, eclectic approach with more concrete guidance and agreement on early stages but no systematic, empirically-supported approach exists and later stages of treatment are not well described and have no consensus. Even highly experienced therapists have few patients that achieve a unified identity.[58] Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive behavioral therapy (CBT),[18] insight-oriented therapies,[16] dialectical behavioral therapy (DBT), hypnotherapy and eye movement desensitization and reprocessing (EMDR). Medications can be used for co-morbid disorders and/or targeted symptom relief.[5][40] Some behavior therapists initially use behavioral treatments such as only responding to a single identity, and then use more traditional therapy once a consistent response is established.[59] Brief treatment due to managed care may be difficult, as individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic alliance.[5] Regular contact (weekly or biweekly) is more common, and treatment generally lasts years—not weeks or months.[5][18] Sleep hygiene has been suggested as a treatment option, but has not been tested. In general there are very few clinical trials on the treatment of DID, none of which were randomized controlled trials.[27]






Little is known about prognosis of untreated DID.[4] It rarely, if ever, goes away without treatment[6][20] but symptoms may resolve from time to time[6] or wax and wane spontaneously.[20] Patients with mainly dissociative and posttraumatic symptoms face a better prognosis than those with comorbid disorders or those still in contact with abusers, and the latter groups often face lengthier and more difficult treatment. Suicidal ideation, failed suicide attempts and self-harm also occur.[20] Duration of treatment can vary depending on patient goals, which can extend from elimination of all alters to merely reducing inter-alter amnesia, but generally takes years.[20]


There is little systematic data on the prevalence of DID.[61] It occurs more commonly in young adults[61] and declines with age.[62] Reported rates in the community vary from 1% to 3% with higher rates among psychiatric patients.[5][15] It is 5 to 9 times more common in females than males during young adulthood, though this may be due to selection bias as males who could be diagnosed with DID may end up in the criminal justice system rather than hospitals.[7] In children rates among females and males are approximately the same (5:4).[6] DID diagnoses are extremely rare in children; much of the research on childhood DID occurred in the 1980s and 1990s and does not address ongoing controversies surrounding the diagnosis.[31]


Changing prevalence[edit]

Rates of diagnosed DID were increasing, reaching a peak of approximately 40,000 cases by the end of the 20th century, up from less than 200 before 1970.[6][7] Initially DID along with the rest of the dissociative disorders were considered the rarest of psychological conditions, numbering less than 100 by 1944, with only one further case added in the next two decades.[16] In the late 1970s and 80s, the number of diagnoses rose sharply.[16] An estimate from the 1980s places the incidence at 0.01%.[6] Accompanying this rise was an increase in the number of alters, rising from only the primary and one alter personality in most cases, to an average of 13 in the mid-1980s (the increase in both number of cases and number of alters within each case are both factors in professional skepticism regarding the diagnosis).[16] Others explain the increase as being due to the use of inappropriate therapeutic techniques in highly suggestible individuals, though this is itself controversial[13][41] while proponents of DID claim the increase in incidence is due to increased recognition of and ability to recognize the disorder.[7] Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries.[63]

North America[edit]


DID is a controversial diagnosis and condition, with much of the literature on DID still being generated and published in North America, to the extent that it was once regarded as a phenomenon confined to that continent[38][64] though research has appeared discussing the appearance of DID in other countries and cultures.[65] A 1996 review offered three possible causes for the sudden increase in people diagnosed with DID:[8]





The first case of DID was thought to be described by Paracelsus in 1646.[9] In the 19th century "dédoublement" or double consciousness, the historical precursor to DID, was frequently described as a state of sleepwalking, with scholars hypothesizing that the patients were switching between a normal consciousness and a "somnambulistic state".[30]

An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries,[64] running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings.[66] Hypnosis, which was pioneered in the late 18th century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.[64]

The 19th century saw a number of reported cases of multiple personalities which Rieber[66] estimated would be close to 100. Epilepsy was seen as a factor in some cases,[66] and discussion of this connection continues into the present era.[67][68]


Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation.[70] It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation.[71] One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality.[71]

In the early 20th century, interest in dissociation and multiple personalities waned for a number of reasons. After Charcot's death in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet's association with Charcot tarnished his theories of dissociation.[64] Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.[64]

In 1908, Eugen Bleuler introduced the term schizophrenia to represent a revised disease concept for Emil Kraepelin's dementia praecox.[72] Whereas Kraepelin's natural disease entity was anchored in the metaphor of progressive deterioration and mental weakness and defect, Bleuler offered a reinterpretation based on dissociation or "splitting' (Spaltung) and widely broadened the inclusion criteria for the diagnosis. A review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States.[73] The rise of the broad diagnostic category of dementia praecox has also been posited in the disappearance of "hysteria" (the usual diagnostic designation for cases of multiple personalities) by 1910.[74] A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.[70]

Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports.[70] With the rise of a uniquely American reframing of dementia praecox/schizophrenia as a functional disorder or "reaction" to psychobiological stressors—a theory first put forth by Adolf Meyer in 1906—many trauma-induced conditions associated with dissociation, including "shell shock" or "war neuroses" during World War I, were subsumed under these diagnoses.[72] It was argued in the 1980s that DID patients were often misdiagnosed as suffering from schizophrenia.[70]

The public, however, was exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe had a formidable impact.[66] In 1957, with the publication of the bestselling book The Three Faces of Eve by psychiatrists Corbett H. Thigpen and Hervey M. Cleckley, based on a case study of their patient Chris Costner Sizemore, and the subsequent popular movie of the same name, the American public's interest in multiple personality was revived. Consequently, more cases of dissociative identity disorder were diagnosed in the following years.[75] The cause of the sudden increase of cases is indefinite, but it may be attributed to the increased awareness, which revealed previously undiagnosed cases or new cases may have been induced by the influence of the media on the behavior of individuals and the judgement of therapists.[75] During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.[70]


In 1974, the highly influential book Sybil was published, and later made into a miniseries in 1976 and again in 2007. Describing what Robert Rieber called "the third most famous of multiple personality cases",[76] it presented a detailed discussion of the problems of treatment of "Sybil", a pseudonym for Shirley Ardell Mason. Though the book and subsequent films helped popularize the diagnosis and trigger an epidemic of the diagnosis,[37] later analysis of the case suggested different interpretations, ranging from Mason's problems being iatrogenically induced through therapeutic methods used by her psychiatrist, Cornelia B. Wilbur or an inadvertent hoax due in part to the lucrative publishing rights,[76][77] though this conclusion has itself been challenged.[78] As media attention on DID increased, so too did the controversy surrounding the diagnosis.[9]

With the publication of the DSM-III, which omitted the terms "hysteria" and "neurosis" (and thus the former categories for dissociative disorders), dissociative diagnoses became "orphans" with their own categories[79] with dissociative identity disorder appearing as "multiple personality disorder".[16] In the opinion of McGill University psychiatrist Joel Paris, this inadvertently legitimized them by forcing textbooks, which mimicked the structure of the DSM, to include a separate chapter on them and resulted in an increase in diagnosis of dissociative conditions. Once a rarely occurring spontaneous phenomena (research in 1944 showed only 76 cases),[80] became "an artifact of bad (or naïve) psychotherapy" as patients capable of dissociating were accidentally encouraged to express their symptoms by "overly fascinated" therapists.[79]


"Interpersonality amnesia" was removed as a diagnostic feature from the DSM III in 1987, which may have contributed to the increasing frequency of the diagnosis.[16] There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990.[83] Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.[84] Scientific publications regarding DID peaked in the mid-1990s then rapidly declined.[85]




Society and culture[edit]


Despite its rareness, DID is portrayed with remarkable frequency in popular culture, producing or appearing in numerous books, films and television shows.[41]


Surveys of the attitudes of Canadian and American psychiatrists' attitudes towards dissociative disorders completed in 1999[55] and 2001[90] found considerable skepticism and disagreement regarding the research base of dissociative disorders in general and DID in specific, as well as whether the inclusion DID in the DSM was appropriate.

NFL player Herschel Walker published an autobiography in 2008 discussing his life and diagnosis of DID.[91]

Legal issues[edit]

Within legal circles, DID has been described as one of the most disputed psychiatric diagnoses and forensic assessments.[3] The number of court cases involving DID has increased substantially since the 1990s[11] and the diagnosis presents a variety of challenges for legal systems. Courts must distinguish individuals who mimic symptoms of DID for legal or social reasons. Within jurisprudence there are three significant problems:[3]


In cases where not guilty by reason of insanity (NGRI) is used as a defence in a court, it is normally accompanied by one of three legal approaches—claiming a specific alter was in control when the crime was committed (and if that alter is considered insane), deciding whether all (or which) alters may be insane, or whether only the dominant personality meets the insanity standard.[9] NGRI is rarely successful for individuals with DID accused of committing crimes while in a dissociated states.[10]


See also[edit]


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