Inside DID: A Closer Look at Dissociative Identity Disorder

What Is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is a type of dissociative disorder. It most often develops in early childhood among children who experience long-term trauma, such as emotional, physical, or sexual abuse, neglect, or unpredictable caregiver behavior.

Some children cope by compartmentalizing traumatic experiences and displacing them onto other aspects of themselves, allowing them to distance psychologically from pain. Dissociation can help a child move through life without constant reminders of distressing events.

According to DID expert Milissa Kaufman, MD, PhD, young children have a natural capacity for magical thinking. They might believe, for example, that Superman is real or that they could fly someday.

Similarly, children may displace their own feelings onto a personified stuffed animal or imaginary companion: “I’m not worried about my first day of kindergarten, but Fluffy is!” This is developmentally appropriate and, in the context of trauma, can become a coping mechanism.

A child experiencing repeated abuse might think, “It’s too overwhelming to feel fear or anger. That’s not me—that’s someone else.” By displacing overwhelming thoughts and emotions onto separate, personified aspects of self, the child creates a “not me” experience—the cornerstone of DID.

Kaufman notes, “A child doesn’t have many other ways to cope. They can’t turn to their parents, since that is the origin. They feel like there are other people inside of them, and they can’t tell anybody.” Despite this, DID often allows children to maintain attachments, creativity, and humor under extremely difficult circumstances.

However, when dissociation continues into adulthood after the danger has passed, it can interfere with—or even prevent—recovery from trauma.

Kaufman observes that the women she works with often have histories of childhood abuse, PTSD, and co-occurring conditions, such as eating disorders or substance addiction. While DID also affects men, she believes they are less likely to seek help, partly due to stigma and partly because mental health professionals may be less likely to recognize it.

“The media depicts women most often as having this disorder, so men may not be asked about it,” she explains.

Understanding Dissociation

A 1986 study by Frank W. Putnam and others in the Journal of Clinical Psychiatry found the average patient with DID has been in the mental health delivery system for an average of 6.8 years and has received three other diagnoses. This reflected either misdiagnoses or occurrences of other diagnoses or symptoms that delayed an accurate diagnosis.

Dissociation occurs along a spectrum, from “spacing out” while driving and missing an exit to being hyper-focused on a topic.

Further along are depersonalization and derealization—which Kaufman describes as a profound detachment from sense of self or sense of body, a sensation of being apart from one’s self, perhaps viewing what is happening from a distance.

The furthest end of the spectrum is fragmentation of identity, where “my feelings or my thoughts or my body feel like they don’t belong to me,” she says.

Recognizing Signs and Symptoms of Dissociative Identity Disorder

Most people with DID rarely show noticeable signs of the condition. Friends and family of people with DID may not even notice the switching—the sudden shifting in behavior and affect—that can occur in the condition.

The subtle symptoms are often a mixture of dissociative symptoms, such as a sense of being detached from one’s own sense of self or from one’s surroundings, and post-traumatic stress disorder (PTSD) symptoms, such as flashbacks.

Someone with DID becomes skilled at displacing and personifying aspects of their experience onto other aspects of their self. This shifting happens throughout life, even once the traumatic situation has passed. This can occur even in circumstances when a trigger for dissociating isn’t harmful.

People with DID often experience or show symptoms related to:

• Anxiety
• Depression
• Self-puzzlement
• Disordered eating
• Self-destructive behavior
• Substance misuse
• Memory gaps
• Suicidal thoughts or self-harm

Someone with DID may feel very detached from experiences or even forget doing or saying something that others witnessed. The gaps in memory, confusion, and stress of living with the subjective sense of having “not-me” experiences can become distressing.

Those with DID often experience depression, mood swings, and difficulty fully trusting in relationships.

Although people with DID have a strong internal sense of identity fragmentation, it is a common misconception that people living with DID display “multiple personalities.” In fact, in most individuals, the condition is hidden.

According to a 2010 Psychiatric Times article, only 5% of people with DID exhibit obvious switching between identity “states.”

If you believe someone close to you may have DID, gently share your observations. Encourage them to see a mental health professional, or if they are under your care, share your concerns with their primary care provider or therapist, if they have one.

Dissociative Identity Disorder Is Treatable

The overarching goal of DID treatment is to maintain stability, rather than moving quickly into focusing on processing trauma.

In contrast to PTSD stemming from a single event that happened in adulthood, DID is associated with repeated traumatic events during critical developmental periods in early childhood.

Because of this, typical treatments for PTSD, such as a time-limited course of prolonged exposure or eye movement desensitization and reprocessing (EMDR), are not the standard of care for DID.

DID is best treated with a three-phased approach that involves focusing on safety and stability, processing traumatic events, and eventually being able to go through life without dissociating. Any phase of the process can take several years, and often the phases overlap.

In addition to symptoms of PTSD and dissociation, individuals with DID often need treatment for co-occurring issues. These include depression, suicidality, self-harm behaviors, disordered eating, and body image distortions.

Phase 1

The first step in treatment aims to reinforce the safety of the person with DID with a focus on more serious symptoms like self-harm or suicidal ideation.

In treatment, a licensed mental health expert helps the person with DID to replace any harmful coping techniques they use with healthier options. At the same time in treatment, the clinician works with the patient to identify PTSD symptoms they may be experiencing.

They also start the process of teaching ways to understand that dissociated identity states represent important feelings, thoughts, and memories that, while very difficult to accept, are part of a whole self.

Phase 2

The second step focuses on identifying, addressing, and working through traumatic memories.

Doing this under clinical care helps the patient build distress tolerance and manage reactions to traumatic memories in a safe environment. Doing so with the help of a mental health professional is key to avoid re-traumatization.

As symptoms of PTSD and co-occurring issues stabilize, DID patients begin to integrate compartmentalized experiences.

They begin to understand that painful thoughts, emotions, and memories they mentally packed away as children—however difficult they may be—really do belong to them. They learn to connect their life experiences to their sense of self. They begin to feel as though they have a whole and coherent narrative of their own life.

Phase 3

Lastly, DID patients learn to live their life now without relying on dissociative defenses to cope. As new and different coping methods are used successfully, they will likely experience greater confidence, increased self-awareness, stronger self-regulation skills, and more emotional stability.

Treatment must also focus on individuals’ struggles to feel safe in close relationships and the world. People with DID often view themselves as damaged, somehow at fault for the abuse sustained during childhood, and unworthy of care.

Because of this, the development of a trusting alliance and safety and symptom management during treatment takes time. Trauma-focused work must be paced gradually.

Debunking Myths About Dissociative Identity Disorder

Given the amount of misinformation around the condition, it’s possible that what you’ve heard about DID isn’t true.

Myth: DID Is Obvious

Despite what the media may portray, it is not easy to tell when someone has DID. However, the experience of having a fragmented sense of self and “not me” thoughts, feelings, memories, and even body image, feels very real for people with DID.

Characters portrayed in the media as having DID are often shown wearing uncharacteristic clothes, displaying wildly changing mannerisms, or appearing to be a different person altogether. People with DID rarely express their identities in such obvious ways.

Myth: People With DID Experience Psychosis

Many believe that those with DID have psychosis—a lost sense of reality. In fact, unless people with DID are in the throes of PTSD and are being highly triggered, they have an intact sense of reality.

According to a 2018 article in Dialogues in Clinical Neuroscience, “When not overwhelmed by post-traumatic intrusions, DID patients show … a hyperdeveloped capacity to observe their own psychological processes.”

Myth: People With DID Are Dangerous

Many people with DID have been portrayed as dangerous individuals who perform violent acts under different “personalities.”

People with DID are no more violent or dangerous than the general population. Their symptoms and behaviors reflect that they are afraid of dangerous situations.

In fact, due to their histories of childhood trauma, many people with the condition feel frightened and do their best not to call attention to themselves.

Myth: DID Is a Rare Condition

Because DID has been misunderstood and is hard to detect, it is often called a rare condition. In fact, DID occurs in approximately 1% of the general population. This is the same percentage of people who have schizophrenia.

Myth: DID Cannot Be Effectively Treated

DID is a serious mental health condition. It’s hard for many therapists who are untrained in dissociative disorders to recognize it. But with effective treatment from mental health providers who are trained in trauma and dissociation or able to receive consultation with someone trained, people with DID can and do recover. People with DID can live full and productive lives.

Myth: Health Care Providers Convince Patients of Past Trauma That Isn’t True

One of the controversies about DID is a theory that mental health professionals bring DID on by suggesting false accounts of past abuse to gullible patients. This suggests that therapists who obtained information from the media might somehow lead their patients into thinking they have histories of childhood abuse when abuse never happened.

However, a 2016 publication in the Harvard Review of Psychiatry states that no study has ever supported this “fantasy model.” Instead, several studies confirm that DID develops in individuals who have experienced severe trauma. DID is also repeatedly found in people who are unaware of the disorder and in cultures where the condition is unknown.

Myth: DID Is Faked or Exaggerated

DID can also be wrongly connected to malingering (exaggerated) and factitious (inauthentic) disorders, where patients make claims either with or without motivation for personal gain. The best-known example of a factitious disorder is the severe form once known as Munchausen syndrome.

“That’s not what it looks like,” says Dr. Kaufman. “It’s a very real, very well-studied psychiatric disorder.”

“It typically is at the hands of a caretaker. It can be sexual abuse, it can be physical abuse, it can be emotional abuse. But generally, people who have DID have had many different types of abuse at the hands of multiple perpetrators.”

Supporting Someone Living With Dissociative Identity Disorder

While a diagnosis of DID can be confusing or scary at first, it can be managed by better understanding the condition. We’ve compiled several top tips to help manage the disorder, whether it’s your own diagnosis or the diagnosis of someone that you care about.

1. Learn About Dissociative Identity Disorder

One of the best ways you can support someone’s DID journey—whether your own or a loved one’s—is to learn more about the condition.

Find books and documentaries about DID. Connect with organizations, such as the National Alliance on Mental Illness (NAMI) to learn more about DID and join support groups.

2. Listen and Offer Support

If a loved one is diagnosed with DID, talk to them. Let them know you are open to listening to their experiences to the point they feel comfortable sharing. You can start a conversation by simply saying, “I’m here for you. How are you?” You don’t need to solve their problems. Just listen.

If you are the person with DID, ask your friends or family members if you can talk about how you’re feeling, or what’s happening in your life. Create a support system within your social circles.

3. Connect With Support Services

If you or a loved one needs help finding a therapist or other services, there are ways to find treatment and support.

4. Meet Them Where They Are

It can feel confusing to interact with a loved one who is dissociating. While signs of dissociation tend to be subtle, sometimes people with DID may suddenly appear disengaged, frightened, or spacey. If you notice such behaviors, remain calm and remember that people with DID often dissociate automatically as a way of feeling safer.

If you are the person with DID, you can provide as much information as possible to your loved ones about the condition so that they are more able to be as supportive as possible when it comes to condition management.

5. Address Self-Harm and Suicidal Behavior

If you or someone you care about is hurting themselves or struggling with suicidal thoughts, it is urgent that you or they receive help.

Call or text the 988 Suicide & Crisis Lifeline at 988, connect them with professional help immediately, or take them to the nearest emergency department.

Find access to additional suicide prevention resources.

6. Help Prevent Triggers

Triggers are external stimuli that cause distress. Examples of triggering situations include being in a crowd or hearing a particular word or a loud noise. Potential triggers are limitless and are highly individual.

For someone with DID, triggers can provoke flashbacks and dissociation. You can learn about your loved one’s—or your own—triggers by asking directly or by observation. With this information, you can help prevent distressing situations.

7. Take Care of Yourself

When we support people who have experienced trauma and/or have mental health conditions, it is important to take care of ourselves, too. Such self-care can include quiet time or engaging in restorative activities such as creating art or exercising. Self-care can also include seeing your own therapist and participating in support groups.

Researching Dissociative Disorders

Scientists are exploring potential biological or genetic links that could predispose a person to DID. Studies to date have shown that in the classic form of PTSD, the brain’s amygdala—which controls the “fight-or-flight” response—is overactive while the prefrontal cortex is not, generating a hyper-aroused state.

But in the dissociative subtype of PTSD, Kaufman says, the prefrontal cortex is overactive to the point where a person can be numb and detached.

In fact, both the amygdala and prefrontal cortex become overactive in patients with DID. “The trauma state in DID looks like classic PTSD,” says Kaufman.

“In a numbed state of mind, it looks more like the dissociative subtype, where the brakes are on too tight.”

Scientists are also looking at the brain’s attentional activation system—how a person concentrates.

“People who are dissociative have a really refined ability to focus attention, particularly in multitasking,” she says. Researchers are working to understand how the brains of people with DID have a different allocation of resources toward attentional systems.

Finally, there are also studies on potential genetic links.

“You aren’t born with DID, but you can have a genetic predisposition to dissociate, so we are also looking for genetic markers.”

But Kaufman stresses that people with DID should not give up hope.

“It’s treatable. It’s a pretty phenomenal coping mechanism when you are growing up, but it becomes disruptive when you don’t need it anymore.”

Seeking Help for DID

Dissociative identity disorder is treatable. If you or someone you know is experiencing symptoms, the first step is to address it with a licensed health care professional or a mental health facility, like McLean.

If symptoms are serious and point to signs of self-harm or suicidality, call the Suicide & Crisis Lifeline at 988, connect with professional help immediately, or go to the nearest emergency department.

Contributors

Milissa Kaufman, MD, PhD