Dissociative Identity Disorder: Treatment and Management

by Hassaan Tohid

Myth DID is a rare condition DID, although uncommon, is not very rare and affects around 1–1.5% of the general population [2]. However, some studies showed it as high as 6% [2]. Considering all the uncertainty involved with the condition and difficult diagnosis, several cases remain undiagnosed, which means the actual cases are even higher.

Myth Patients with DID can have only a few alter and are not aware of their alters or their condition Some people with DID may have only a few ‘alters,’ whereas there may be a case where several alters co-exist, and some that were not apparent were discovered during therapy. Although people who have undergone extreme abuse like child trafficking or ritual abuse may even have hundreds of alters in the DID system, there is no direct association between the number of alters and the severity of trauma.

Myth The alters always are other human personalities. NON-human ‘alters’ cannot exist Since the cause of DID is rooted in childhood trauma and the abuse is inflicted by other humans, the children are usually afraid of the adults, and these ‘alters’ develop to dissociate them from their memories [6]. The inhuman ‘alters’ are fairly common as well. A harmless animal, a feared robot, or an entity may feel safer than the terrifying world around them. The appearance or development of alters is not a person’s conscious decision or is never decided by the person.

Myth Patients with DID may not be able to lead normal lives and be independent and will remain dependent on therapy and shifting between hospitals. Although the outcome may vary from patient to patient, successful therapy may differ for everyone. People with DID are functioning and working in all walks of life and are functioning normally. There are several cases where they have reached the top positions of life while living with the condition and after undergoing treatment.

Myth The word ‘alter’ or ‘part’ in DID is synonymous with the alter ego. This is another misconception about the condition, where the terminology used to describe distinct personalities can be misunderstood. In the context of DID, ‘alter’ means ‘an alternate state of consciousness or the alternate personality.’ The terminology altered personality fits the clinical context the most and is used by clinicians and researchers. The word alter ego, however, does not correlate with the actual disorder. Witkins and Witkins described the alters as different from egos because of having distinct personalities, memories, autobiographies, and habits

Sleep Model (SM) The direct cause of dissociation, according to this hypothesis, is a variable sleep–wake cycle or, more importantly, the interference of sleep and waking states, which results in conflicting states of consciousness. In simple terms, dissociation could be described as the state of sleep seeping into the waking state, and the condition of waking can intervene in the state of sleep, as shown by parasomnias and other uncommon dreaming and sleeping experiences. Nightmares, vivid dreams, kinesthetic dreams, and hypnagogic and hypnopompic hallucinations (i.e., hallucinatory perceptions occurring during sleep–wake transitions) are all examples of sleep-related experiences (SREs) that are strongly linked to dissociation and were conceptualized initially by Watson as “dissociations of the night.”

According to the SM, it is the solution to the issue that the trauma model lacks a mechanism for explaining how trauma causes dissociation (the proposed mechanism being alterations in sleep).

Compulsive mimicking of other people’s words or behaviors

Indiscriminate, uncontrolled imitations of the actions of others (resembles Latah)

After a frightening event, they fear their soul has left their body. Symptoms include weight loss, fatigue, myalgia, headache, diarrhea, insomnia, lack of motivation, low self-esteem

Current evidence suggests a 2–5% prevalence among psychiatric inpatients, 2–3% among outpatients, and a 1% prevalence in the general population [10–12].

Nonverbal experiences and sensory feelings are noted by the patient, and a perception of the positive and negative associations become internalized and is identified by the person as a part of the self.

The affected individual should also have the liberty of autonomy to determine and reflect when inappropriate situations arise, with the alter and the affected individual being in denial. It helps the affected to understand the alters as their system.

Fusions of different alter personalities should be performed whenever it appears to be appropriate. This may be through the wish of the patient, or due to the loss of function of an alter personality. Integration is a broader reorganization. Integration starts from the beginning of the treatment and continues with fusions. Fusions can occur spontaneously or be induced by the therapist. The preparedness of the alternate personalities should be assessed by the general status of the patient and the explicit ratification by the host and in particular of the alternate personalities. Spontaneous fusions occur after the gradual dissolving of dissociative barriers and the emergence of co-consciousness between alters. Fusion can be carried out through a ritual or ceremony using visual imagination.

Most of the DID patients think on suicide. However, the majority of suicide attempts are thwarted by anti-suicide hosts or alter personalities. “Internal homicide” due to a conflict between two alter personalities is also a version of suicide [7]. Assessment of suicidality should consider relational aspects as well.

The latter may be due to the overall severity of the condition, suicidality claimed by the majority of host and alter personalities, severe major depression generalized to the whole personality system, or living in a highly abusive environment.

Experiencing Inside or Outside Although mental intrusions from within (e.g., interference of alternate personality states) may have unlimited capacities to escape reality as an activity of the inner world, they are limited in agency. This is due to the partial control still maintained by the host and other personality states of the internal system. The opposite is valid for externally experienced mental content unless a culture or subculture enables liberty to some of these deviations from normative. An example of this might be an experience of possession by shared external entities that operate like “currencies,” making exchange possible; i.e., in contrast to private alternate personality states, they can move from one person to another.

Dissociative Psychosis One type of severe decompensation of DID is called as “revolving door crisis” [7] when the alternate personality states enter in a loop of rapid switching. An alternative to this situation is the collapse of dissociative barriers: “co-consciousness crisis (Kluft, personal communication 1995). Both conditions may evolve to a “dissociative psychosis,” a condition formerly known as hysterical psychosis [20]. Amnesias, hallucinations, somatic experiences, and discontinuities in associations may appear like manic, schizophrenic, or delirious conditions. Such brief psychotic attacks may cease in a few hours or a few weeks latest. Nevertheless, there are cases of dissociative psychosis with a longer duration that resemble schizophrenic disorder.

Accordingly, it is in service of the patient’s safety as well as eventual integration that mapping the patient’s identity system is often employed as a means of appreciating its baseline structure on presentation and any changes to it throughout treatment [16]. Whether a DID patient can ultimately gain a model of their own identity system is often dependent on the clinician’s capacity to do so. This process typically requires mending ruptures of the therapeutic alliance that may occur throughout treatment and especially when engaging alternate identities that developed in traumatic circumstances with the patient still “not wanting to know now what was not known then”

Is it possible that you are walking or driving a car and suddenly change your personality? Or does it happen only when you are resting or eating? Etc. What I am doing does not affect whether or not I switch personalities. All I need is an appropriate trigger. If I were to change into a different alter while driving it would be okay because we have a rule that forbids child alters from driving. If a switch occurs during normal activities such as eating, there is no harm done.