Dissociative Identity Disorder (DID)
In some cultures, this disruption of a unified sense of self may be understood as an experience of possession that is not considered congruent with that culture’s spiritual/religious practices.
In addition, individuals with DID experience Dissociative Amnesia (DA): a disruption in memory for important personal information, as well as for current and past personal experience, that is inconsistent with ordinary memory problems.
This significant disruption in a unified sense of self and memory can occur in a number of ways that include hard to explain disturbances and/or variability in:
- Bodily sensations or functioning
These disruptions and alterations cannot be better explained by the effects of alcohol or drugs, or a medical or brain disorder, such as epileptic seizures. These symptoms must cause significant problems with functioning.
Unlike portrayals in the media, the “fascinating”, stereotyped external characteristics of DID self states, such as different names, voice tone, accents, wardrobe, hair-styles, handwriting, and more, are not essential for diagnosis and are secondary factors to the core phenomena of DID.
The diagnostic criteria for DID mean that there are two or more relatively separate centers of information processing in the mind. Each information processing center in the mind is characterized by:
- A sense of personal identity
- A self-image
- A set of (state dependent) autobiographical memories
- A sense of ownership of personal experience
- Capacity to control/enact behavior
These self states may shift, switch, or overlap in a number of ways that lead to the disruption in self and continuity of experience in DID.
The individual’s personality/identity/self states are NOT separate people. These are subjective states of the individual’s mind. All of the DID states together make up the whole person and that person’s total personality.
Because of this, and unlike descriptions in the popular media, the individual with DID as a whole person is held responsible for behavior, even if experienced with amnesia or a sense of lack of control over one’s actions.
The Development of Dissociative Identity Disorder
Individuals with DID report the highest rates of childhood trauma, particularly physical, sexual, and emotional abuse – generally beginning before the age of six – of patients with any psychiatric disorder. Because of this, DID can be conceptualized as a childhood onset, posttraumatic developmental disorder in which the traumatized child is unable to complete the normal developmental processes involved in consolidating a core sense of self. Together with disturbed caretaker-child attachment and parenting, repeated early trauma disrupts the development of normal processes involved in the elaboration and consolidation of a unified sense of self. Therefore, the child fails to integrate the different experiences of self that normally occur across different states and contexts.
DID has been found in children, adolescents, and adults. Unfortunately, early trauma may be a risk factor for later trauma. DID individuals report very high rates of adult rape, intimate partner violence, and other forms of exploitation, such as being a victim of trafficking.
DID is both a disorder and a form of resilience. Psychological compartmentalization of traumatic/overwhelming experiences allows for more normal development of the capacity for clear thinking, intellectual and creative abilities, the ability to understand reality, development of a sense of humor, the capability for attachment to others, and a capacity for insight – all important in the psychotherapy treatment of DID.
Symptoms of Dissociative Identity Disorder (DID)
The posttraumatic origins of DID mean that anywhere between 80 and 100% of individuals with DID who receive treatment also have symptoms of posttraumatic stress disorder (PTSD - see section on PTSD). Other disorders commonly associated with DID are depression or very rapid “mood swings” that frequently do not (or only very partially) respond to medications; substance abuse; and unexplained medical symptoms with repeated “negative” work ups, typically for apparent seizures or other neurological disorders.
One of the most common symptoms of DID is hearing voices, most often within the mind. Because of this, many individuals with DID are unsuccessfully treated with medications for schizophrenia or other psychotic disorders (see section on psychotic disorders).
Individuals with DID have very high rates of self-destructive and suicidal behavior and often have multiple, usually unproductive, hospitalizations for mood disorders, personality disorders, and/or psychotic diagnoses. The average individual with DID spends five to 12.5 years in mental health treatment until a correct diagnosis is made.
Having suicidal or self-destructive thoughts, impulses, urges, plans or behavior require emergency treatment, including calling 911 or going to the nearest Emergency Department or Mental Health Urgent Care Clinic.
A diagnosis of dissociative identity disorder should be suspected if you or your loved one:
- Receives numerous different psychiatric diagnoses, yet does not respond to many different types of treatments including multiple medications, types of psychotherapy, or neurostimulation treatments like electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).
Unlike the stereotype of DID, symptoms of DID are usually subtle and hidden, and individuals with DID do not readily reveal their symptoms without careful examination by a mental health professional.
You or your loved ones may notice the person is:
- Repeatedly very “moody”
- Highly changeable from time to time, and
- Has difficulty recalling important personal experiences.
- This can include a variety of current behaviors and parts of the life history, that are not related to use of substances or medications, or to brain injuries or diseases.
These difficulties recalling important personal experiences can include:
- Significant gaps in memory for life history
- Experiencing “black outs” or “time loss”: gaps in remembering current life history
- Lack of recall of complex, witnessed behaviors – even positive behaviors, such as doing well in a presentation at work
- Not remembering or difficulty remembering important events, such as graduations, birthdays, weddings, and vacations, that other family members recall well
- Recurring puzzling lack of memory for things that the person has purchased or created
- Inexplicable alterations in abilities and habits, such as forgetting that one can play a musical instrument, or changing suddenly from a smoker to a non-smoker, then back again
- Repeated unexplained travel or “getting lost” in familiar places
- Repeated rationalizations for being “forgetful” or “preoccupied”
Other common symptoms of DID include:
- Hearing voices, particularly inside one’s mind; these are often experienced as having their own sense of self, such as a child’s voice, an angry voice, a caring and supportive voice, among others
- Seeing things that others do not see, such as people, faces, or visions, including seeing the “people” that one is hearing talking
- Out of body experiences, as if watching oneself from a distance outside, or even inside oneself, frequently accompanied by the feeling that one can observe, but not control what one is doing
- Feeling like you are disconnected from the world around you as if seeing through a fog; things seem unreal
- Experiencing repeated inexplicable, sudden intrusions of thoughts, feelings, urges, or actions that one does not control
- Experiencing repeated inexplicable, sudden deletion of thoughts, feelings, behavior that one does not control
- Feeling divided with different senses of self that seem relatively independent of one another, and often are in a conflict or a struggle
- Inexplicably feeling very different at different times with varying opinions, abilities, habits, and access to memory and learned information
Treatment of Dissociative Identity Disorder
DID is a treatable disorder once it is properly diagnosed. Clinicians who understand DID symptoms can diagnose DID in the clinical interview. There are also paper and pencil tests that can help clinicians diagnose DID and other dissociative disorders.
Studies show that DID symptoms improve over time when treated using Phasic Trauma Treatment.
Phasic Trauma Treatment
Phasic trauma treatment is a psychotherapeutic treatment that has three phases:
- Safety and stability
- Work on traumatic memories
- Re-integration into life
In DID treatment, working directly with the DID identities is crucial to diminish symptoms and to maximize the resilience found in most people with DID. The first phase, safety and stability, is the most important. During this phase, individuals learn how to stabilize symptoms of DID and PTSD, using a variety of psychotherapeutic techniques and sometimes adjunctive/add-on medications.
It is critical for the individual with DID to develop safety from suicidal and self-destructive behaviors, substance abuse, eating disorders, high risk behaviors, unsafe people, and other dangerous behaviors and situations. This is because DID develops in a childhood environment of repeated lack of safety and unpredictable danger.
Without development of safety, DID treatment will not progress.
Not all individuals with DID wish to address his/her traumatic experiences in depth. However, if the individual with DID agrees, and has achieved safety and stability, Phase 2 is focused more on carefully and slowly recalling the life history – which is often experienced as PTSD flashbacks. Therefore, this phase also involves ongoing work on safety and additional stabilization of DID and PTSD symptoms.
In Phase 3, the individual’s DID and PTSD symptoms have usually substantially moderated, and the individual with DID may even experience subjective fusion of some or all self states, with complete merging of the characteristics of these subjective identities. This frees up energy for a focus on living better in the present.
Adjunctive/Add-On Treatments for Dissociative Identity Disorder
Hypnotherapy: Hypnotherapy can be helpful in stabilizing DID and PTSD symptoms. However, hypnotherapy can only be used if the therapist has received certification in using hypnosis and has specialized training in its use in DID and other posttraumatic disorders. Make sure to ask your provider about his/her credentials in using hypnosis.
Medications: Medications are adjunctive (add-on) treatments in DID treatment and do not directly affect the basic symptoms of DID. In DID treatment, medications do not have a major direct effect on symptoms unless there are other specific disorders present. For example, there are medications that can substantially improve symptoms of PTSD, although some people cannot take these due to side effects.
Medications for depression and mood symptoms usually have limited effects, but may provide some symptom relief as long as the patient and practitioner have carefully identified which symptoms will and will not be helped by medications. Medications for anxiety symptoms can be moderately helpful but must be monitored carefully, especially in individuals with a history of substance abuse.
Individuals with DID often have a complex, chronic sleep disturbance with difficulty falling asleep, staying asleep, nightmares, and even complex behaviors that appear to emerge out of sleep. There are medications that can help PTSD nightmares and this may improve sleep, if the patient does not have problematic side effects. Sedating medications often are only partially helpful. Specific DID psychotherapy is often required to assist with fears and flashbacks related to bed, night, and sleep, and nighttime dissociative symptoms.
Other Types of Psychotherapy that can Assist with DID Treatment
Other forms of psychotherapy such as dialectical behavioral therapy (DBT) and cognitive behavioral therapy (CBT) that is focused on trauma-related cognitive distortions can be helpful as adjunctive/add-on to the phasic psychotherapy for DID.
Eye-Movement Desensitization and Reprocessing Therapy (EMDR): Eye-movement Desensitization and Reprocessing Therapy (EMDR) is a treatment that has been found to improve PTSD symptoms, typically in people who have experienced specific adult traumas.
EMDR can significantly worsen the symptoms of DID, especially if used before the DID patient is stabilized in treatment. EMDR can be an adjunctive/add-on treatment if the therapist has full training in EMDR and has specialized training in its use in DID and other complex posttraumatic disorders.
Group Therapy: Group therapy can be helpful for the stabilization of individuals with DID if they are in a group dedicated to patients with this diagnosis, and the group is facilitated by practitioners that are knowledgeable about DID treatment. Individuals with DID usually do not do well in general therapy groups, even those that focus on PTSD and trauma, but are not designed for severely dissociative patients.
In general, DID experts do NOT recommend the use of non-professionally facilitated support groups in the treatment of DID, including online support groups. Both in-person and online “support” groups ultimately may have a severely negative impact on the individual with DID and his/her treatment.
Family Involvement: Family treatment, usually with the patient’s spouse, or significant other can be helpful, for education and to help support both the patient and the family during an often long and difficult treatment. In particular, family members are educated to not directly interact with the patient’s varying self states, but should regard their partner as a “whole human being,” and not a group of separate “people.” Specialized couple’s therapy may be helpful if the therapist is knowledgeable about treatment of childhood trauma and its impact on adult relationships.
Rehabilitation Therapies: Adjunctive/add-on rehabilitation therapies like art therapy and occupational therapy can be helpful if the therapist has training in the use of these modalities in the treatment of complex posttraumatic disorders like DID.
To learn more about dissociative identity disorder, visit The Trauma Disorders Program's section of our website and the International Society for the Study of Trauma and Dissociation's website.