What is the average number of personalities in dissociative identity disorder?

Comorbidity

Multiple personalities commonly suffer additional mental disorders. It may be difficult to be sure whether the diagnostic criteria for some of these other disorders are satisfied by symptoms emerging from multiple personality or whether they indicate co-occurring diagnoses that require treatments of their own. Posttraumatic stress disorder, major depression, various substance abuses, borderline personality disorder, other anxiety and affective disorders, somatoform disorders, sexual dysfunctions, eating disorders, and other personality disorders commonly co-occur. Symptoms of another disorder may be found in all or most of the personalities, but sometimes only in particular personalities. Distinguishing between comorbidities and look-alike epiphenomena can prove challenging.

Prognosis may be determined more by the treatability of comorbid conditions than by the multiple personality. For example, a multiple personality with posttraumatic stress disorder and a depression that responds well to medication has a much better prognosis than one with posttraumatic stress disorder, anorexia nervosa, rapid-cycling bipolar disorder, and borderline personality disorder.

Dissociative Identity Disorder (Multiple Personality Disorder)

DID is defined by the presence of two or more distinct identities or personality states that recurrently take control of behavior. This disorder represents the failure to integrate various aspects of identity, memory, and consciousness. Characteristics of this disorder are memory disturbances and amnesia. In contrast to other dissociative disorders, the degree of amnesia experienced in DID is usually asymmetrical. That is, it selectively involves different areas of autobiographical information, i.e., alters (personality states or identities) differ in the degree of amnesia for the experiences of other alters and the access to autobiographical information.

Usually there is a primary or host personality that carries the patient's given name. Often the host is not completely aware of the presence of alters. Because of the presence of amnestic barriers, different personalities may have varying levels of awareness of the existence of other personalities. On average there are 2 to 4 personalities present at the time of diagnosis, and usually up to 13 to 15 personalities are discovered during the course of treatment.

The symptoms that usually prompt patients or their families to seek treatment include memory deficits, moodiness, erratic and unpredictable behavior, depression, self-mutilation, suicidal ideation or attempts, and the overt manifestation of an alternate personality. Transition from one personality to another is usually sudden and is commonly triggered by environmental/interpersonal factors.

Alter identities may have different names, sexes, ages, and personal characteristics and often reflect various attempts to cope with difficult issues and problems. Alters can have a name and well-formed personalities, e.g., Rose, an 8-year-old girl, or can be named after their function or description, e.g., the Angry One.

The factors that can lead to the development of DID are quite varied, but most authors seem to agree that physical and sexual abuse during childhood is the most commonly found etiological factor in these patients. In fact, a history of sexual and/or physical abuse has been reported in 70–97% of patients suffering from DID, with incest being the most common form of sexual trauma (68%). Other forms of childhood trauma that are associated with later development of DID include physical abuse other than sexual abuse (75%), neglect, confinement, severe intimidation with physical harm, witnessing physical or sexual abuse of a sibling, witnessing the violent death of a relative or close friend, traumatic physical illness on self, and near-death experiences.

The actual incidence and prevalence of this disorder are unclear. The estimated prevalence of DID in the general population has been reported to range from 0.01 to 1%. The average time from the appearance of symptoms to an accurate diagnosis is 6 years. The average age at diagnosis is 29 to 35 years. It has been described to be more common in women than in men by a ratio of 3–9:1. Female patients are also reported to present more personalities (average of 15) than men (average of 8).

There is a high incidence of comorbid psychiatric and medical syndromes. Of the psychiatric disorders, depression is the most common (85–88%), followed by posttraumatic stress disorder, BPDs, and substance abuse. There are a number of other psychiatric symptoms common to patients with DID, including insomnia, suicide attempts or gestures, self-destructive behaviors, phobias, anxiety, panic attacks, auditory and visual hallucinations, somatization, conversion reactions, and psychotic-like behavior.

As in cases of dissociative amnesia and fugue, the differential diagnosis of dissociative disorders includes an organic condition (e.g., temporal lobe epilepsy, brain malignancy, head trauma, medication side effect, drug abuse, and intoxication), other dissociative disorders, psychotic disorders (e.g., schizophrenia), factitious disorder, and malingering.

Multiple personality disorder and other dissociative disorders

Multiple personality disorder (MPD) is a psychiatric disorder characterized by the spontaneous generation of an alternate version of self. The personalities have distinctive styles of expressing themselves and they often posses separate names, genders, ages, family histories, and lifestyles. They may have different occupations, sets of friends, and social networks. Sometimes, the physiologic differences between the various MPD personalities can be really surprising: differences in IQ, handiness, handwriting style, visual acuity, and other features have been reported in the literature. Although personalities can be complementary to one other, very often one can distinguish an original personality from another personality that acts like a persecutor.

MPD is likely to occur as an attempt to integrate the consequences of traumatic experiences in individuals with high suggestibility. The exposure to a severe and emotionally overwhelming physical or mental trauma could somehow provoke dissociative disorders, as if the individual is unable to cope with the trauma of maintaining unit his own personality.

MPD is a controversial subject. Some scholars insist that it usually goes undetected; others have criticized the conception of childhood trauma. Actually, an explicit trauma may or may not be present. Trauma may also occur only in the internal, emotional world of the subject, without any detectable recognizable events is. This debate directly concerns the foundation of psychoanalysis.

MPD poses several puzzling problems for the theory of personal identity; this also holds true also for other dissociative disorders. Some patients are able to dissociate memories of single events (dissociative amnesia), or memories of complex behaviors, which they can accomplish in a trancelike state (dissociative fugue, somnambulism, trance disorders). In the final analysis, dissociation appears to be an effort to repair models of self and others, namely, dissociative disorders show that we are constantly creating versions of ourselves and others, and these versions depend upon the social contexts and some inner capacities to select our memories both consciously and unconsciously.

Moral philosophers may be intrigued by this continuum, which begins with conscious fiction, passes through self-deception, akrasia, and autosuggestion, and arrives at dissociative disorders. Actually, there is a psychiatric syndrome that clearly enlightens all these aspects, called Ganser’s syndrome (currently classified in DSM-IV among Dissociative Disorders not otherwise specified). Ganserian patients are usually jailers who pretend to be mad. Their fictitious symptoms include bizarre delusions, amnesia, and confabulation. After a certain time Ganserian patients begin to believe more and more in their fiction until they develop a true ‘false psychosis,’ namely, dissociative disorders out of the control of their will that faithfully reproduce the original mental disturbance. From a legal and ethical perspective it is highly controversial whether Ganserian patients should be treated as if they are remarkable simulators or actual mentally disturbed people.

Types of Dissociative Disorders Associated with Sleep

There are five diagnostic categories of DDs in DSM-IV47 including (1) dissociative identity disorder (formerly multiple personality disorder), (2) dissociative fugue, (3) dissociative amnesia, (4) depersonalization disorder, and (5) dissociative disorder not otherwise specified (DD NOS). Of these, three are considered SRDD: dissociative identity disorder, dissociative fugue, and DD NOS. Most but not all patients with SRDD have both daytime DD episodes as well as previous episodes of SRDD.1,48

Dissociative Identity Disorder (DID)

The phenomena subsumed under DID have been previously called double or multiple personality, but the DSM-IV changed the name to underline that the core of the condition is not the presence of many personalities, but the failure to integrate various aspects of the individual into a single personality. This terminological change has the implication that a unified personality is an achievement rather than a given. Thus, the current therapeutic goal in the treatment of DID is to integrate different aspects or states of the person so that the person can partake of a common memory, self-attribution, and control, rather than trying to find the real personality, as was the goal earlier on.

DID is defined by the DSM-5 as experienced or observed disruption of identity characterized by two or more distinct personality states or experiences of possession, involving marked discontinuity in the senses of self and agency, and with alterations in affect, memory, states of consciousness, and other psychological processes. Another diagnostic requirement is psychogenic amnesia, and the symptoms must create marked distress and/or impairment and not just be part of an accepted cultural practice. DID is the most severe of the DD and typically subsumes a number of other symptoms, including depersonalization, hearing voices not attributed to the self, episodes of unawareness/unresponsiveness, experiences of self-alteration, anxiety, depression, affective lability (including self-injury and suicide attempts), chronic anxiety, phobias, conversion and other somatization problems, substance abuse, and eating, sexual, and personality symptoms (particularly avoidant and borderline syndromes within the last category). This multiplicity of symptoms has led some authors to propose that the lack of identity integration is not as important as the multiplicity of symptoms, which helps explain why many patients with DID have a history of many previous diagnoses, often of a mood disorder or schizophrenia, before receiving the DID one. It has also been observed that the severity and patterning of symptoms can vary across individuals and times. There are DID patients who can function quite well and may even go undetected by those around them, whereas other patients may at times become frankly psychotic.

Some authors have questioned the validity of this diagnosis but have failed to provide empirical support for an iatrogenic hypothesis. On the other hand, literature reviews and empirical studies support the validity and reliability of the DID diagnosis, and memory and neuroimaging studies have been consistent with the DID patients' reports that they experience alternate, not consciously integrated, psychophysiological states, and are not just “faking” them.

Regarding etiological factors, in a number of studies, the vast majority of DID patients have reported severe and chronic forms of early abuse. Some critics have countered that such reports, coming from highly hypnotizable individuals are suspect, but other studies have shown that the search for some type of independent corroboration, which may be very difficult after many years have elapsed, has been substantially consistent with the patients' reports. Nonetheless, it is clear that the vast majority of children who suffer severe abuse or neglect do not develop DID, thus other factors have to be involved. A genetic predisposition to dissociate interacting with some form of disorganized or disrupted attachment seem to also be important etiological factors. Traumatic events, particularly in the context of problems in attachment, are important particularly if they occur early in life, when a sense of an integrated self is being developed and is thus vulnerable to disruptions. The differential diagnoses include schizophrenia, affective disorders, and seizure disorder.

The DSM-5 has now included pathological spirit possession under DID. Spirit possession is typically characterized by a temporary alteration of consciousness defined by the replacement of the usual sense of identity by another one (which may be recognized as an ancestor or a spiritual force), stereotyped behaviors attributed to the possessing entity, and typically full or partial amnesia for the possession episode. Most spirit possessions are not pathological and are associated with religious or other rituals. Research has shown that many if not most devotees who experience possession in a ritual setting evidence good psychological adjustment. Nonetheless, in some cases in both industrialized and nonindustrialized societies, possessions may occur outside of cultural norms, be dysfunctional, and/or produce distress, thus becoming pathological.

Perhaps the psychoses are the closest disorders to DID, but a general distinction is that individuals with DID may exhibit organized (but limited) identities, rather than present the blatant cognitive disorganization and failure of reality testing in schizophrenia.

Dissociative Identity Disorder

Among the dissociative disorders, DID has received the most attention over the last two decades and has endured considerable controversy. The positive aspects of this controversy involve an ongoing debate regarding the interplay of society on psychiatric nosology, as well as a careful reexamination of all dissociative phenomena and their relationship to consciousness and pathology. DID is defined in the DSM-IV as “the presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and the self).” In addition, the DSM specifies that “at least two of these identities” must periodically “take control of the person's behavior.” Finally, there must be a demonstrated “inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.” (Table 35-3 lists the DSM-IV criteria of this condition and exclusions to it.)

An essential aspect of DID is the amnestic quality for alternate personalities displayed by the primary personality. However, in many instances different personality states have varying levels of awareness of other personalities (often called alters) and often a dominant personality state exists that is cognizant of all of the various personalities. The term co-consciousness has been used to describe the simultaneous experience of multiple entities at one time. Thus, one personality may be aware of another's feelings regarding an ongoing experience.

DID is characterized by high rates of co-morbid depression, and often by affective symptoms that constitute the presenting complaint. In addition, from one-third to one-half of cases of DID experience auditory hallucinations. Some researchers have suggested that these hallucinations are described as “inner voices,” helping to differentiate these symptoms from the external voices heard by those suffering from schizophrenia and other psychotic disorders. Also, in contrast to individuals suffering from schizophrenia, patients with DID are unusually hypnotizable and do not display evidence of a formal thought disorder.

DID is reported more commonly in women than in men, and the mean number of distinct personalities is approximately 13. The prevalence rate is estimated at 1%, with co-morbid conditions (such as depression and borderline personality disorder) being relatively common. Additionally, somatic symptoms (including headaches, gastrointestinal distress, and genitourinary disturbances) are also frequent, as well as increased rates of corresponding conversion symptoms, factitious disorders, and malingering. It is in fact this somewhat messy compilation of diagnoses that contributes to some of the controversy that surrounds DID in general.

DID is usually diagnosed in the third or fourth decade, though those suffering from DID usually report symptoms during childhood and adolescence. Most case series document a chronic, fluctuating course, characterized by relapse and remission. Making the diagnosis of DID in a particular patient is not without controversy. Some clinicians have proposed that the diagnosis must be persistently pursued if a patient's symptoms even subtly hint at the possibility of dissociation. These clinicians describe patients who are either unaware of, or who wish to hide, their disorder, and therefore need to be “educated” about DID. Critics contend that patients with DID are highly suggestible and that clinicians “create” such patients by “suggesting” symptoms. The critics emphasize that clinicians who show interest and enthusiasm in the multiplicity of personalities reinforce the symptoms.

Extended psychotherapy remains the treatment of choice, although approaches vary widely and remain controversial. Some clinicians describe specialized treatment for DID, including delineating and mapping the alters, inviting each to participate in the treatment, and facilitating communication between the various alters. Through careful exploration of all alternate identities, clinicians attempt to understand past episodes of trauma as experienced by each personality. Hypnosis is sometimes employed to reach dissociated states. Other clinicians focus on the function of the dissociative process in the here-and-now of the patient's life and the ongoing treatment. They help patients become aware of using dissociation to manage feelings and thoughts within themselves and to manage the closeness and distance within relationships. All approaches seek to increase affect tolerance and to integrate the dissociated states within the patient.

Psychopharmacological treatments (such as antidepressants and anxiolytics) are often useful in treating the common accompanying complaints of depression and anxiety. However, no pharmacological treatment has been found to reduce dissociation, per se. Benzodiazepines reduce anxiety but can also exacerbate dissociation. Although not routinely used for dissociative disorders, neuroleptics are sometimes employed in patients who are grossly disorganized.11,20,21

Dissociative identity changes

In some forms of dissociative identity disorder and the similar phenomenon of “lucid possession” (Oesterreich, 1974), the subject is aware of the mental contents of an alternate personality or possessing agent but otherwise unable to control his or her speech or actions (Deeley et al., 2014). An experimental model of these experiences and attributions of control by another agent involved a suggestion of an engineer conducting research into limb movement. The engineer had found a way to enter the subject and control movement from within. The subject was aware of the thoughts and motives of this possessing agent but unable to control the hand movements produced by it. Suggested control by the external agent was associated with an increase in functional connectivity between M1 (a key movement implementation region) and BA 10, demonstrating functional coupling with brain regions involved in the representation of agency in experiences of loss of motor control to another agent (Deeley et al., 2014).

Rhode Island Versus Quattrocchi—Science Intensive Litigation Ends Criminal Prosecutions based upon Uncorroborated ‘Recovered Memories,’ ‘RRM-MPD,’ and Related Controversial Notions

At the peak of the RRM-MPD therapy epidemic, thousands of US citizens were prosecuted based solely upon “recovered memory” allegations lacking any reliable corroborative evidence. Widespread prosecutions based solely on RRM-MPD testimony ended in the US following the 1995–97 wave of malpractice lawsuits, subsequent licensing prosecutions, and international media reports as well as the landmark ruling in Rhode Island v. Quattrocchi.41

The Quattrocchi hearings reportedly remain perhaps the most complex, lengthy, and exhaustively litigated Daubert–Kumho hearings on memory issues in history. Following multiple weeks of technical, detailed, methodological analyses of many dozens of research studies plus extensive examinations and cross-examinations of multiple (seven) expert witnesses including a number of internationally acclaimed scientists, the court ruled that RRM-MPD and related theories and practices were unreliable, controversial, and not generally accepted by the relevant scientific community—thus ending the case. US criminal prosecutions based solely on RRM-MPD testimony became quite rare in the US following the landmark Quattrocchi decision.42

5 Personality (Re)Integration

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Develop a trusting therapeutic relationship. With a multiple personality, this means a trusting relationship with the original personality as well as subpersonalities.

Educate patient about multiple personality disorder in order to increase their understanding of subpersonalities

Facilitate identification of the needs of each subpersonality, the role they have played in psychic survival

Facilitate identification of the need that each subpersonality serves in the personal identity of the person

Facilitate identification of the relationship between stress and personality change

Facilitate identification of the stressful situations that precipitate a transition from one personality to another

Decrease fear and defensiveness by facilitating subpersonalities to understand that integration will not lead to their destruction, but to a unified personality within the individual

Facilitate understanding that therapy will be a long-term process, which is often arduous and difficult

Be supportive and reassuring.

Dissociative Identity Disorder

Perhaps the most severe reaction to trauma is evident when symptoms of dissociative identity disorder (DID) are present. In this disorder, the trauma that the child experienced was so severe that the personality became fragmented and various components that normally become integrated throughout development begin to coexist independently. Separate identities often take on different names, although this may not be apparent when symptoms begin during early childhood. When these ‘alters’ take over the ‘host’ personality, the patient exhibits distinct changes in attitude, behavior, and demeanor, and these differences are much more pronounced than those evident during normal mood changes. Severe anxiety is often present and may be connected with specific settings, people, or situations. In rare and severe cases, psychosis may co-occur, especially during times of intense anxiety and dissociation.

DID is rare in adults and extremely rare in children. Although the vast majority of cases seen in adulthood are thought to begin in childhood, as a result of severe child abuse, the symptoms associated with this syndrome are rarely evident in childhood, and prodromal disturbance may be evident, characterized by anxiety, moodiness, fear and avoidance of certain people or settings, and other disturbances (for example, sleep problems). The pattern characteristic of DID (distinct switching of alters that take over the host’s body) is not usually recognizable until late adolescence or adulthood.

As with ASD or PTSD, when clinicians encounter children or adolescents who present symptoms that may be characteristic of DID, all symptom groups must be managed. Intensive psychological and pharmacological treatment is likely to be necessary, and psychosis should not be treated in isolation. While using an antipsychotic may be helpful, it is not likely to be effective unless the other symptoms are also being addressed. Unfortunately, this will usually mean that multiple supplements, in addition to intense psychotherapy, will need to be used, and such cases should be approached with extreme caution.