DID is controversial within both psychiatry and the legal system. Dissociation , the term that underlies the dissociative disorders including DID, lacks a precise, empirical, and generally agreed upon definition. Thus it is unknown if there is a common root underlying all dissociative experiences, or if the range of mild to severe symptoms is a result of different etiologies and biological structures. Some terms have been proposed regarding dissociation.
Psychiatrist Paulette Gillig draws a distinction between an "ego state" behaviors and experiences possessing permeable boundaries with other such states but united by a common sense of self and the term "alters" each of which may have a separate autobiographical memory , independent initiative and a sense of ownership over individual behavior commonly used in discussions of DID.
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Efforts to psychometrically distinguish between normal and pathological dissociation have been made, but they have not been universally accepted. According to the fifth Diagnostic and Statistical Manual of Mental Disorders DSM-5 , DID symptoms include "the presence of two or more distinct personality states" accompanied by the inability to recall personal information, beyond what is expected through normal forgetfulness.
Other DSM-5 symptoms include a loss of identity as related to individual distinct personality states, and loss referring to time, sense of self and consciousness. Individuals with DID may experience distress from both the symptoms of DID intrusive thoughts or emotions and the consequences of the accompanying symptoms dissociation rendering them unable to remember specific information. Around half of people with DID have fewer than 10 identities and most have fewer than ; as many as 4, have been reported.
However, it is unclear whether this is due to an actual increase in identities, or simply that the psychiatric community has become more accepting of a high number of compartmentalized memory components. Most identities are of ordinary people, though historical, fictional, mythical, celebrity and animal identities have been reported.
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The psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures. Comorbid disorders can include substance abuse , eating disorders , anxiety , post traumatic stress disorder PTSD , and personality disorders. 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. 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.
Both groups also report higher rates of physical and sexual abuse than the general population, and patients with BPD also score highly on measures of dissociation. 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 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-induced 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. 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.
People diagnosed with DID often report that they have experienced severe physical and sexual abuse , especially during early to mid-childhood  although the accuracy of these reports has been disputed  , and others report an early loss, serious medical illness or other traumatic event. What may be expressed as post-traumatic stress disorder PTSD in adults may become DID when occurring in children, possibly due to their greater use of imagination as a form of coping. Delinking early trauma from the etiology of dissociation has been explicitly rejected by those supporting the early trauma model.
However, a 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. Evidence is increasing that dissociative disorders are related both to a trauma history and to "specific neural mechanisms". The suggestion that DID was the result of childhood trauma increased the appeal of the diagnosis among health care providers, patients and the public as it validated the idea that child abuse had lifelong, serious effects.
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There is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption. The prevailing post-traumatic model of dissociation and dissociative disorders is contested. This behavior is enhanced by media portrayals of DID. 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.
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The therapy-caused cases of DID, it is argued, are strongly linked to false memory syndrome , a concept and term coined by members of the False Memory Syndrome Foundation in reaction to memories of abuse they allege were 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. There is little agreement between those who see therapy as a cause and trauma as a cause. Lower rates in other countries may be due to an artificially low recognition of the diagnosis.
DID is rarely diagnosed in children, despite the average age of appearance of the first alter being three years. Conversely, if children are found to only develop DID after undergoing treatment it would challenge the traumagenic model. While children have been diagnosed with DID before therapy, several were presented to clinicians by parents who were themselves diagnosed with DID; others were influenced by the appearance of DID in popular culture or due to a diagnosis of psychosis due to hearing voices — a symptom found similarly in DID.
No studies have looked for children with DID in the general population, and the single study that attempted to look for children with DID not already in therapy did so by examining siblings of those already in therapy for DID. An analysis of diagnosis of children reported in scientific publications, 44 case studies of single patients were found to be evenly distributed i. 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.
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. 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. It has also been found difficult to diagnose the disorder in the first place, due to there not being a universal agreement of the definition of dissociation. Specially designed interviews such as the SCID-D and personality assessment tools may be used in the evaluation as well.
The diagnosis has been criticized by supporters of therapy as a cause or the sociocognitive hypothesis as they believe it is a culture-bound and often health care induced condition. The DDIS can usually be administered in 30—45 minutes. All are strongly intercorrelated and except the Mini-SCIDD, all incorporate absorption , a normal part of personality involving narrowing or broadening of attention.
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— People with DID are diagnosed with five to seven comorbid disorders on average—much higher than other mental illnesses.
Due to overlapping symptoms, the differential diagnosis includes schizophrenia , normal and rapid-cycling bipolar disorder , epilepsy , borderline personality disorder , and autism spectrum disorder. 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 the person 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. Although auditory hallucinations are common in DID, complex visual hallucinations may also occur. DID must be distinguished from, or determined if comorbid with, a variety of disorders including mood disorders , psychosis , anxiety disorders , PTSD, personality disorders , cognitive disorders , neurological disorders , epilepsy , somatoform disorder , factitious disorder , malingering , other dissociative disorders, and trance states.
In contrast, genuine people with DID typically exhibit confusion, distress and shame regarding their symptoms and history. A relationship between DID and borderline personality disorder has been posited, with various clinicians noting overlap between symptoms and behaviors and it has been suggested that some cases of DID may arise "from a substrate of borderline traits". Reviews of DID patients and their medical records concluded that the majority of those diagnosed with DID would also meet the criteria for either borderline personality disorder or more generally borderline personality.
Many features of dissociative identity disorder can be influenced by the individual's cultural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. Similarly, in settings where normative possession is common e. Acculturation or prolonged intercultural contact may shape the characteristics of other identities e. Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion.
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". First, the change emphasizes the main problem is not a multitude of personalities, but rather a lack of a single, unified identity  and an emphasis on "the identities as centers of information processing".
The diagnostic criteria also changed to indicate that while the patient may name and personalize alters, they lack an independent, objective existence. The ICD places the diagnosis in the category of "dissociative disorders", within the subcategory of "other dissociative conversion disorders", but continues to list the condition as multiple personality disorder.
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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. Several changes to the criteria for dissociative identity disorder have been made in DSM First, Criterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder.
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Second, Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions. Some believe that DID is caused by health care, i.
This belief also implies that those with DID are more susceptible to manipulation by hypnosis and suggestion than others. The iatrogenic model also sometimes states that treatment for DID is harmful. Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation —the fact that people with DID report childhood trauma does not mean trauma causes DID—and point to the rareness of the diagnosis before as well as a failure to find DID as an outcome in longitudinal studies of traumatized children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as "personality state" and "identities", and question the evidence for childhood abuse beyond self-reports, the lack of definition of what would indicate a threshold of abuse sufficient to induce DID and the extremely small number of cases of children diagnosed with DID despite an average age of appearance of the first alter of three years.
In his opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses. He also asserts that Piper and Merskey have cherry-picked data and not incorporated all relevant scientific literature available, such as independent corroborating evidence of trauma.