Myths and Misconceptions

Image: "Depersonalization Disorder" by JanIne

CC BY-NC-ND 2.0

Myth: Dissociative identity disorder (DID) is only about having multiple personalities.

Fact: DID is a disorder characterized by having dissociated parts (alters) as a result of chronic childhood trauma. While alters are the best known symptom of this disorder, they aren't the only or even necessarily the main symptom. Because DID is the result of trauma, it's highly comorbid with posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (C-PTSD), and flashbacks, emotional numbing, nightmares, emotional dysregulation, and pessimism about the future are common. Individuals with DID often have other comorbid disorders as well, including mood disorders (such as major depressive disorder), anxiety disorders (such as social anxiety disorder), personality disorders (such as borderline personality disorder (BPD)), eating disorders (such as anorexia nervosa), or conversion disorder (American Psychiatric Association (APA), 2013)¹.

As well, DID includes a range of dissociative symptoms. Identity alteration accounts for the existence of alters, and dissociative amnesia accounts for unawareness of the individual's trauma history as well as amnesia between alters (inter-identity amnesia). DID also involves high levels of identity confusion (being unsure who one is), depersonalization (feeling disconnected from aspects of oneself, including one's emotions, thoughts, memories, physical sensations, body or parts of one's body, or identity), and derealization (feeling disconnected from one's environment or feeling like nothing is real). Individuals with DID may also experience: trance states, in which they show minimal awareness of or ability to respond to their surroundings; perceptual disturbances, such as feeling as if sounds are coming from far away; and somatic symptoms, such as stomachaches, headaches, or joint pain in response to emotional stress (Dell, 2006)². DID is so strongly associated with dissociative symptoms that a diagnosis of DID renders any other dissociative disorder diagnoses unnecessary.

Individuals with DID also often experience memory problems beyond simple inter-identity amnesia. They might hear "voices" that they might not at first understand are originating from their alters. They often find themselves doing or saying things that they didn't plan to do or say, or they might have the urge to act in a specific manner; both of these can indicate that an alter is present and has either taken some control over the body or is imposing their desires on the host part. Similarly, an individual with DID might have thoughts or feelings that originate from alters and so do not feel like their own. Their skills and abilities might fluctuate, as might their knowledge. They might find evidence of their amnesia, such as unfamiliar objects in their possession or being approached by unknown individuals (Dell, 2006)². Many individuals with DID feel like they're losing their mind! Most try to hide their symptoms, function like everyone around them, and suffer in silence. Unfortunately, this isn't always possible. Over 70% of individuals with DID have attempted suicide, and self harm is also common (APA, 2013)¹.

Myth: Alters are just ego states / moods with names attached / imaginary friends.

Fact: Alters are dissociated self states that can be highly differentiated from each other. They can have unique names, ages, gender identities, sexualities, memories, skills, abilities, and ways of viewing and interacting with the world. Alters can even perceive themselves as different species or as members of a different race or ethnicity (Hart, Nijenuis, & Steele, 2006)³. They can have different psychological disorders or physiological markers and reactions to stimuli, including "differences in visual acuity, medication responses, allergies, plasma glucose levels in diabetic patients, heart rate, blood pressure readings, galvanic skin response, muscle tension, laterality, immune function, electroencephalography and evoked potential patterns, functional magnetic resonance imaging activation, and brain activation and regional blood flow using single photon emission computed tomography and positron emission tomography among others" (International Society for the Study of Trauma and Dissociation, 2011)⁴. This is possible because many physiological functions are highly responsive to one's mental state, neurological functioning, and hormones.

No one can choose to have alters or what their alters are like. Alters' creation is entirely unconscious and is the result of failed integration of thoughts, memories, emotions, learned behaviors, traits, and similar (Hart, Nijenuis, & Steele, 2006)³. This is very different from fantasy processes. Individuals who create characters or write stories may sometimes feel like they're not consciously deciding what actions their characters take in all situations or may be able to imagine conversations with their characters, but this is still not the same as alters taking actions that are perceived as independent. Most alters have their own sense of identity. While an individual may be able to forcefully regain control over an alter's activities, they cannot actually control the alter. As well, for individuals with DID, alters have some degree of inter-identity amnesia between them (APA, 2013)¹.

That said, it must be noted that alters are not completely separate people. An individual with DID has one brain and one body. Dissociative barriers between alters are not literal boundaries, and knowledge, memories, skills, preferences, and traits may bleed through. As well, there may be many commonalities between alters due to shared underlying factors. An important part of treating DID is helping individuals to realize that all of the alters present in a system experienced the same trauma, they are all responsible for what their body does, all of their opinions and needs are equally important, and they must all work together in order to function and thrive.

Myth: Individuals with DID are never aware that they have alters.

Fact: It is common for individuals with DID to have awareness of their alters, to hear their alters communicating, and to have knowledge of at least some of their alters' activities (Dell, 2006)². Many individuals with DID have been aware of signs of their alters since their childhood. They may once have known that they contained other "people" or known their alters personally but may have begun to ignore, forget, or reject this knowledge as they became older and realized that having alters isn't "normal." Many with DID are aware that their memory is often unreliable, that they do things without remembering having done them, and that they sometimes act highly out of character without being able to stop or control their actions. It's not uncommon for those with DID to hear the voices of their alters but not understand what this means or to think that it's a sign of impending insanity. Sometimes, individuals with DID will piece together that they have DID based on the growing availability of relevant information regarding the disorder, and of course individuals who are diagnosed with DID will then be aware that they have DID!

Myth: Individuals with DID are never aware of what their alters do and cannot communicate with their alters.

Fact: While all individuals with DID experience some degree of amnesia towards their alters, many can remain co-conscious with at least some of their alters. Co-consciousness is the ability for two or more alters to remain aware of each other or the outside world at the same time. Regarding internal communication, 95% of individuals with DID report hearing child voices, 90% report hearing persecutory voices, 89% hear voices arguing with each other, and 95% hear voices commenting on their life or activities. Rarely, individuals with DID can actually see and hear their alters projected externally (Dell, 2006)². All of these indicate the potential for communication between alters. Many individuals with DID can or learn to speak internally with their alters, a process which may manifest as "hearing" their alters as internal projections, having a sense for what their alters are trying to communicate, or experiencing their alters' words as involuntary thoughts that they do not feel originated with them. Some individuals with DID can "see" or "hear" their alters through internal representations commonly called internal worlds (Hart, Nijenuis, & Steele, 2006)³. Even those with poor internal communication can communicate through leaving notes, leaving messages with trusted third parties (such as therapists), or journaling.

Individuals with other specified dissociative disorder subtype 1 (OSDD-1) often have no amnesia for their alters' activities. This is one of the potential defining differences between DID and OSDD-1.

Myth: DID is obvious and easy to notice in those who have it.

Fact: Only 5-6% of those with DID are overtly inflicted with the disorder. The other 94-95% cannot be casually identified as having the disorder. Individuals who have DID are more likely to be thought to have mood disorders (such as bipolar disorders or major depressive disorder), personality disorders (such as borderline personality disorder), psychotic disorders (such as schizophrenia), other dissociative disorders (such as other specified dissociative disorder or dissociative amnesia), posttraumatic stress disorder alone, conversion disorder, seizure disorders, obsessive-compulsive disorder, paranoia, or cognitive disorders (APA, 2013)¹.

Myth: DID is only caused by severe child abuse.

Fact: DID is caused by long term or repeated childhood trauma. Child abuse fits this criteria and is the most common cause of DID, with around 90% of individuals with DID having experienced child abuse or neglect. However, other forms of childhood trauma that are associated with DID include repeated medical and surgical procedures, war, human trafficking, and terrorism (APA, 2013)¹. Disorganized attachment plays a role, as well.

Myth: DID is caused by therapists / the media / thinking oneself into it.

Fact: There is an abundance of evidence that supports that DID is due to long term or repeated childhood trauma. Research supports that iatrogenic/sociocognitive DID (DID resulting from therapeutic or social influences) is not the same as genuine DID.

Myth: DID is incredibly rare.

Fact: Between 0.1% and 2% of the population has DID. The DSM-5 places this prevalence at 1.5% (APA, 2013)¹. That's almost 3.2 million Americans, 0.65 million citizens of the United Kingdom, or 71 million people worldwide!

Myth: DID is an American phenomenon.

Fact: DID has been found in all of the countries in which it has been sought, and some very forward-thinking research regarding DID comes from the Netherlands, Turkey, Puerto Rico, and New Zealand.

Myth: DID didn't exist before Sybil.

Fact: The first known case of DID was that of Jeanne Fery in 1584 (van der Hart, Lierens, Goodwin, 1996)⁵. Sybil brought awareness to DID and so allowed for an increasing number of diagnoses to be made as more funding went towards DID education and research, but DID did not begin with Sybil (nor with Eve, who came before Sybil).

Myth: DID is easy to fake / is often faked.

Fact: While non-professionals may not be able to distinguish between those who do and do not truly have DID, professionals are trained to recognize the difference between DID and disorders that may present similarly (such as C-PTSD or BPD) or between DID and factitious disorders or malingering. Diagnoses done using the "gold-star" Structural Clinical Interview for Dissociative Disorders are very likely to be reliable (Welburn et. al, 2003)⁶.

As well, it must be noted that DID is not faked at exceptionally high rates. Studies have found rates of factitious or malingered dissociative disorders to be between 2% and 14%, with higher rates being found in inpatient and expert consultant settings. This is comparable to general rates of malingering, which range from 7% to 17% with higher rates found in forensic settings, and factitious disorders, which range from 0.5% to 6% in the general population (Brand, McNary, Loewenstein, Kolos, & Barr, 2006)⁷.

Myth: DID can form in adults.

Fact: DID cannot form in an individual who has a fully integrated personality, and chronic childhood trauma is necessary to disrupt normal personality development (Spring, 2012)⁸. It is generally accepted that this must occur before ages 6 to 9. Age 6 is considered a critical period for the integration of one's sense of self and self history because of the maturation of the hippocampus and prefrontal cortices at this time (Nijenhuis, Hart, & Steele, 2010)⁹. This is addressed in more depth here. Trauma later in life can instead cause PTSD, C-PTSD, or other mental health symptoms. As well, an individual who already has DID or OSDD-1 can develop additional alters at any age.

Myth: DID is the same thing as schizophrenia.

Fact: Schizophrenia is a spectrum of disorders characterized by: delusions; hallucinations; paranoia; flat affect; disorganized thoughts, speech, and movements; catatonia; and social withdrawal. It does not involve alters and often does not involve dissociation. In contrast, those with DID are not delusional or hallucinating their alters (APA, 2013)¹. While both those with schizophrenia and those with DID may hear voices, the voices that those with DID hear are usually the internal projections of their alters. Schneiderian first-rank symptoms that occur in those with DID are different from those that occur in schizophrenic individuals, and while individuals with DID may experience dissociative or reactive psychosis, this is not the same as an organic psychotic disorder (Dell, 2006)².

Myth: DID is the same thing as bipolar disorders.

Fact: Bipolar disorders are mood disorder characterized by depressive, manic, or mixed states. They have nothing to do with alters or dissociation. Those with DID may appear to be rapid cycling when they switch, but this is because their alters might have different moods (APA, 2013)¹ or because of a trigger. The two disorders are not actually similar.

Myth: DID is the same thing as borderline personality disorder.

Fact: There are many similarities between dissociative identity disorder and borderline personality disorder. Both disorders are thought to be caused (or often caused) by childhood trauma and insecure/disorganized attachment and can be explained through the theory of structural dissociation. Those with DID experience themselves as having multiple distinct parts whereas those with BPD experience their identity as being poorly defined and possibly fragmented. DID is a dissociative disorder while BPD often involves dissociative features. Both DID and borderline personality disorder may involve trouble forming or maintaining healthy attachments. However, BPD does not involve fully differentiated parts, and while individuals with BPD may rarely experience dissociative trance or fugue states, this is not the same as inter-identity amnesia as is found in those with DID. Those with DID are less likely to view the world and others in all black and white or have an intense fear of abandonment. BPD and DID can be and often are comorbid, but they are not the same disorder (Mosquera, Gonzalez, & Hart, 2012)¹⁰.

Myth: Individuals with DID can choose to get rid of, kill off, or immediately integrate their alters.

Fact: Alters are dissociated parts of the self. They cannot be gotten rid of or killed any more than one's traits, flaws, or other mental health symptoms can be magically be gotten rid of or cured. Unfortunately, unlike many other mental health conditions, DID cannot be treated by medication. Medication can help with depressive symptoms, anxiety, sleep disturbances, or other comorbid symptoms, but medication cannot get rid of alters. Integration, or lowering dissociative barriers between alters until all alters own all parts of the personality and only one individual remains, is possible but takes time and effort. Alters are formed by trauma and remain separate due to an internal failure to integrate and due to having experienced different events and so having developed and differentiated themselves as individuals. Integration is not the right choice for all systems, and it is a personal choice. In many cases, increased communication and cooperation among alters is more desirable, though it may lack some of the benefits of complete integration. Even when a system has integrated, treatment should continue until the individual has become more used to integrated life (International Society for the Study of Trauma and Dissociation, 2011)⁴.

Myth: Those with DID are dangerous killers!

Fact: Like other mentally ill populations, those with DID are no more likely to be dangerous or abusive than anyone else. However, DID forms because of chronic childhood trauma, and individuals with DID are highly likely to be re-traumatized and be victims of further abuse and violence. Contrary to popular belief, it's not common for those with DID to have an "evil" alter.

A study of 173 individuals with dissociative disorders found that dissociative, posttraumatic, emotion dysregulation, depressive, or substance use symptoms cannot predict criminality in this population. This is somewhat in contrast with the general population, in which substance use disorders are the most common mental illnesses among violent offenders, emotion dysregulation is a mediator for violent behavior among individuals with BPD, and dissociation among inpatients is associated with sexual aggression, general aggression, and intergenerational abuse. Only 3% of the individuals in the study had been charged with an offense within the past 6 months, 1.8% had been fined, and 0.6% had been incarcerated. No convictions or probations were reported. A handful of older studies specifically on individuals with DID found that the majority are not violent and do not have violent alters; the exceptions were a 1990 study of 11 individuals with DID and another small 1990 study of only males with DID that found higher rates of violent alters and incarceration. A newer and large 2014 study found that only 3.5% of individuals with DID had engaged in any form of interpersonal violence. Another more recent international study reported that only 2% of clinicians had patients with DID or OSDD who had sexually coerced or assaulted a partner; 3.5% of patients were reported by their therapists to have engaged in any physical or sexual abuse of their partners. In contrast, high rates of internally directed violence (ie, suicidal alters) have been found, and a study found that 26.1% of individuals with DID are at risk of being assaulted. Unfortunately, mentally ill individuals are often aware of others' perceptions of them as potentially violent, and this can worsen their isolation, negative emotions, and treatment adherence (Webermann & Brand, 2017)¹¹.

¹ 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

² Dell, P. F. (2006). A new model of dissociative identity disorder. Psychiatric Clinics of North America, 29(1), 1-26. doi:10.1016/j.psc.2005.10.013

³ Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: W.W. Norton.

⁴ International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187.

⁵ Van der Hart, O., Lierens, R., & Goodwin, J. (1996). Jeanne Fery: A sixteen century case of dissociative identity disorder. The Journal of Psychohistory, 24(1).

⁶ Welburn, K. R., Fraser, G. A., Jordan, S. A., Cameron, C., Webb, L. M., & Raine, D. (2003). Discriminating dissociative identity disorder from schizophrenia and feigned dissociation on psychological tests and structured Interview [Abstract]. Journal of Trauma & Dissociation, 4(2), 109-130. doi:10.1300/j229v04n02_07

⁷ Brand, B. L., McNary, S. W., Loewenstein, R. J., Kolos, A. C., & Barr, S. R. (2006). Assessment of genuine and simulated dissociative identity disorder on the Structured Interview of Reported Symptoms. Journal of Trauma & Dissociation, 7(1), 63-85. doi:10.1300/j229v07n01_06

⁸ Spring, C. (2012). What causes dissociative identity disorder? Retrieved from http://www.pods-online.org.uk/index.php/information/articles/faqs-dissociation/what-causes-dissociative-identity-disorder

⁹ Nijenhuis, E. R. S., van der Hart, O., & Steele, K. (2010). Trauma-related structural dissociation of the personality. Activitas Nervosa Superior, 52(1), 1-23.

¹⁰ Mosquera, D., Gonzalez, A., & Hart, O. (2012). Borderline personality disorder, childhood trauma and structural dissociation of the personality. Revista Persona, 11(1), 44-73.

¹¹ Webermann, A. R. & Brand, B. L. (2017). Mental illness and violent behavior: The role of dissociation. Borderline Personality Disorder and Emotion Dysregulation, 4(2). doi: 10.1186/s40479-017-0053-9

"Contrary to popular belief, having multiple personalities doesn't make you a psychopath. Unfortunately, the media blows everything out of proportion."

-Alpha