DID in the DSM-5-TR

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The DSM-5-TR gives the following criteria for a diagnosis of dissociative identity disorder:

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or other medical condition (e.g., complex partial seizures) (American Psychiatric Association, 2022).

Criterion A refers to the presence of at least one alter (distinct personality state) in addition to the main, or host, personality. The alter(s) may sometimes be mistaken for spirits and the experience of dissociation for one of possession. Alters may each have their own perception of themself as a unique individual or entity, or they may demonstrate sharp discontinuities that go beyond what would be expected from normal state shifting in an integrated individual. Alters can have different degrees of emotional expressiveness, behave in different ways, experience consciousness in different ways, have different memories, perceive themselves and the world around them in different ways, think in different ways and have different cognitive skills, and have different skills and abilities related to sensory-motor functioning. A small number of alters even identify or present as animals or mythical figures, particularly in cultural contexts in which alters may be interpreted as spirits or other external entities. Other people may have noticed these differences (for example, the individual might switch during a diagnostic interview or friends and family of the individual might have told them about their alters’ behaviors) or the individual might have noticed changes due to finding evidence of their alters’ activities or due to the ability to remain co-conscious with their alters. For example, the individual might report sudden experiences of feeling like they are a different gender, are multiple ages at once, or don't fit in their body. They may or may not associate these experiences with distinct internal parts, and they may be hesitant to disclose anything about the existence of parts that they are aware of. Attempts to conceal symptoms are typical.

It must be noted that the majority of individuals with DID are covert (i.e., not easily recognizable as having DID) the majority of the time. DID may be more visible when it presents as an experience of possession or when the individual is going through a period of extreme stress. Even clinicians may not immediately recognize the presence of alternate identities. More readily noticeable may be sharp discontinuities of opinion and memory without any parts announcing themself as such. It must also be noted that some DID systems have no alters that are distinct enough to have their own names, let alone drastically different presentations. Very few individuals with DID have parts that wear noticeably different clothing, style their hair in very different ways, have extremely different accents, or other highly overt changes associated with media portrayals of DID. That said, in some cases, identities may have drastic and immediately obvious differences, such as speaking a different language (e.g., a bilingual individual with DID having an alter that only speaks the language not shared by others in the individual's current location) or presenting as a possessing spirit. More common are individuals presenting with subtle alterations in identity accompanied by reports of depersonalization; periods of feeling like an observer or passenger in their body; internal voices; imposed or ego-dystonic thoughts, emotions, urges, or actions; the abrupt vanishing or inhibition of thoughts, emotions, urges, or actions; and confusing shifts in opinion, ability, self-concept, and temperament.

Criterion B refers to the inability of one or more alters to remember things that one or more other alters have experienced. This specific type of dissociative amnesia is most commonly associated with amnesia for everyday events in which an alter other than the current alter was present. This is what leads to some dissociative individuals finding evidence of their time loss in the form of clothing or other items that they apparently own but don’t recognize, journal entries or sticky notes in their handwriting that they don’t remember writing, or insistent strangers calling them a name that isn’t theirs. It is not uncommon for individuals to have fugue episodes, in which they suddenly become aware that they're in a new location (e.g., a different city, their place of work, their closet) with no memory of how they got there. This criterion can also be fulfilled by alters being unable to recall pertinent personal information such as the body’s age, current residence, or spouse. The individual may report lacking memory for highly personally relevant experiences such as their wedding or the birth of their child, and they may intermittently lose access to well-rehearsed skills such as driving or performing their job. However, this criterion is generally not considered fulfilled just because the host or other alters are unable to recall traumatic experiences. That alone would not point to inter-identity amnesia and so would result in a diagnosis of other specified dissociative disorder subtype 1. This criterion also cannot be fulfilled by incidents that can be explained by ordinary forgetting. Notably, the individual with DID may attempt to downplay or rationalize their episodes of amnesia, which may be more apparent to observers (e.g., the individual may try to make excuses for not remembering having dinner with their parents the week before, but their spouse reports this is highly unusual because many important discussions happened that night which the individual no longer shows any awareness of). The individual may be "amnesiac to their amnesia" and display no awareness of sudden discontinuities in their memory. 

Criterion C refers to the fact that DID is a disorder. If a condition doesn’t cause distress or impairment, it is not a disorder and does not belong in the DSM-5. This criterion is present in the criteria of over half of all DSM-5 diagnoses in order to reduce the rate of false positive diagnoses given for non-clinically significant symptoms.

Criterion D excludes presentations that mimic DID due to culture or religion (such as a spiritual leader acting as a medium as part of cultural ceremonies) or due to imaginary play. It is important to reiterate that possession experiences can be culturally normative and require no diagnosis or can be involuntary, distressing, dysfunctional, and culturally atypical in a way that suggests DID is an appropriate diagnosis. DID that presents as possession is more common in rural areas in low- and middle-income countries and among certain religious groups.

Criterion E excludes presentations and symptoms that are due to organic, physiological, or situational causes. For example, blacking out while drunk is not an example of amnesia that meets Criterion B, and feeling like a different person while experiencing an altered consciousness due to a seizure is not an example of Criterion A.

As discussed elsewhere on this website, individuals with DID often have comorbid posttraumatic stress disorder (PTSD), depression, anxiety, or other mental health conditions. Functional neurological (conversion) symptoms are also common; in non-Western settings, this often presents as non-epileptic seizures, and in Western settings, this may present as headaches, seizures, or symptoms suggestive of disorders such as multiple sclerosis. Reactive dissociative psychosis is also possible, especially for individuals in highly violent, chaotic, or oppressive environments with prolonged absence of appropriate treatment or support. Avoidant personality features are common, and borderline features (e.g., highly unstable mood or self-injury) may become prominent in times of extreme stress. Obsessive traits are also common. A minority of people with DID present with histrionic, antisocial, or narcissistic features. Risky or self-destructive behaviors such as substance misuse, self-injury, and suicide attempts are common; over 70% of outpatients with DID have attempted suicide. Despite this, functional impairments range from minimal to profound. 

DID is often confused for other disorders. Although it often co-occurs with or involves depersonalization/derealization, dissociative amnesia, conversion symptoms, posttraumatic stress, and depressed mood, its full clinical picture is more complex than any of these disorders alone. Alters may be confused for mood cycling in bipolar disorder, hallucinatory voices in schizophrenia spectrum disorders, or identity confusion and variable relational styles in borderline personality disorder, but the actual presentation and phenomenology differs significantly. In short, DID is unique for its requirement of personality / identity states with alterations in self and agency (alters) as well as inter-identity dissociative amnesia.

American Psychiatric Association. (2022). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., Text Revision).