Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder, is characterized by two or more distinct personalities that take control of a person. Psychotherapy is the primary treatment, involving establishing trust and safety, mapping alters and trauma history, processing trauma memories, and integrating alters. Integration aims to unite alters into a single identity, while resolution stabilizes alter cooperation. Relapse is common, requiring ongoing treatment to solidify gains and prevent dissociative coping.

1. Dissociative Identity
Disorder
By Annika Smith
Introduction to Psychology Final Presentation

2. Introduction
What is Dissociative Identity Disorder?
Prevalence
Brief History of Dissociative Identity Disorder

3. What is Dissociative Identity
Disorder?
 Dissociative Identity Disorder (DID) is a dissociative
disorder characterized by:
 Having two or more distinct personalities with
the ability to take control of the person with
DID (Murray, 1994; Kluft, 1999)
 Amnesia (Kluft, 1999).

4. Prevalence
 Five times more woman than men have DID, possibly
because women are more often abused sexually (Murray,
1994).
 3-4% of the North American population show severe
symptoms of dissociation, 1% of which have severe enough
symptoms to be diagnosed with a dissociative disorder
(Elzinga, Van Dyck, & Spinhoven, 1998).
 In the psychiatric population 15% have a dissociative
disorder, and 4-5% have DID (Elzinga et al., 1998).

6. Brief History of Dissociative
Identity Disorder
 The first case of DID was identified almost four centuries ago
(Murray, 1994).
 DID was formerly known as Multiple Personality Disorder (MPD)
(Kluft & Foote, 1999).
 The American Psychiatric Association (APA) accepted Multiple
Personality Disorder as a diagnostic category in 1980 (Murray,
1994).

7. Brief History of Dissociative
Identity Disorder
 Cases of DID have drastically increased since the APA’s
recognition of it as a diagnostic criteria (Murray, 1994).
 Up until 1970 there were only 79 cases reported worldwide (Elzinga
et al., 1998).
 In 1986 the number diagnosed in North America was roughly 6,000
(Elzinga et al., 1998).
 Now the number of cases is innumerable and the disorder can no
longer be considered “rare” (Elzinga et al., 1998).

8. Cause, Symptoms and
Diagnosis
What causes DID?
Symptoms
Misdiagnosis
How does DID work?

9. What Causes DID?
 There is a strong association between childhood trauma (especially
sexual abuse) and the formation of DID (Murray, 1994).
 Dissociation may be a strategy scared children use to distance
themselves from the harsh realities of their lives (Murray, 1994).
 Only 3% of the 100 students evaluated in a 1986 study did not have a
history of childhood abuse (Murray, 1994).
 DID is often formed in childhood but often takes years to be diagnosed.
Oftentimes, another psychological problem is the first diagnosis, and it
takes six years of therapy before the DID is discovered (Murray, 1994).

11. Symptoms
 In addition to the alternating personalities, DID patients experience a
wide variety of symptoms (Murray, 1994).
 DID patients may satisfy the DSM criteria for diagnosis at one time and
not at others. This appearing and disappearing of symptoms is similar
to bipolar depression symptom behavior (Murray, 1994).
 Often, symptoms will be admitted to in one portion of an interview and
denied in another (Murray, 1994).
 Symptoms may appear in a “window of diagnosibility” (Murray, 1994).

12. Symptoms
 One of the most important symptoms is the presence of
multiple personalities.
 The average number of alters is 13 and the mode is six. However,
there have been cases of patients with over one hundred alters.
(Elzinga et al., 1998).
 Each personality will have different sets of thoughts, memories,
feelings, and behaviors (Murray, 1994).
 They can also have different handwriting, genders, sexual
orientations, ages, clothing tastes, and even allergies (Murray,
1994).

13. Symptoms
 The host personality Is the dominant personality, or the one in
control the majority of the time. It is the “original” personality
(Murray, 1994).
 68% of DID patients’ host personalities were unaware of their
alters (Murray, 1994).
 The host, although often unaware of his alters, may sense that
something is wrong (Murray, 1994).
 An “alter” is any other personality existing in a DID patient.

14. Symptoms
 Amnesia is the second constant symptom of DID (Kluft, 1999).
 Both the original (host) personality and the alters are aware of lost
periods of time (Murray, 1994).
 Often, memories of the trauma which caused DID are not recovered
until well into the therapy process (Kluft, 1999).
 Other variable symptoms include (Murray, 1994):
 Substance abuse
 Suicidal tendencies
 Dissociative disorders apart from DID

15. Symptoms
 Studies show that DID patients also meet criteria for:
 Borderline Personality Disorder (Elzinga et al., 1998)
 Somatization Disorder (Elzinga et al., 1998)
 Post Traumatic Stress Disorder (Elzinga et al., 1998; Murray,
1994; Tsai, Condie, Wu, & Chang, 1999)
 Anxiety Disorders (Elzinga et al., 1998)
 Depression (Elzinga et al., 1998).

17. Symptoms
 DID may also affect a person’s neurobiology.
 An fMRI case study (Tsai et al., 1999) discovered that a woman
with DID had a hippocampal volume which was significantly
smaller than that of an average female adult. It was similar to
the volume found in people with Alzheimer’s disease.

18. Symptoms
 Symptoms are often hidden phenomena in DID. Secrecy is an important dimension
to be considered in diagnosis and treatment of DID patients (Murray, 1994).
 They are often hesitant to talk about their symptoms of amnesia or their
multiple selves.
 They exhibit all known forms of psychological defense.
 Roughly 94% of DID patients deny, dissimulate, or rationalize their condition.
 Their overuse of repression, denial, and continual use of secrecy are the
biggest obstacles in treatment.

19. Some alters will admit to DID symptoms, while
others will not.

20. Misdiagnosis
 There is a high rate of misdiagnoses in DID patients,
because symptoms often overlap with other psychiatric
conditions.
 Schizophrenia is a common misdiagnosis, since many DID
symptoms are also symptoms of schizophrenia (Murray,
1994).

21. Schizophrenia is not the same as DID.

22. How does DID work?
 Relationships between the alters usually follow one of three patterns:
 1) They are mutually aware of each other.
 2) They are mutually unaware of each other.
 3) One is aware of the other, but the awareness is not reciprocated (Murray, 1994).
 In its simplest form, two personalities alternate with each other, each
unaware of the other.
 Another pattern involves two or more dominant personalities and one or
more subordinates (Murray, 1994).

23. How does DID work?
 68% of DID patients weren’t aware of their alters.
 86% had personalities that claimed to be aware of all alters (Murray,
1994).
 The majority of DID patients are unaware of their alter personalities,
though they may sense that something isn’t right.
 A DID patient, “Gina,” didn’t like hot chocolate but began finding
mugs with leftover hot chocolate in the sink.
 This made her aware of something wrong (Murray, 1994).

24. How does DID work?
 A DID patient forms alters in order to cope with trauma or
disturbing experiences (Murray, 1994).
 Different alters seem to handle different problems of the
DID patient (Murray, 1994).
 Personalities are often polar opposites, which in extreme
cases may represent the conflict between restraint and self-
indulgence that all humans experience to some degree
(Murray, 1994).

25. How does DID work?
 Research conducted by Tsai et al. (1999) suggested that certain parts of
the brain were involved in the process of switching personalities.
 There was bilateral hippocampal inhibition during the switch from host to
alter personality, with inhibition being stronger on the right side.
 The right parahippocampal and medial temporal regions were inhibited, along
with small parts of the substantia nigra and globus pallidus.
 The switch back to the host personality, however, only involved activation of
the right hippocampus.
 This points to a hippocampal-mediated process involved in
switching personalities.

26. Treatments
Psychotherapy
Other Treatments
Post-Unification Treatments
Future Treatments

28. Psychotherapy
 Pyschotherapy is the primary method of treatment.
 Kluft (1999) outlines nine stages of psychotherapy
treatment.
 Stage 1: Establishing the Psychotherapy.
 This first stage of therapy involves “the creation of an empathetic
atmosphere of safety, within which the security of the treatment
can be made, the therapeutic alliance can be established, and the
patient can be prepared for the therapy that will follow” (Kluft,
1999, p. 290).

29. Psychotherapy
 Stage 1: Establishing the Psychotherapy cont.
 This stage should include conversations about:
 The proposed treatment and its expected benefits and risks
 Alternative choices of treatment and their probable results
 Techniques likely to be used during treatment along with their
benefits and drawbacks
 Appropriate warnings to the DID patient

30. Psychotherapy
 Stage 2: Preliminary Interventions
 The focus in this stage is to:
 strengthen the patient across all alters in order to stabilize the
personality system
 to make contact the easily available alters
 establish agreements with as many alters as possible. These
agreements are:
 Not to abruptly interrupt therapy
 Not to commit suicide or self-harm

31. Psychotherapy
 Stage 2: Preliminary Interventions cont.
 To stop as many dysfunctional behaviors as the patient is willing to give up.
 This is also the stage to deal with any issues between the patient and therapist.
 As many alters as possible should be brought into the therapeutic alliance, and
communication and cooperation between them should be fostered.
 Communication between identities is encouraged using free-association journaling.
 If there is symptomatic relief available, it will be offered in this stage.
 Coping methods for dealing with the affects of DID will be taught now.

32. Psychotherapy
 Stage 2: Preliminary Interventions cont.
 Patients can be taught to substitute alters to:
 “stabilize the system, to create the subjective experience of
sanctuary, to reduce the intensity with which they experience
distressing materials, to put upset alters to sleep between sessions,
to sequester overwhelming material between sessions, to break
intense experiences into less overwhelming ones, and to
reconfigure their alter system to effect coping that does not
involve dysfunctional or self-destructive behavior.” (Kluft, 1999, p.
292-293).

34. Psychotherapy
 Stage 3: History Gathering and Mapping
 During this stage, the therapist investigates each alter in depth.
 He learns each personality’s concerns, origins, and relationships to each other.
 The therapist presses for more and more collaboration and cooperation
between alters.
 The therapist begins to learn how the system of personalities reacts to
traumata.
 This stage is necessary to continuing on to stages in which trauma is
worked through, in order to prevent unforeseen crises involving
multiple alters with similar concerns (Kluft, 1999).

35. Psychotherapy
 Stage 4: Metabolism of the Trauma
 This stage focuses on accessing and processing the trauma which
caused the DID.
 It is useful to reminds patients that traumatic memories will be worked
through for the patient’s own good, and that just because they have a
memory of something does not mean that it is verifiable.
 Oftentimes, the therapist must revisit issues addressed in earlier stages,
as it is necessary to maintain the stability of the personality system.
 Hypnosis and EMDR are commonly used in this stage

36. Psychotherapy
 Stage 5: Moving Toward Integration / Resolution
 This is the stage in which efforts are made towards working
through the traumatic material across all alters.
 More cooperation, communication, mutual empathy, and
identification is encouraged between alters.
 As inner conflicts are reduced, it isn’t uncommon for alters to begin
blurring their characteristics, fading in prominence.
 Identity confusion will probably occur.
 Oftentimes alters will not know who they are, or “experience themselves
as co-present with other alters” (Kluft, 1999, p. 293).

38. Psychotherapy
 Stage 6: Integration/ Resolution
 This is the point in therapy when the patient finally achieves a
workable condition.
 either as a single personality (integration)
 or as a stable collaboration of alters (resolution).
 Integration is the preferable outcome, but some patients do
not want to take that step.

39. Psychotherapy
 Stage 7: Learning New Coping Skills
 Learning new coping skills has gone on throughout therapy,
but it now becomes the focus.
 The patient will need help in dealing with circumstances in a
better way than the previously used dissociation.
 Major life decisions and relationships may change as a result
of reevaluation, without the distortion imposed by the multiple
personalities.

40. Psychotherapy
 Stage 8: Solidification of Gains and Walking Through
 This may be a long stage.
 The patient needs to learn how to live through life’s struggles without
using dissociative coping.
 Stage 9: Follow-Up
 This stage involves the assessment of the patient’s stability.
 It is incredibly important, especially in patients who opted for resolution
instead of integration.
 Sometimes, new layers of alters are discovered

41. Previously undiscovered alters often surface at multiple points of
psychotherapy.

42. Psychotherapy
 Kluft (1999) also describes five “stances” of treatment.
 The stance taken by the therapist about treatment of DID
plays a major role.
 Strategic Integrationalism
 Focuses on eliminating the dissociative defenses, so that the
condition collapses from within.
 The goal is the complete integration of the personality and
resolution of the patient’s symptoms and difficulties.

43. Psychotherapy
 Tactical Integrationalism
 This stance is similar to Strategic Integrationalism
 However, instead of focusing on one end goal, it focuses on
multiple, smaller goals.
 The end goal is integration.
 Personality-Oriented Treatment
 Focuses less on integration and more on cooperation between
alters.
 Integration can be pursued.

44. Psychotherapy
 Personality-Oriented Treatment cont.
 This may also refer to a stance in which the therapist sees each alter as a
genuine person who must be nurtured into health.
 While this approach is sometimes successful, there have been several
unfortunate outcomes
 Adaptationalism
 Prioritizes management of life and maintenance and improvement of
function.
 Avoids focusing on trauma work and recovery
 Stems from supportive psychotherapy.

45. Psychotherapy
 Adaptationalism cont.
 Integration is not a goal.
 Minimization
 A stance which comes from the assumption that DID is not a “genuine
clinical phenomenon” (Kluft, 1999, p. 297). It is endorsed by skeptics of
DID.
 Any therapist taking this stance thinks that if the symptoms of DID are
not reinforced with attention, they will disappear.
 Minimization has not been successful in anything more than temporarily
suppressing symptoms. Every patient treated with this stance had DID at
follow-up.

46. Other Treatments
 There are no drugs to treat DID itself, but they can be used to treat
symptoms like PTSD, depression, and anxiety (Kluft, 1999).
 Clinician-led group therapies are often helpful because they give
patients the opportunity to relate to others in similar positions (Kluft,
1999).
 “Self-help” groups are not as helpful (Kluft, 1999).
 Family therapies are useful in helping loved ones of the DID patient, but
not as useful for the DID patient himself (Kluft, 1999).

48. Post-Unification Treatment
 The majority of patients who seem to achieve integration experience a
relapse into DID or discovery of more personalities (Kluft, 1988).
 The more complex the patient, the more likely this will be.
 Post-unification treatment is vital when dealing with DID patients in
order to deal with any relapses or discoveries of further alters (Kluft,
1988).
 This treatment may take longer than the treatment before integration
did.

49. Future Treatments
 A study by Tsai et al. (1999) suggests that there may be a
“possible neurophysiological basis for an empirical
treatment principle in DID” because of the apparent
involvement of the hippocampus in the process of switching
personalities.

50. Controversies
Is DID iatrogenic?
Is DID overdiagnosed?
Is it possible to repress or create traumatic memories?

51. There are plenty of clinicians who doubt the validity
of DID as a diagnostic entity.

52. Is Dissociative Identity Disorder
Iatrogenic?
 It has been contended that DID is iatrogenic (that it is created in
therapy).
 It has been shown that false memories can be created, especially with
the use of hypnosis (Elzinga et al., 1998).
 Some argue that this can undermine DID, since it is caused by forgotten
memories of child abuse. These memories are often discovered in therapy –
which often uses hypnosis as a treatment method.
 Additionally, there is evidence that therapists can unintentionally create
new alters while conducting therapy (Elzinga et al., 1998).

53. Is Dissociative Identity Disorder
Iatrogenic?
 While in some cases DID may have been created in therapy by
the expectations of both the therapist and the patient, this is
not always the case (Elzinga et al., 1998).
 There are patients who enter therapy with DID right from the
start (Elzinga et al., 1998).
 DID is a genuine disorder that develops as a result of trauma
(Elzinga et al., 1998).

54. Is Dissociative Identity Disorder
Overdiagnosed?
 It has been argued that the vast increase in DID cases in recent decades is
the result of overdiagnosis.
 This could be attributed to the vague criteria in the DSM-IV, which leave
plenty of room for interpretation by therapists (Elzinga et al., 1998).
 This problem is furthered by high comorbidity, which confuses the issue of
whether DID is a symptom of other disorders, or other disorders are a
symptom of it (Elzinga et al., 1998).
 However, this is not a problem unique to DID. It is a problem in the DSM approach
of all discrete diagnostic entities (Elzinga et al., 1998).

55. Is Dissociative Identity Disorder
Overdiagnosed?
 Elzinga et al. (1998) suggested that structured interviews and measuring
instruments are more useful in diagnosis of DID than the DSM-IV.
 The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) has
been validated and is reliable for detecting symptoms of DID (Elzinga et al., 1998).
 Some argue that the presence of such instruments is proof that DID is a
diagnostic entity.
 However, anyone could make up a questionnaire which could uncover the
symptoms of some imaginary disorder (Elzinga et al., 1998).

57. Is It Possible to Create or Repress
Traumatic Memories?
 Skeptics of DID sometimes argue that the memories of child abuse which
surface during psychotherapy are created by the therapists.
 Multiple studies have proven that false memories can be created (Elzinga et al.,
1998).
 However, these experiments created false memories that were unremarkable,
common experiences such as being lost in a shopping mall (Elzinga et al., 1998).
 This isn’t comparable to inducing memories of being repeatedly raped as a little girl
by your father.
 Ethics prevent research to be conducted on the possibility of creating false traumatic
memories (Elzinga et al., 1998).

58. Is It Possible to Create or Repress
Traumatic Memories?
 There is no evidence that supports the idea that traumatic memories
can be falsely created.
 Alternately, skeptics argue that it is not possible to forget a traumatic
experience such as sexual abuse.
 There is evidence that repressing trauma is indeed possible
 Hippocampically-based memories are often stored as fragments of
emotion and sensation because of information bombardment in the
amygdala during trauma (Elzinga et al., 1998).
 This would make such a person unable to verbally express the trauma, though
the experience could still affect behavior and functioning.

59. Is It Possible to Create or Repress
Traumatic Memories?
 Furthermore, studies showed that 38% of female trauma victims who were
abused severely enough to visit the hospital had no memory of the event
twenty or more years later (Elzinga et al., 1998).
 Amnesia is strongly associated with repeated and long-lasting abuse (Elzinga et
al., 1998).
 There is a documented relationship between the severity of dissociative
symptoms and the severity of childhood abuse (Elzinga et al., 1998).
 These all point to the probability that traumatic memories can be repressed.

60. References
 Elzinga, B. M., Van Dyck, R., & Spinhoven, P. (1998). Three Controversies About Dissociative
Identity Disorder. Clinical Psychology and Psychotherapy, 5(1), 13-23.
 Kluft, R. P. (1988). The Postunification Treatment of Multiple Personality Disorder: First Findings.
American Journal of Psychotherapy, 42(2), 212-228.
 Kluft, R. P., & Foote, B. (1999). Dissociative Identity Disorder: Recent Developments. American
Journal of Psychotherapy, 53(3), 283-288.
 Kluft, R. P. (1999). An Overview of the Psychotherapy of Dissociative Identity Disorder. American
Journal of Psychotherapy, 53(3), 289-319.
 Murray, J. B. (1994). Dimensions of Multiple Personality Disorder. The Journal of Genetic
Psychology 155(2), 233-246.
 Tsai, G. E., Condie, D., Wu, M., & Chang, I. (1999). Functional Magnetic Resonance Imaging of
Personality Switches in a Woman with Dissociative Identity Disorder. Harvard Review of Psychiatry
7(2), 119-122.