DID Around the World

Image: "World Map - Abstract Acrylic" by Nicolas Raymond

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Some individuals incorrectly believe that dissociative identity disorder (DID) is an American or Western phenomenon. However, this is simply untrue. DID has been found in all of the countries in which studies have been conducted regarding it. While DID may normally be diagnosed at a lower rate in countries which do not in general acknowledge, understand, or diagnose mental disorders, prevalence studies place rates of DID in all countries at a similar level. Finally, presentations of DID can be different between countries due to cultural influences, but the core characteristics of the disorder remain constant.

DID has been found in the following countries: India (Adityanjee, Raju, & Khandelwa, 1989)¹ (Gupta & Kumar, 2005)² (Chaturvedi, Desai, & Shaligram, 2010)³; the Netherlands (Boon & Draijer, 1993)⁴ (Friedl & Draijer 2000)⁵; China (Yu et al., 2010)⁶; the United Kingdom (Silberman, Putnam, Weingartner, Braun, & Post, 1985)⁷ (Hart, 1993)⁸; Belgium (Hart, 1993)⁸; Russia (Hart, 1993)⁸; Norway (Hart, 1993)⁸ (Bøe, Haslerud, & Knudsen, 1993)⁹; Israel (Hart, 1993)⁸ (Ginzburg, Somer, Tamarkin, & Kramer, 2010)¹⁰ (Somer, Ross, Kirshberg, Bakri, & Ismail, 2015)¹¹; Germany (Hart, 1993)⁸ (Gast, Rodewald, Nickel, & Emrich, 2001)¹²; Canada (Horen, Leichner, & Lawson, 1995)¹³ (Ellason & Ross, 1997)¹⁴; South Africa (Gangdev, & Matjane, 1996)¹⁵; Australia (Middleton & Butler, 1998)¹⁶; Puerto Rico (Martinez-Taboas, 1989)¹⁷; Japan (Umesue, Matsuo, Iwata, & Tashiro, 1996)¹⁸.

A recent study on the effectiveness for treatment of individuals with DID or other specified dissociative disorder (OSDD) recruited therapists from the US (n=220), Canada (n=25), the UK (n=8), the Netherlands (n=7), Germany (n=4), Australia (n=4), Sweden (n=3), Scotland (n=2), Belgium (n=2), New Zealand (n=2), Spain (n=2), Argentina (n=1), Norway (n=1), Brazil (n=1), Finland (n=1), Taiwan (n=1), Singapore (n=1), Israel (n=1), Slovakia (n=1), and South Africa (n=1) (Brand et al., 2009)¹⁹. As well, a letter to the editor of the Journal of Nervous & Mental Disease addressed multiple points of contention regarding DID being referred to as a "fad," the biggest concern being the lack of attention paid to international studies regarding DID. The letter was written by Martinez-Taboas (from Puerto Rico), Dorahy (from New Zealand), Sar (from Turkey), Middleton (from Australia), and Krügar (from South Africa). It referenced studies from England, the Netherlands, Turkey, Puerto Rico, Northern Ireland, Germany, Finland, China, and Australia. According to this letter, epidemiological general population studies place the prevalence of DID at 1.1-1.5% and the prevalence of any DSM-IV dissociative disorder at 8.6-18.3% (Martinez-Taboas, Dorahy, Sar, Middleton, & Krügar, 2013)²⁰.

The idea of DID as an international phenomenon is not a new one. A journal from 1992 shows that 10% of Swedish psychiatrists had seen at least one case of DID during their career. The prevalence of DID in Switzerland was given to be 0.05-0.1% at a time when the DSM-III was still in use and comparatively little was known about how to recognize and diagnose DID (Modestin, 1992)²¹. A 1999 study of Turkey revealed a minimum prevalence for DID of 0.4% of the general population, a population that had no exposure to public awareness about DID nor access to systematic psychotherapy (Akyüz, Doǧan, Şar, Yargiç, & Tutkun, 1999)²².

More recent studies of dissociation in Turkey have revealed significantly higher prevalence rates, suggesting that increased awareness of dissociation and improved diagnostic tools can lead to an increased ability to diagnose dissociative disorders. In Turkey, much of the recent focus on dissociative disorders is due to the extremely high rates of somatoform dissociation in its population. The lifetime prevalence of conversion symptoms was found to be 48.2% for individuals who had been screened in a primary health care center; 27.2% of individuals had had conversions symptoms within the last month alone. Two different Turkish studies on the relationship between somatoform dissociation and psychoform dissociation found that 30.5% to 47.4% of individuals with a conversion disorder diagnosis had previously had a DSM-IV dissociative disorder. In another study, the prevalence of all dissociative disorders in Turkey was found to be 18.3%. 8.3% of individuals were found to have DDNOS, and 1.1% were found to have DID. The combined prevalence of DID and DID-like DDNOS (now known as OSDD-1) was reported to be 5.2% (Sar, 2006)²³.

It has been suggested that dissociative disorders are actually more common in developing countries than in developed Western countries. This may be in part due to the inclusion of conversion disorders, which are associated with dissociative disorders in the ICD. For example, when one study from Oman examined a psychiatric hospital's records for diagnosed dissociative disorders, it found that almost half of the diagnoses were for dissociative convulsions and almost another quarter were for dissociative motor disorder. The other diagnoses were for dissociative trance disorder, mixed dissociative disorders, dissociative disorder of movement and sensation, dissociative sensory loss, and dissociative stupor.  (Chand  et al., 2000)²⁴. That some of these presentations were attributed to spirit possession may indicate that DID was covertly present in many cases.

There is much evidence that so called "culture-bound" possession disorders around the world are actually different manifestations of dissociative identity disorder. This is reflected in the DSM-5 including possession-form phenomena in criterion A of dissociative identity disorder (American Psychiatric Association, 2013)²⁵. Additional support for this theory is found in the evidence that possession disorders that are supposedly unique to other cultures (latah, bebainan, amok, and pibloktoq) can be found in white, American, English-speaking trauma program inpatients in the US, 73% of whom report having a dissociative disorder (Ross, Schroeder, & Ness, 2013)²⁶. Disorders such as "amok, bebainan, latah, pibloktoq, ataque de nervios and possession, shin-byung, enchantment, lack of spirit, Zar and djinnati" (Hosseinbor & Bakhshani, 2014)²⁷ have all been found to be dissociative in nature. Djinnati in particular, a supposedly culture-bound syndrome of Iran and Pakistan, was found to have a total prevalence of 0.5% and 1.03% among a rural population in Baluchestan and in the women of that population respectively, a very similar prevalence to DID. Its symptoms include "disruption in consciousness, memory and stereotyped behaviors...which are attributed to a new identity known as 'Djinn'" (Hosseinbor & Bakhshani, 2014).²⁷ These attacks are preceded by somatic and conversion symptoms and may include loss of speach, speaking in a different language, or speaking with a different rhythm and tone of voice. Partial and sometimes complete amnesia are common, and djinnati is associated with traumatic experiences (Hosseinbor & Bakhshani, 2014)²⁷.

Another study has found that possession experiences in Uganda closely match DID in the DSM-5 through symptoms such as passive-influence, changes in consciousness, talking in a voice attributed to "spirits," and hearing voices (Duijl, Kleijn, & Jong, 2013)²⁸. Those reporting possession reported more severe psychoform dissociation, somatoform dissociation, and potentially traumatizing events, though the possible link between the possession and trauma was culturally unacknowledged (Duijl, Nijenhuis, Komproe, Gernaat, & Jong, 2010)²⁹. Spirit possession in South Asia has also been linked to dissociative origins as well (Castillo, 1994)³⁰. Another study in a town of central eastern Turkey had 2.1% of women report a possession experience, and possession experiences were found to be associated with childhood and adult trauma, PTSD, and dissociative disorders. A number of possession and paranormal phenomena correlate with secondary features of DID (Sar, Alioğlu, & Akyüz, 2014)³¹. The DSM-5 acknowledges that cultural differences play a role in the secondary features of dissociative identity disorder by stating that neurological symptoms such as psychogenic non-epileptic seizures, paralysis, and sensory deprivation are more common outside of the US, though they do still occur in individuals with DID in the US (American Psychiatric Association, 2013)²⁵.

It is common for culture to impact how "individuals display and communicate their symptoms, how such symptoms are interpreted, and what type of care is sought" (Dorahy et al., 2014)³². This is not unique to DID but has also been found to be true for eating disorders, personality disorders, depression, schizophrenia, and anxiety disorders. Regarding DID in particular, it has been theorized that the higher prevalence of possession-form DID in non-Western cultures is due to an emphasis in these cultures on interdependence and unity instead of the Western focus on independence and separation of self (Dorahy et al., 2014)³². A similar explanation has been given for the higher number of alters associated with North American and European cases of DID as compared to cases from countries such as Puerto Rico, Japan, India, and South America. While typical cases of DID involve around 13 alters, Puerto Rican cases are more likely to involve only 4 to 6 alters (Martinez-Taboas et al., 1995)³³.

In all cases, DID is associated with trauma of some sort, particularly severe and early-onset childhood abuse. Even in countries where the link between (largely possession-form) DID and abuse is largely unexplored, DID is linked with more covert traumatization such as highly dysfunctional families and disorganized attachment in cultures where family bonds and unity are stressed (Dorahy et al., 2014)³². In Puerto Rico, rejection and isolation from peers and living with an unstable and emotionally unavailable mother have also been implicated as potential causes of DID. In cases where abuse is present, it's often verified with independent corroboration (Martinez-Taboas et al., 1995)³³, further strengthening the perceived link between trauma at an early age and DID. Similar applies to international findings regarding dissociation as a whole. Dissociation has been linked to abuse, neglect, maternal dysfunction, overall dysfunctional family dynamics, and overwhelming expectations in studies originating from the Netherlands, Germany, South Africa, Japan, Israel, and Turkey (Sar, 2006)²³.

It is important to keep in mind that possession-form DID, like all other disorders, is not a culturally accepted practice and is pathological in nature (Dorahy et al., 2014)³². Experiences that can be labeled possession-form DID are experienced as distressing, uncontrollable, recurrent, and persistent and can cause conflict between the afflicted individual and others as well as manifest in culturally and religiously unacceptable times and places (American Psychiatric Association, 2013)²⁵. As well, it must be remembered that possession-form DID is not the only form of DID present even in countries in which there's very little knowledge of DID. In these countries, a variety of other labels may be applied to the dissociative individual. Unfortunately, when DID is not recognized and treated appropriately, its symptoms will not resolve on their own. Individuals who have DID and who have been falsely diagnosed with epilepsy, depression with psychotic traits, schizophrenia, or other such diagnoses are likely to continue to be shuffled through the mental health care system, may be unsuccessfully placed on a variety of unnecessary medications, and will be forced to continue to struggle with their symptoms until more appropriate treatment can be given (Martinez-Taboas et al., 1995)³³.

In short, even in countries where the general population has had little or no exposure to any information pertaining to DID, DID is present. In some cases, it may present as possession-form DID while in others, it may be extremely similar to the prototypical American case. There is a clear link between trauma and dissociation across cultures, and until individuals with DID are provided appropriate treatment that acknowledges their dissociation and all that it entails, they won't be able to heal. All of this clearly refutes the idea that dissociative disorders such as DID are a North American phenomenon or can be explained by unique cultural, social, or professional factors.

¹ Adityanjee, Raju, G. S., & Khandelwal, S. K. (1989). Current status of multiple personality disorder in India [Abstract]. American Journal of Psychiatry, 146(12), 1607-1610.

² Gupta, A., & Kumar, D. (2005). Multiple personality disorder - A case report from Northern India. German Journal of Psychiatry, 98-100.

³ Chaturvedi, S. K., Desai, G., & Shaligram, D. (2010). Dissociative disorders in a psychiatric institute in India - A selected review and patterns over a decade [Abstract]. International Journal of Social Psychiatry, 56(5), 533-539. doi:10.1177/0020764009347335

⁴ Boon, S., & Draijer, N. (1993). Multiple personality disorder in the Netherlands: A clinical investigation of 71 patients [Abstract]. American Journal of Psychiatry, 150(3), 489-494. doi:10.1176/ajp.150.3.489

⁵ Friedl, M. C., & Draijer, N. (2000). Dissociative disorders in Dutch psychiatric inpatients. American Journal of Psychiatry, 157(6), 1012-1013. doi:10.1176/appi.ajp.157.6.1012

⁶ Yu, J., Ross, C. A., Keyes, B. B., Li, Y., Dai, Y., Zhang, T., . . . Xiao, Z. (2010). Dissociative disorders among chinese inpatients diagnosed with schizophrenia. Journal of Trauma & Dissociation, 11(3), 358-372. doi:10.1080/15299731003793468

⁷ Silberman, E. K., Putnam, F. W., Weingartner, H. J., Braun, B. G., & Post, R. M. (1985). Dissociative states in multiple personality disorder: A quantitative study. Psychiatry Research, 15(4), 253-260. doi:10.1016/0165-1781(85)90062-9

⁸ Hart, O. (1993). Multiple personality disorder in Europe: Impressions. Dissociation, 101(2), 102-118.

⁹ Bøe, T., Haslerud, J., & Knudsen, H. (1993). Multiple personality--a phenomenon also in Norway? [Abstract]. Tidsskr Nor Laegeforen, 113(26), 3230-3232.

¹⁰ Ginzburg, K., Somer, E., Tamarkin, G., & Kramer, L. (2010). Clandestine psychopathology: Unrecognized dissociative disorders in inpatient psychiatry. The Journal of Nervous and Mental Disease, 198(5), 378-381. doi:10.1097/NMD.0b013e3181da4d65

¹¹ Somer, E., Ross, C., Kirshberg, R., Bakri, R. S., & Ismail, S. (2015). Dissociative disorders and possession experiences in Israel: A comparison of opiate use disorder patients, Arab women subjected to domestic violence, and a nonclinical group. Transcultural Psychiatry, 52(1), 58-73. doi:10.1177/1363461514552584

¹² Gast, U., Rodewald, F., Nickel, V., & Emrich, H. M. (2001). Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic [Abstract]. The Journal of Nervous and Mental Disease, 189(4), 249-257. doi:10.1097/00005053-200104000-00007

¹³ Horen, S. A., Leichner, P. P., & Lawson, J. S. (1995). Prevalence of dissociative symptoms and disorders in an adult psychiatric inpatient population in Canada. [Abstract]. Canadian Journal of Psychiatry, 40(4), 185-191.

¹⁴ Ellason, J. W., & Ross, C. A. (1997). Two-year follow-up of inpatients with dissociative identity disorder. American Journal of Psychiatry, 154(6), 832-839. doi:10.1176/ajp.154.6.832

¹⁵ Gangdev, P. S., & Matjane, M. (1996). Dissociative disorders in black South Africans: A report on five cases. Dissociation, 9(3), 176-181.

¹⁶ Middleton, W., & Butler, J. (1998). Dissociative identity disorder: An Australian series. Australian and New Zealand Journal of Psychiatry, 32(6), 794-804. doi:10.3109/00048679809073868

¹⁷ Martinez-Taboas, A. (1989). Multiple personality disorder in Puerto Rico: analysis of fifteen cases. Dissociation, 2, 128–131.

¹⁸ Umesue, M., Matsuo, T., Iwata, N., & Tashiro, N. (1996). Dissociative disorders in Japan: A pilot study with the dissociative experience scale and a semi-structured interview. Dissociation, 9(3), 182-189.

¹⁹ Brand, B., Classen, C., Lanins, R., Loewenstein, R., Mcnary, S., Pain, C., & Putnam, F. (2009). A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 153-171. doi:10.1037/a0016210

²⁰ Martinez-Taboas, A., Dorahy, M., Sar, V., Middleton, W., & Krügar, C. (2013). Growing not dwindling: International research on the worldwide phenomena of dissociative disorders [Letter to the editor]. Journal of Nervous & Mental Disease, 201(4), 353.

²¹ Modestin, J. (1992). Multiple personality disorder in Switzerland [Abstract]. The American Journal of Psychiatry, 149(1), 88-92. doi:10.1176/ajp.149.1.88

²² Akyüz, G., Doǧan, O., Şar, V., Yargiç, I., & Tutkun, H. (1999). Frequency of dissociative identity disorder in the general population in Turkey. Comprehensive Psychiatry, 40(2), 151-159. doi:10.1016/S0010-440X(99)90120-7

²³ Sar, V. (2006). The scope of dissociative disorders: An international perspective. Psychiatric Clinics of North America, 29(1), 227-244. doi:10.1016/j.psc.2005.10.007

²⁴ Chand, P., AlAdawi, S., Martin, R., Mustapha, S., Zaidan, Z A J., Viernes, N. (2000). Dissociative disorders in the Sultanate of Oman. Acta Psychiatrica Scandinavica, 102(3), 185-7. doi: 10.1034/j.1600-0447.2000.102003185.x

²⁵ American Psychiatric Association. (2013). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm08

²⁶ Ross, C. A., Schroeder, E., & Ness, L. (2013). Dissociation and symptoms of culture-bound syndromes in North America: A preliminary study [Abstract]. Journal of Trauma & Dissociation, 14(2), 224-235. doi:10.1080/15299732.2013.724338

²⁷ Hosseinbor, N., & Bakhshani, N. (2014). Djinnati syndrome in Baluchestan: The role of traumatic and abuse experiences on individual vulnerability. International Journal of High Risk Behaviors and Addiction, 3(4). doi:10.5812/ijhrba.23610

²⁸ Duijl, M., Kleijn, W., & Jong, J. (2013). Are symptoms of spirit possessed patients covered by the DSM-IV or DSM-5 criteria for possession trance disorder? A mixed-method explorative study in Uganda [Abstract]. Social Psychiatry and Psychiatric Epidemiology, 48(9), 1417-1430. doi:10.1007/s00127-012-0635-1

²⁹ Duijl, M., Nijenhuis, E., Komproe, I. H., Gernaat, H. B., & Jong, J. T. (2010). Dissociative symptoms and reported trauma among patients with spirit possession and matched healthy controls in Uganda. Culture, Medicine, and Psychiatry, 34(2), 380-400. doi:10.1007/s11013-010-9171-1

³⁰ Castillo, R. J. (1994). Spirit possession in South Asia, dissociation or hysteria? Part 2: Case histories [Abstract]. Culture, Medicine and Psychiatry, 18(2), 141-162. doi:10.1007/BF01379447

³¹ Sar, V., Alioğlu, F., & Akyüz, G. (2014). Experiences of possession and paranormal phenomena among women in the general population: Are they related to traumatic stress and dissociation? Journal of Trauma & Dissociation, 15(3), 303-318. doi:10.1080/15299732.2013.849321

³² Dorahy, M., Brand., B, Sar, V., Kruger., C, Stavropoulos, P., Martinez, A., ... Lewis-Fernandez, R. (2014). Dissociative identity disorder: An empirical overview. Australian and New Zealand Journal of Psychiatry, 48(5), 402-417. doi: 10.1177/0004867414527523

³³ Martinez-Taboas, A., Camino-Gaztambide, R., Cruz-Igartua, A., Francia-Martinez, M., Gelpi-Merheb, E., & Rodriguez-Cay, J. R. (1995). What a group of clinicians have learned about multiple personality disorder in Puerto Rico. Puerto Rican Journal of Psychology, 10(1), 197-213.