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Dissociative Identity Disorder

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Ismail Munir

Overview

Dissociative identity disorder (DID) refers to a mental health condition that is characterized by the formation of two or more completely separate personalities. These personalities are in complete control of the person and are often known to cause gaps in memories and several other issues<a href="#accordion">[13]</a>.

While movies and TV shows have shone a lot of light on DID, it did a lot more damage than good. With every other movie doing their take on the disorder, in most cases, the depiction of the disease is in one way or another related to violence. The movie &ldquo;Split&rdquo; was inspired by the case of Billy Milligan, a convict who was accused and found guilty of committing several murders. Mr. Robot is another example of a person with DID showing violent and sinister tendencies. This has led the masses into believing that it is a made-up disorder. The realism and the existence of the disorder has been met with skepticism by many, including healthcare professionals.

This is because DID is a very rare occurrence and only 1.5% of the world&rsquo;s population suffers from it. Hence, many psychiatrists and psychologists are not well equipped with the experience or knowledge to diagnose and treat it<a href="#accordion">[11]</a>. Additionally, in many countries, especially countries like Pakistan, a disease that may cause a person to change personalities is often regarded as something supernatural rather than a disease.&nbsp;

This is why there is a dire need for proper awareness and education for the public, for the sake of people who struggle with this disease on a daily basis. 
&nbsp;

This is the aspect where most TV shows and movies fail to acknowledge and display the complete spectrum of alters. Hollywood has created an entire genre of movies related to mental illnesses and the very first movie that displayed the disorder was released in 1920, called Dr. Jekyll and Mr. Hyde<a href="#accordion">[12]</a>.&nbsp;

Only two types of alters are ever shown, including a soft, seemingly normal gullible personality and the other one being a violent alter that is often shown to induce harm to others, with no actual motive. In reality, these personalities are much more complex. Following are some of the types of personalities that are commonly found in people with DID: 
&nbsp;

<ul>
	<li>Normal Alters &ndash; They are also regarded as the host personality. They&#39;re the main personality who carry out daily routine works, but have no clue about the past trauma. A great example of this is shown in Mr. Robot and the new Marvel series called Moon Knight, where the main character is a little aware of their mental situation with respect to memory gaps when other alters chime in. However, host alters can be more than one, but all the other alters ensure that they are not made aware of the trauma or anything mentally harmful.</li>
</ul>

&nbsp;

<ul>
	<li>Emotional Parts &ndash; These parts are known to hold the traumatic events that may have led to this disorder. These types of alters are overwhelmed by the trauma and emotion, and in many cases, are unable to perform daily life tasks. Hence, the need for normal, unaware alters.</li>
</ul>

&nbsp;

<ul>
	<li>Animal Alters &ndash;&nbsp;Children who are closer to animals and are able to relate to them develop animal alters, albeit this is a very rare occurrence. There have been instances of alters like tigers that are meant for protection, and children with these alters have been observed to make growling sounds. Additionally, these alters are created if the child is being abused. Specifically, when their abusers compare them with an animal or treat them like one. These alters are often indistinct and can manifest in a way that you may not even realize you are talking to an animal alter.</li>
</ul>

&nbsp;&nbsp;

<ul>
	<li>Persecutors&nbsp;&ndash;&nbsp;Of all the alters, these are the most harmful. They are created in order to protect the main host, but with time, the alter can develop suicidal tendencies and may even try to murder the host. They are often regarded as &lsquo;misguided protectors<a href="#accordion">[5]</a>. Persecutors also have the tendency to blame the host for the abuse. This is also a reason why people with DID suffer from depression and suicidal tendencies. In many cases, hosts are aware of the hostile behavior persecutors have against them.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Child Or Adolescent Alters&nbsp;&ndash;&nbsp;They are very common and very easily discovered during psychotherapy. In many cases, these alters act like infants and are unable to speak. They do not grow as the individual ages, but in some rare cases, they may start talking. Their presence is detected through their body language. Child alters on the other hand are called &ldquo;littles&rdquo;. These alters talk in a childish manner and even mimic a child&rsquo;s voice. However, they register complex words and emotions like an adult. These alters often are aware of the abuse the host may have experienced, and the age of this alter is consistent with the age when the abuse first started<a href="#accordion">[13]</a>.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Dead Alter&nbsp;&ndash;&nbsp;This alter is often present in people who have suffered a near-death experience during their time of abuse. This alter does not present itself or take control of the host, but stays in the head in a way that it can be felt by others.</li>
</ul>

&nbsp;

<ul>
	<li>Evil Or Demonic Alters &ndash;&nbsp;This type of alter is the kind that is most commonly shown in television and movies. They are often made when the child is exposed to groups where they abuse the child as well as blame the child&rsquo;s personality on a supernatural entity. This causes the child to believe that they are possessed or have supernatural abilities. Hence, they develop an evil or demonic personality. Some people with DID have reported that they found themselves dressed up like a demon with makeup and hair, looking in the mirror, and telling themselves that they are a demon. These alters are most commonly found in children that were raised in cults or were exposed to cult-like activities from a very young age.</li>
</ul>

&nbsp;

<ul>
	<li>Famous People Based Alters&nbsp;&ndash;&nbsp;A great depiction is done in the TV show &ldquo;Moon Knight&rdquo; where the host alter himself is completely based on a fictional movie character that the individual admired as a child. These alters are also regarded as introjects or internalized representations. However, these alters are mostly reported in people who have suffered ritual abuse, where they are led to believe that they may be special religious figures or some other supernatural beings<a href="#accordion">[14]</a>.&nbsp;</li>
</ul>

&nbsp;

<h5 dir="ltr">Other Types</h5>

Apart from dissociative identity disorder, there are two more types of the same kind. These include: 
&nbsp;

<ul>
	<li>Dissociative Amnesia: This disorder is different from normal forgetting of things. It is often characterized by the person forgetting crucial life events and information about oneself. The disorder, much like DID, is triggered due to a traumatic event. This type of amnesia is further divided into three types: 
	&nbsp;</li>
</ul>

<ol>
	<li>Generalized &ndash; A very rare occurrence, but it involves complete memory loss of identity and life history</li>
	<li>Selective &ndash; This type is characterized by the inability to recall a certain time period</li>
	<li>Localized &ndash; This is the most common type of dissociative amnesia, where the person completely blocks out a certain period or an event.&nbsp; 
	&nbsp;</li>
</ol>

<ul>
	<li>Depersonaliation: Also known as derealisation disorder, this is another highly complex disorder and has two aspects to it. One is depersonalization, which involves complete detachment from your mind and body. The person may feel like they are having an out-of-body experience in a way that they are able to see what is happening in their surroundings from a third-person perspective. Another aspect of it is derealisation where the person is completely detached from their surroundings and people&nbsp;as if they do not exist or are not real<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ul>

Signs And Symptoms

The usual symptoms that people often associate with DID involve certain dramatic aspects like waking up as a different person, randomly getting aggressive or violent, being completely unaware of your own situation, and thinking that you are leading a normal life. However, this couldn&rsquo;t be further from the truth. Symptoms of DID include: 
&nbsp;

<ul>
	<li>Identity Confusion &ndash; Due to the alters switching in, and in many cases even being able to communicate with one another, the patient suffers a lot from identity confusion. Especially, when they are aware of their disorder and struggle to determine the main personality 
	.</li>
	<li>Memory Problems &ndash; Depending on the type of alter that is in control, not all personalities are aware of what is happening around them, and in many cases, when an alter takes over, everything that is experienced by them is shielded from other alters. This causes gaps in the memory of the patient. 
	&nbsp;</li>
	<li>Inability To Handle Sudden Emotions &ndash; The person with DID created these other alters in order to protect themselves from trauma that they experienced in the past. This is why oftentimes triggers can cause the appearance of a tough alter that can take the news and deal with it accordingly, keeping the main personality clueless. 
	&nbsp;</li>
	<li><a href="https://www.merisehat.pk/disease/depression" target="_blank">Depression </a>And <a href="http://www.merisehat.pk/disease/anxiety">Anxiety</a> &ndash; These two disorders go hand-in-hand with DID. The sufferer often develops this either due to the past trauma that triggered DID itself or even from their daily life, where they are unable to participate actively in life due to the restrictions that surround DID. 
	&nbsp;</li>
	<li>Derealization &ndash; As mentioned above, they may have an out-of-body experience. Especially, in case of an alter that may not show itself by taking control of the body, but is believed to quietly observe it all. The famous TV show Mr. Robot does justice to this symptom by its accurate depiction.&nbsp; 
	&nbsp;</li>
</ul>

However, the signs and symptoms of DID are limited due to its rare occurrence and limited data availability.&nbsp; 
&nbsp;

Causes

The main cause of dissociative identity disorder is childhood trauma. The trauma experienced is very extreme, and is mostly physical or sexual that repeats itself overtime. In these events, the brain tends to create an alter personality to deal with the pain and the suffering in order to shield the main personality. However, the trauma may even be a response to a natural disaster<a href="#accordion">[3]</a>. The underlying premise is to dissociate the host personality from the experience in a way that a person feels like that the trauma is is happening to someone else not and not them, and the trauma is being dealt with by someone other than themselves<a href="#accordion">[12]</a>. 
&nbsp;

DES Scale is also known as a Dissociative Experiences Scale. It is a questionnaire based on 28 points about the experiences you have in your daily life. Additionally, the test also focuses on the frequency of occurrence of the experience (occasional or regular). The tool is widely used and in case if the individual has a high DES score, a more extensive structured clinical interview (SCID-D) is taken to determine and diagnose DID<a href="#accordion">[6]</a>. 
&nbsp;

Diagnosis

After proper screening, an extensive diagnosis is required where the doctors try to rule out any possibility of a medical condition interfering with or distorting your reality. The diagnostic process may include a physical examination, where your doctor asks you several in-depth questions about your past experiences, personal history of trauma, family history of mental illness, and may check for any physical injuries to the head or possible brain diseases.

A physical exam is then followed by an extensive psychiatric exam, where your feelings, thoughts, and behaviours are evaluated along with testimonials of your family with regards to possible and abrupt changes in your behavior. The symptoms are then compared to the given diagnostic criteria in the DSM-5 to give the complete diagnosis<a href="#accordion">[9]</a>. 
&nbsp;

Treatment

Treatment of dissociative identity disorder requires a lot of dedication. The disorder develops over time and the more the number of alters, the longer will be the treatment. While there may be some use of antidepressants, mood stabilisers, and antipsychotics, the main treatment is done through effective psychotherapy<a href="#accordion">[7]</a>. The therapy mainly focuses on firstly making the host personality aware of their condition, and involves channeling and talking to other personalities to avoid any further dissociation. However, multiple practices of psychotherapy are employed to fully understand the extent of the disorder and to effectively manage it.

&nbsp;

Cognitive Behavioural Therapy: This type of therapy challenges the thought patterns of people with DID and aims towards making them more positive, productive, and centered toward reality. CBT is also known to aid in processing past traumas, especially in the host&#39;s personality. 
&nbsp;

Dialectical Behavior Therapy: DBT focuses on several aspects commencing with managing overwhelming feelings that often serve as a trigger for other alters to take over. The therapy also focuses on mindfulness, allowing the person to be more careful and aware of their environment. It focuses on the person&rsquo;s ability to take control and set up boundaries with other alters. 
&nbsp;

Psychodynamic Psychotherapy: This kind of therapy deals with what goes on in your mind unconsciously that may have a negative impact on your suffering. This is another type of therapy that makes the person more aware of past traumas affecting their current habits and behaviors<a href="#accordion">[2]</a>. 
&nbsp;

Following are the commonly faced complications in people with DID:

<ul>
	<li>Alcoholism and drug abuse</li>
	<li>Mutilation or self-harm</li>
	<li>Suicidal tendencies</li>
	<li>Sexual dysfunction and no libido</li>
	<li>Eating disorders</li>
	<li>Non-epileptic seizures</li>
	<li>Difficulties in maintaining personal relationships</li>
	<li>Post-traumatic stress disorder</li>
	<li>Personality disorders 
	&nbsp;</li>
</ul>

The biggest risk factor is abuse, be it sexual or physical. 90% of the people with DID in the US and Canada are victims of childhood abuse<a href="#accordion">[1]</a>. Children who have experienced war, seen the death of a sibling or a loved one up close, have been blamed for it, or are reminded of it in a violent manner are also very susceptible to developing dissociative identity disorder<a href="#accordion">[4]</a>. 
&nbsp;

Till date, the aetiology of DID is very poorly understood. Scientists attempted to determine the robustness and sensitivity of a brain-base measure of dissociation severity. This was achieved by applying an intrinsic network connectivity analysis to MRI scans of 65 women, and the Multidimensional Inventory of Dissociation was used to measure possible dissociation. While the model only managed to estimate dissociation moderately, it is still regarded as a big step towards a much better and developed approach for an accurate estimation of the severity and the diagnosis of dissociative disorders<a href="#accordion">[8]</a>. A team of researchers at McLean Hospital discovered that imagining analyses may help in increasing our understanding of the etiology of DID, by determining the change in functional connections between brain regions whenever a person is experiencing dissociation<a href="#accordion">[10]</a>. 
&nbsp;

Key Points

<ul>
	<li>DID has been the most commonly displayed mental illness in TV shows and movies.&nbsp;</li>
	<li>The disorder is characterised by dissociation of a person into multiple personalities that are also known as alters.</li>
	<li>This occurs due to past recurring childhood trauma. Small details of the trauma may induce the creation of certain alters.</li>
	<li>The alters are also based on past experiences that may be somehow related to the trauma itself, or are in some way related to the person and their ability to relate to the alters.</li>
	<li>There is no cure out there when it comes to DID. The only solution is management of the disorder through long-term psychotherapy. However, antipsychotics, antidepressants, mood stabilisers, and anxiolytics are still prescribed to manage other symptoms of the illness.</li>
	<li>The disorder may also cause the person to suffer from other mental illnesses like depression, anxiety, and <a href="https://www.merisehat.pk/disease/ptsd-post-traumatic-stress-disorder" target="_blank">PTSD</a>.</li>
	<li>Due to the low prevalence of DID, not much research is done or even can be done because there are not many test subjects out there. Thus, greatly limiting researchers in coming up with effective treatments and therapy. 
	&nbsp;</li>
</ul>

[1] American Psychiatric Association, 2018. What Are Dissociative Disorders?

[2] Bailey, A., 2022. How to Treat Dissociative Identity Disorder

[3] Cleveland Clinic, 2021. Dissociative Identity Disorder (Multiple Personality Disorder)

[4] Crichton-Stuart, C., 2018. What is dissociative identity disorder?

[5] Frank, M., 2019. 10 Types of 'Alters' in Dissociative Identity Disorder

[6] FW, B. E. P., 1986. Development, reliability and validity of a dissociation scale. J. Nerv. Ment. Dis., 174(12), pp. 727-735.

[7] Healthline, 2017. Dissociative Identity Disorder

[8] Lauren A.M. Lebois, P. M. L. P. J. T. B. M. P. J. D. W. B. D. W. M. P. A. M. L. B. E. G. P. S. W. M. J. R. B. A. G. P. S. A., 2020. Large-Scale Functional Brain Network Architecture Changes Associated With Trauma-Related Dissociation. The American Journal of Psychiatry, p.

[9] Mayo Clinic, 2017. Dissociative disorders

[10] McLean Hospital, 2020. Novel Neuroimaging Study on Dissociative Symptoms Reveals Wounds of Childhood Trauma.

[11] Mitra, P. & Jain., A., 2022. Dissociative Identity Disorder. [Online]

[12] Orford, S., 2021. What Causes Dissociative Identity Disorder (DID)?

[13] Sampson, V., 2020. The Portrayal of Dissociative Identity Disorder in Films. Elon Journal of Undergraduate Research in Communications, 11(2), pp. 79-88.