assignment controversy associated with dissociative disorders

ORIGINAL RESEARCH article

Revisiting false-positive and imitated dissociative identity disorder.

• Research Centre for Trauma & Dissociation, SWPS University of Social Sciences and Humanities, Katowice, Poland

ICD-10 and DSM-5 do not provide clear diagnosing guidelines for DID, making it difficult to distinguish ‘genuine’ DID from imitated or false-positive cases. This study explores meaning which patients with false-positive or imitated DID attributed to their diagnosis. 85 people who reported elevated levels of dissociative symptoms in SDQ-20 participated in clinical assessment using the Trauma and Dissociation Symptoms Interview, followed by a psychiatric interview. The recordings of six women, whose earlier DID diagnosis was disconfirmed, were transcribed and subjected to interpretative phenomenological analysis. Five main themes were identified: (1) endorsement and identification with the diagnosis. (2) The notion of dissociative parts justifies identity confusion and conflicting ego-states. (3) Gaining knowledge about DID affects the clinical presentation. (4) Fragmented personality becomes an important discussion topic with others. (5) Ruling out DID leads to disappointment or anger. To avoid misdiagnoses, clinicians should receive more systematic training in the assessment of dissociative disorders, enabling them to better understand subtle differences in the quality of symptoms and how dissociative and non-dissociative patients report them. This would lead to a better understanding of how patients with and without a dissociative disorder report core dissociative symptoms. Some guidelines for a differential diagnosis are provided.

Introduction

Multiple Personality Disorder (MPD) was first introduced in DSM-III in 1980 and re-named Dissociative Identity Disorder (DID) in subsequent editions of the diagnostic manual ( American Psychiatric Association, 2013 ). Table 1 shows diagnostic criteria of this disorder in ICD-10, ICD-11, and DSM-5. Some healthcare providers perceive it as fairly uncommon or associated with temporary trends ( Brand et al., 2016 ). Even its description in ICD-10 ( World Health Organization, 1993 ) starts with: “This disorder is rare, and controversy exists about the extent to which it is iatrogenic or culture-specific” (p. 160). Yet, according to the guidelines of the International Society for the Study of Trauma and Dissociation ( International Society for the Study of Trauma and Dissociation, 2011 ), the prevalence of DID in the general population is estimated between 1 and 3%. The review of global studies on DID in clinical settings by Sar (2011) shows the rate from 0.4 to 14%. However, in studies using clinical diagnostic interviews among psychiatric in-patients, and in European studies these numbers were lower ( Friedl et al., 2000 ). The discrepancies apparently depend on the sample, the methodology and diagnostic interviews used by researchers.

Table 1. Diagnostic criteria for dissociative identity disorder.

Diagnosing complex dissociative disorders (DID or Other Specified Dissociative Disorder, OSDD) is challenging for several reasons. Firstly, patients present a lot of avoidance and rarely report dissociative symptoms spontaneously without direct questioning ( Boon and Draijer, 1993 ; International Society for the Study of Trauma and Dissociation, 2011 ; Dorahy et al., 2014 ). In addition, standard mental state examination does not include these symptoms and healthcare professionals do not receive appropriate training in diagnosing dissociative disorders ( Leonard et al., 2005 ). Secondly, complex dissociative disorders are polysymptomatic, and specialists would rather diagnose these patients with disorders more familiar to them from clinical practice, e.g., anxiety disorders, eating disorders, schizophrenia, or borderline personality disorder ( Boon and Draijer, 1995 ; Dell, 2006 ; Brand et al., 2016 ). For these reasons, complex dissociative disorders are underdiagnosed and often mis-diagnosed. For example, 26.5–40.8% of DID patients would already have been diagnosed and treated for schizophrenia ( Putnam et al., 1986 ; Ross et al., 1989 ). On the other hand, because there is so much information about DID in the media (Hollywood productions, interviews and testimonies published on YouTube, blogs), people who are confused about themselves and try to find an accurate diagnosis for themselves may learn about DID symptoms on the Internet, identify themselves with the disorder, and later (even unintentionally) report core symptoms in a very convincing way ( Draijer and Boon, 1999 ). This presents a risk of making a false positive diagnosis, which is unfavorable for the patient, because using treatment developed for DID with patients without autonomous dissociative parts may be inefficient or even reinforce their pathology.

Authors who wrote about patients inappropriately diagnosed with this disorder used terms such as ‘malingering’ or ‘factitious’ DID ( Coons and Milstein, 1994 ; Thomas, 2001 ). According to Draijer and Boon (1999) , both labels imply that patients intentionally simulate symptoms, either for external gains (financial benefits or justification for one’s actions in court) or for other forms of gratification (e.g., interest from others), while in many cases their motivation is not fully conscious. Getting a DID diagnosis can also provide structure for inner chaos and incomprehensible experiences, and be associated with hope and belief it is real. On the other hand, diagnostic errors often result in inappropriate treatment plans and procedures.

Already in 1995 Boon and Draijer stressed that a growing number of people self-diagnosed themselves based on information from literature and the Internet, and reported symptoms by the book during psychiatric or psychological assessment. Based on their observation of 36 patients in whom DID had been ruled out after applying the structured clinical interview SCID-D, these clinicians identified differences between genuine and imitated DID. They classified their participants into three groups: (1) borderline personality disorder, (2) histrionic personality disorder, or (3) persons with severe dissociative symptoms but not DID. Participants in that study reported symptoms similar to DID patients, including: amnesia (but only for unacceptable behavior), depersonalisation, derealisation, identity confusion, and identity alteration. However, they presented themselves and interacted with the therapist in very different ways. While DID patients are usually reluctant to talk about their symptoms and experience their intrusions as shameful, people who imitated DID were eager to present their problems, sometimes in an exaggerated way, in an attempt to convince the clinician that they suffered from DID ( Boon and Draijer, 1995 ; Draijer and Boon, 1999 ). Similar observations were expressed by Thomas (2001) saying that people with imitated DID can present their history chronologically, using the first person even when they are highly distressed or allegedly presenting an altered personality, and are comfortable with disclosing information about experiences of abuse. They can talk about intrusions of dissociative parts, hearing voices or difficulties controlling emotions, without shame.

Unfortunately, ICD-10, ICD-11, and DSM-5 offer no specific guidelines on how to differentiate patients with personality disorders and dissociative disorders by the manner in which they report symptoms. There are also limited instruments to distinguish between false-positive and false-negative DID. From the clinical perspective, it is also crucial to understand the motives for being diagnosed with DID, and disappointment when this diagnosis is disconfirmed. Accurate assessment can contribute to developing appropriate psychotherapeutic procedures ( Boon and Draijer, 1995 ; Draijer and Boon, 1999 ). Apart from observations already referred to earlier in this article, there are no qualitative analyses of false-positive DID cases in the past 20 years. Most research was quantitative and compared DID patients and simulators in terms of cognitive functions ( Boysen and VanBergen, 2014 ). This interpretative phenomenological analysis is an idiographic study which explores personal experiences and meaning attributed to conflicting emotions and behaviors in six women who had previously been diagnosed with DID and referred to the Research Centre for Trauma and Dissociation for re-evaluation. It explores how they came to believe they have DID and what had led clinicians to assume that these patients could be suffering from this disorder.

Materials and Methods

This study was carried out in Poland in 2018 and 2019. Rich qualitative material collected during in-depth clinical assessments was subjected to the interpretative phenomenological analysis (IPA), a popular methodological framework in psychology for exploring people’s personal experiences and interpretations of phenomena ( Smith and Osborn, 2008 ). IPA was selected to build a deeper understanding of how patients who endorsed and identified with dissociative identity disorder made sense of the diagnosis and what it meant for them to be classified as false-positive cases during reassessment.

Interpretative phenomenological analysis uses phenomenological, hermeneutic, and idiographic principles. It employs ‘double hermeneutics,’ in which participants share their experiences and interpretations, followed by researchers trying to make sense and comment on these interpretations. IPA uses small, homogenous, purposefully selected samples, and data are carefully analyzed case-by-case ( Smith and Osborn, 2008 ; Pietkiewicz and Smith, 2014 ).

This study is part of a larger project examining alterations in consciousness and dissociative symptoms in clinical and non-clinical groups, held at the Research Centre for Trauma & Dissociation, financed by the National Science Centre, and approved by the Ethical Review Board at the SWPS University of Social Sciences & Humanities. Potential candidates enrolled themselves or were registered by healthcare providers via an application integrated with the website www.e-psyche.eu . They filled in demographic information and completed online tests, including: Somatoform Dissociation Questionnaire (SDQ-20, Pietkiewicz et al., 2018 ) and Trauma Experiences Checklist ( Nijenhuis et al., 2002 ). Those with elevated SDQ-20 scores (above 28 points) or those referred for differential diagnosis were consulted and if dissociative symptoms were confirmed, they were invited to participate in an in-depth clinical assessment including a series of interviews, video-recorded and performed at the researcher’s office by the first author who is a psychotherapist and supervisor experienced in the dissociation field. In Poland, there are no gold standards for diagnosing dissociative disorders. The first interview was semi-structured, open-ended and explored the patient’s history, main complaints and motives for participation. It included questions such as: What made you participate in this study? What are your main difficulties or symptoms in daily life? What do you think caused them? Further questions were then asked to explore participants’ experiences and meaning-making. This was followed by the Trauma and Dissociation Symptoms Interview (TADS-I, Boon and Matthess, 2017 ). The TADS-I is a new semi-structured interview intended to identify DSM-5 and ICD-11 dissociative disorders. The TADS-I differs in several ways from other semi-structured interviews for the assessment of dissociative disorders. Firstly, it includes a significant section on somatoform dissociative symptoms. Secondly, it includes a section addressing other trauma-related symptoms for several reasons: (1) to obtain a more comprehensive clinical picture of possible comorbidities, including symptoms of PTSD and complex PTSD, (2) to gain a better insight into the (possible) dissociative organization of the personality: patient’s dissociative parts hold many of these comorbid symptoms and amnesia, voices or depersonalisation experiences are often associated with these symptoms; and (3) to better distinguish between complex dissociative disorders, personality disorders and other Axis I disorders and false positive DID. Finally, the TADS-I also aims to distinguish between symptoms of pathological dissociation indicating a division of the personality and symptoms which are related to a narrowing or a lowering of consciousness, and not to the structural dissociation of the personality. Validation testing of the TADS-I is currently underway. TADS interviews ranging from 2 to 4 h were usually held in sessions of 90 min. Interview recordings were assessed by three healthcare professionals experienced in the dissociation field, who discussed each case and consensually came up with a diagnosis based on ICD-10. An additional mental state examination was performed by the third author who is a psychiatrist, also experienced in the differential diagnosis of dissociative disorders. He collected medical data, double-checked the most important symptoms, communicated the results and discussed treatment indications. Qualitative data collected from six patients out of 85 were selected for this interpretative phenomenological analysis, based on the following criteria for inclusion, which could ensure a homogenous sample expected of IPA studies – (a) female, (b) previously diagnosed or referred to rule in/out DID, (c) endorsement and identification with DID, (d) dissociative disorder disconfirmed in the assessment. Interviews with every participant in this study ranged from 3 h 15 min to 7 h 20 min (mean: 6 h).

Participants

Participants of this IPA were six female patients aged between 22 and 42 years who were selected out of 86 people examined in a larger study exploring dissociation and alterations in consciousness in clinical and non-clinical groups. (Participants in the larger study met criteria of different diagnoses and seven among them had ‘genuine’ DID). These six patients did not meet DID criteria on the TADS-I interview but believed themselves that they qualified for that diagnosis. Four of them had higher education, two were secondary school graduates. All of them registered in the study by themselves hoping to confirm their diagnosis but two (Olga and Katia) were referred by psychiatrists, and the others by psychotherapists. All of them traveled from far away, which showed their strong motivation to participate in the assessment. Four had previously had psychiatric treatment and five had been in psychotherapy due to problems with emotional regulation and relationships. In the cases of Victoria and Dominique, psychotherapy involved working with dissociative parts. None of them recalled any physical or sexual abuse, but three (Dominique, Victoria, and Mary), following therapists’ suggestions, were trying to seek such traumatic memories to justify their diagnosis. They all felt emotionally neglected by carriers in childhood and emotionally abused by significant others. None of them reported symptoms indicating the existence of autonomous dissociative parts. None had symptoms indicating amnesia for daily events, but four declared not remembering single situations associated with conflicting emotions, shame, guilt, or conversations during which they were more focused on internal experiences rather than their interlocutors. None experienced PTSD symptoms (e.g., intrusive traumatic memories and avoidance), autoscopic phenomena (e.g., out-of-body experiences), or clinically significant somatoform symptoms. None had auditory verbal hallucinations but four intensely engaged in daydreaming and experienced imagined conversations as very real. All of them had been seeking information about DID in literature and the Internet. For more information about them see Table 2 . Their names have been changed to protect their confidentiality.

Table 2. Study participants.

The Researchers

The principal investigator (IJP) is a psychotherapist, supervisor, and researcher in the field of community health psychology and clinical psychology. The second co-investigator (RT) is a psychiatrist, psychotherapist, and supervisor. The third co-investigator (SB) is a clinical psychologist, psychotherapist, supervisor, and a consulting expert in forensic psychology, who also developed the TADS-I. They are all mentors and trainers of the European Society for Trauma and Dissociation, with significant expertise in the assessment of post-traumatic conditions. The first co-investigator (AB) has a master’s degree in psychology and is a Ph.D. candidate. She is also a psychotherapist in training. All authors coded and discussed their understanding of data. Their understanding and interpretations of symptoms reported by participants were influenced by their background knowledge and experience in diagnosing and treating patients with personality disorders and dissociative disorders.

Data Analysis

Verbatim transcriptions were made of all video recordings, which were analyzed together with researchers’ notes using qualitative data-analysis software – NVivo11. Consecutive analytical steps recommended for IPA were employed in the study ( Pietkiewicz and Smith, 2014 ). For each interview, researchers watched the recording and carefully read the transcript several times. They individually made notes about body language, facial expressions, the content and language use, and wrote down their interpretative comments using the ‘annotation’ feature in NVivo10. Next, they categorized their notes into emergent themes by allocating descriptive labels (nodes). The team then compared and discussed their coding and interpretations. They analyzed connections between themes in each interview and between cases, and grouped themes according to conceptual similarities into main themes and sub-themes.

Credibility Checks

During each interview, participants were encouraged to give examples illustrating reported symptoms or experiences. Clarification questions were asked to negotiate the meaning participants wanted to convey. At the end of the interview, they were also asked questions to check that their responses were thorough. The researchers discussed each case thoroughly and also compared their interpretative notes to compare their understanding of the content and its meaning (the second hermeneutics).

Participants in this study explained how they concluded they were suffering from DID, developed knowledge about the syndrome and an identity of a DID patient, and how this affected their everyday life and relationships. Five salient themes appeared in all interviews, as listed in Table 3 . Each theme is discussed and illustrated with verbatim excerpts from the interviews, in accordance with IPA principles.

Table 3. Salient themes identified during the interpretative phenomenological analysis.

Theme 1: Endorsement and Identification With the Diagnosis

All six participants hoped to confirm they had DID. They read books and browsed the Internet seeking information about dissociation, and watched YouTube videos presenting people describing multiple personalities. Dominique, Victoria, Mary, and Karina said that a mental health professional suggested this diagnosis to them. Dominique remembers consulting a psychiatrist when she was 15, because she had problems controlling anger at home or in public places. She initially found descriptions of borderline personality captured her experiences well enough, but a psychiatrist refuted the idea and recommended further diagnostics toward a dissociative disorder. However, the girl refused to go to hospital for observation.

During an argument with my mother I felt as if some incredible force took control and I smashed the glass in the cabinet with my hand. It was like being under control of an alien force. I started reading about borderline and I thought I had it. I found a webpage about that and told my mother I should see a psychiatrist. I went for a consultation and told her my story. This lady said: “Child, you don’t have borderline, but multiple personality.” She wanted to keep me in the psychiatric unit but I did not agree to stay for observation. (Dominique).

This led Dominique to research the new diagnosis. Karina also said she was encouraged to seek information about DID, when a doctor suggested she might be suffering with it.

When I was 11, I had problems at school and home. Other children made fun of me. My mom took me to a doctor and he said I had borderline, but later I was diagnosed with an anxiety disorder. That doctor also suggested I had DID and told me that I should read more about this diagnosis. (Karina).

Victoria and Mary shared similar stories about psychotherapists suggesting the existence of dissociative parts, having readily accepted this new category as a good explanation for aggressive impulses or problems with recalling situations evoking guilt or shame. Dominique and Victoria stressed, however, that, apart from feeling emotionally abandoned, they could not trace any significant traumas in their early childhoods, although therapists maintained that such events must be present in dissociative patients.

I have no idea why I have this [DID]. My therapist looked for evidence of childhood trauma, which sounds like the easiest explanation, but I don’t feel I had any horrific memories which I threw out of my consciousness. (Victoria).

Katia and Olga had used psychiatric treatment for anxiety and depression for years. After exploring information about different mental disorders they concluded they had DID. They thought there was a similarity between their personal experiences and those of people publishing testimonials about multiple personalities.

I tried to understand this battle inside, leading me to stagnation. I didn’t know how to describe that but I recently bought a book Healing the fragmented selves of trauma survivors , and everything was explained there. Some of these things I have discovered myself and some were new to me. (Olga).

Subsequently, Katia presented to her doctor a review of literature about DID, trying to persuade him that she had this disorder.

Theme 2: Using the Notion of Dissociative Parts to Justify Identity Confusion and Conflicting Ego-States

Once participants had embraced the idea of having multiple personalities, they seemed to construct inner reality and justify conflicting needs, impulses or behaviors as an expression of dissociative parts. They referred to being uncertain about who they were and having difficulties recognizing personal emotions, needs or interests. Some of them felt it was connected to a negative cognition about themselves as worthless, unimportant, and not deserving to express what they felt or wanted. Victoria said she would rather define herself through the eyes of others:

My therapist asked what I wanted or needed. It turned out that without other people’s expectations or preferences to which I normally adjust, I wouldn’t know who I am or what I want. I usually engage in my friends’ hobbies and do what I think gives them pleasure. Otherwise, I think they will not like me and reject me, because I have nothing to offer. (Victoria).

Since a young age, Dominique tended to immerse herself in a fantasy world, developing elaborated scenarios about people living in a youth center administered by a vicious boss. Different characters in her ‘Story’ represented specific features, interests and plans she had.

Well, there is John who is a teacher and researcher. He teaches mathematics. I have no skills in maths at all. Tim is a philosopher and would like to train philosophers, enroll doctoral studies. He would like me to study philosophy but the rest of the system wants me to be a worrier. Ralf is a caring nurse and would like to become a paramedic. It is difficult to reconcile all these different expectations. Whoever comes up front, then I have these ideas. (Dominique).

Dominique neither had amnesia nor found evidence for leading separate lives and engaging herself in activities associated with her characters. She maintained her job as a playwright, and merely imagined alternative scenarios of her life, expressed by her inner heroes. In other parts of the interview, she referred to them as ‘voices inside,’ but admitted she never heard them acoustically. They were her own vivid thoughts representing different, conflicting opinions or impulses.

Katia said she felt internally fragmented. There were times when she engaged in certain interests, knowledge and skills, but she later changed her goals. Fifteen years ago she gave up her academic career and went on sickness benefit when she became disabled due to medical problems; she experienced this as a great loss, a failure, which affected her sense of identity and purpose.

In recent years I have a growing sense of identity fragmentation. I have problems with defining my identity because it changes. I used to feel more stable in the past. I had these versions of myself which were more dominating, so I had a stronger sense of identity. For example, 20 years ago there was this scientist. I was studying and felt like a scientist, attending conferences. Now I don’t have that and I don’t know who I am. […] I also have changing interests and hobbies because of different personalities. Long ago I liked certain music, played the guitar, sang songs. I don’t do that anymore, I suddenly lost interest in all that. (Katia).

She described changes in her professional and social lives in terms of switches between dissociative parts. Although she maintained the first person narrative (“I was studying,” “I played,” or “I sang”), indicating some sense of continuity, she thought it proved the existence of two or more distinct personalities.

Participants also reported thoughts, temptations, impulses or actions which seemed to evoke conflicting feelings. Attributing them to ‘something inside that is not-me’ could free them from guilt or shame, so they used a metaphor of someone taking over, logging in, or switching. Dominique thought it was inappropriate to express disappointment or anger, but she accepted the thought that her dissociative parts were doing this.

When I’m angry at my therapist, it is not really me but somebody inside who gets angry easily. Greg often switches on in such situations and says: “Tell her this and this”. […] I went to a shop once and discovered that the price on the label was not for a whole package of batteries but a single one. And suddenly Greg switched on and had a row with the cashier. I mean, I did it, but wound up by his anger. This is so weird, I wouldn’t react like that. They just charged incorrectly and I would normally ignore that but Greg said: “I give a shit about their mistakes. I won’t accept that.” What a failure! (Dominique).

Mary said she had parts that expressed anger, sadness, and needs associated with attachment. She observed them and allowed them to step in, when situations required.

There were situations in my life when the teenager must have been active. She protected me. She is ready to fight; I am not like that at all. I hate violence, and that teenager likes using force to protect me. […] My therapist suggested I call her after this interview if I do not feel well. I didn’t accept that but the [inner] girls got upset and told me I needed her help. They made me comply, so I agreed to call her if I do not feel well. It has always been like this. (Mary).

During assessment, no participant provided evidence for the existence of autonomous dissociative parts. It seems that the inner characters described by them personified unintegrated ego-states which used to evoke conflicting feelings.

Theme 3: Exploring Personal Experiences via the Lens of Dissociation

Reading books, websites and watching videos of people who claimed to have DID, encouraged them to compare themselves, talk about and express ‘multiple personalities.’ The participants became familiar with specialist terms and learned about core symptoms mentioned in psychiatric manuals.

I read First person plural which helped me understand what this is all about. The drama of the gifted child and The body keeps the score . More and more girls started to appear. There is a 6-month old baby which showed up only 2 months ago, a sad 11-year old teenager, and a 16-year old who thinks I am a loser. I was a teenager like that. Now she is having problems and becoming withdrawn there are fewer switches, because she knows we need to help the little one first. (Mary).

Olga was also inspired by books. Not only did she find similarities to trauma survivors but she made new discoveries and thought there were other experiences she had been unaware of earlier. Victoria started using techniques which literature recommended for stabilization in dissociative disorders. She said these books helped her understand intense emotions and improve concentration.

This explains everything that happens to me, why I get so angry. I also found anchors helpful. I focus on certain objects, sounds or smells which remind me where I am, instead of drifting away into my thoughts. (Victoria).

It seemed that exploring information about DID encouraged changes in participants’ clinical presentation. At first, they merely struggled with emotional liability or detachment, internal conflicts, and concentration problems. Later, they started reporting intrusions of dissociative parts or using clinical terms (e.g., flashback) for experiences which were not necessarily clinical symptoms. Dominique said that the characters of her story would often ‘log in’ and take control. She demonstrated that during the interview by changing her voice and going into a ‘trance.’ She created her own metaphors, explaining these experiences and comparing them with those described in literature. She stressed that she never had amnesia and remained aware of what was happening during her ‘trance.’

I think it is a form of dissociation on the emotional level. I read a lot… The minds of Billy Milligan or First person plural . For sure, I do not have an alteration of personality. I have co-consciousness. My theory is, we are like a glove, we all stem from one trunk, but we are like separate fingers. (Dominique).

While participants maintained they had flashbacks, they understood them as sudden recollections of past memories but not necessarily related to trauma. Katia said she recently remembered the picture of the house and garden where she played as a child and associated these experiences with moments of joy. Karina also exemplified her flashbacks with ‘intrusions of happy memories’ which belonged to other personalities:

Sometimes I begin to laugh but this is not my laughter, but the laughter of sheer joy. Someone inside me is very happy and wants to talk about happy childhood memories, make jokes. (Karina).

Mary said a child part of her was responsible for flashbacks and making comments about current situations. However, she later denied hearing voices or having any other Schneider’s symptoms.

I can hear her comments, that she does not like something. I can be flooded by emotions and have flashbacks associated with that child. For example, there is a trigger and I can see things that this child has seen. She is showing me what was happening in her life. (Mary).

Participants discussed their dissociative parts, their names and features, exhibiting neither avoidance nor fear or shame. On the contrary, they seemed to draw pleasure by smiling, showing excitement and eagerness to produce more examples of their unusual experiences. At the beginning of the interview, Karina was very enthusiastic and said, “My heart is beating so fast, as if I were in fight-or-flight mode.”

Theme 4: Talking About DID Attracts Attention

Not only were multiple personalities a helpful metaphor for expressing conflicting feelings or needs (already mentioned in Theme 2), but they also became an important topic of conversations with family or friends.

My husband says sometimes: “I would like to talk to the little girl.” He then says that I start behaving differently. I also talk to my therapist using different voices. Sometimes, she addresses them asking questions. If questions are asked directly, they respond, but there are times I do not allow them to speak, because the teenager part can be very mean and attacks people. (Mary).

It may have been easier for Mary to express her needs for dependency and care by ascribing them to a little girl and, because she felt awkward about feeling angry with the therapist, attributing hostile impulses to a teenager could give her a sense of control and reduce guilt. Karina decided to create a video-blog for documenting dissociative parts, and shared her videos with people interested in DID. She said she was surprised to find clips in which she looked dreadful, having her make-up smeared all over the face, because she had no memory of doing that. However, she showed no signs that it bothered her. She discussed the videos with her best friend, a DID fan who had encouraged her to enroll in the study in order to confirm her diagnosis. They were collecting evidence to support the idea that she had a dissociative disorder, which she presented one by one, before being asked about details.

Mark [her friend] reads a lot about DID. He says I sometimes talk in a high voice which is not the way I usually talk. He refers to us as plural. […] In some of these videos I do not move or blink for a minute. I look at some point and there is no expression on my face. I can remember things until this moment, and later I discover myself looking like something from Creepypastas. I am so sorry for people who have to see this… and I found my diary. I have been writing diaries since I was seven. I sometimes have no memory for having written something. I need to find these notes because I would like to write a book about a fantasy world and inner conflicts. (Karina).

Dominique and Katia also wrote journals to record dissociative experiences. Katia hoped to be recognized as an expert-by-experience and develop her career in relation to that. She brought with her a script of a book she hoped to publish 1 day.

Theme 5: Ruling Out DID Leads to Disappointment or Anger

Four participants were openly disappointed that their DID diagnosis was not confirmed. They doubted if their descriptions were accurate enough, or they challenged the interviewer’s understanding of the symptoms. Katia also suggested that she was incapable of providing appropriate answers supporting her diagnosis due to amnesia and personality alterations.

Do you even consider that I might give different answers if you had asked these questions 2 or 5 years ago? I must have erased some examples from my memory and not all experiences belong to me. I know that people can unconsciously modify their narratives and that is why I wanted an objective assessment. […] Nobody believed I was resistant to anesthetics until I was diagnosed with some abnormalities. It was once written in my medical report that I was a hypochondriac. One signature and things become clear to everyone. Sometimes it is better to have the worst diagnosis, but have it. (Katia).

She expected that the diagnosis would legitimize her inability to establish satisfactory relationships, work, and become financially independent. For this reason, she also insisted that the final report produced for her should contain information about how she felt maltreated by family or doctors, and revealed her hopes to claim damages for health injury. Mary and Karina were also upset that the interviewers did not believe they had DID.

Can you try to imagine how hard it is? I am not making things up? You don’t believe me. I am telling you things and you must be thinking, from the adult perspective: “You are making this up.” Nothing pisses me off more than someone who is trying to prove to others that they have just imagined things. They [dissociative parts] feel neglected again, as always! (Mary).

Karina tried to hide her disappointment and claimed she was glad she didn’t have a severe mental illness. However, she thought she would need to build another theory explaining her symptoms. After the interview, she sent more videos trying to prove the assessment results were not accurate.

What about my problems then? I am unable to set boundaries, I have anxiety, I fear that a war might break out. If this is not dissociation, then what? I had tests and they ruled out any neurological problems. I came here and ruled out another possibility. It is some information but I have not heard anything new. (Karina).

Only Victoria seemed relieved that her DID diagnosis was not confirmed. She was happy to discuss how attachment problems or conflicts with expressing emotions and needs affected her social life and career, and receive guidelines for future treatment. She felt liberated from having to uncover childhood traumas that her therapist expected her to have as a dissociative patient.

I was hoping that you would find another explanation for my problems… for what is wrong with me, why I feel so sensitive or spaced out, because it is annoying. I would like to know what is going on. I don’t think I’ve had any severe trauma but everybody wants to talk about trauma all the time. (Victoria).

ICD-10 and DSM-5 provide inadequate criteria for diagnosing DID, basically limited to patients having distinct dissociative identities with their own memories, preferences and behavioral patterns, and episodes of amnesia ( American Psychiatric Association, 2013 ; World Health Organization, 1993 ). Clinicians without experience of DID may therefore expect patients to present disruptions of identity during a consultation and spontaneously report memory problems. However, trauma specialists view DID as a ‘disorder of hiddenness’ because patients often find their dissociative symptoms bizarre and confusing and do not disclose them readily due to their shame and the phobia of inner experiences ( Steele et al., 2005 , 2016 ; Van der Hart et al., 2006 ). Instead, they tend to undermine their significance, hide them and not report them during consultations unless asked about them directly. Dissociative patients can also be unaware of their amnesia and ignore evidence for having done things they cannot remember because realizing that is too upsetting. Contrary to that, this study and the one conducted in 1999 in the Netherlands by Draijer and Boon, show that some people with personality disorders enthusiastically report DID symptoms by the book, and use the notion of multiple personalities to justify problems with emotional regulation, inner conflicts, or to seek attention. As with Dutch patients, Polish participants were preoccupied with their alternate personalities and two tried to present a ‘switch’ between parts. Their presentations were naïve and often mixed with lay information on DID. However, what they reported could be misleading for clinicians inexperienced in the dissociation field or those lacking the appropriate tools to distinguish a genuine dissociative disorder from an imitated one.

Therefore, understanding the subtleties about DID clinical presentation, especially those which are not thoroughly described in psychiatric manuals, is important to come up with a correct diagnosis and treatment plan. Various clinicians stress the importance of understanding the quality of symptoms and the mechanisms behind them in order to distinguish on the phenomenological level between borderline and DID patients ( Boon and Draijer, 1993 ; Laddis et al., 2017 ). Participants in this study reported problems with identity, affect regulation and internal conflicts about expressing their impulses. Some of them also had somatic complaints. These symptoms are common in personality disorders and also in dissociative disorders, which are polysymptomatic by nature. However, the quality of these symptoms and psychological mechanisms behind them may be different. For a differential diagnosis, clinicians need to become familiar with the unique internal dynamics in people who have developed a structural dissociation of personality as a result of trauma. These patients try to cope with everyday life and avoid actively thinking about and discussing traumatic memories, or experiencing symptoms associated with them. Because of that avoidance, they find it challenging to talk about dissociative symptoms with a clinician. Besides experiencing fear of being labeled as insane and sent to hospital, there may be internal conflicts associated with disclosing information. For example, dissociative parts may forbid them to talk about symptoms or past experiences. This conflict can sometimes be indicated by facial expression, involuntary movements, spasms, and also felt by the clinician in his or her countertransference. In other words, it is not only what patients say about their experiences, but how they do this. Therapists’ observations and countertransference may help in assessing the quality of avoidance: How openly or easily do patients report symptoms or adverse life experiences? Is that associated with strong depersonalisation (detachment from feelings and sensations, being absent)? Is there evidence for internal conflicts, shame, fear or feeling blocked when talking about symptoms (often observed in facial expression, tone of voice)? Participants in this study were eager to talk about how others mistreated them and wanted to have that documented on paper. Difficult experiences in the past sometimes triggered intense emotions in them (anger, resentment, and deep sadness) but they did not avoid exploring and communicating these states. On the contrary, they eagerly shared an elaborate narrative of their sorrows and about their inner characters – the multiple personalities they were convinced they had. They became keen on DID and used a variety of resources to familiarize themselves with core symptoms. They also spontaneously reported them, as if they wanted to provide sound evidence about having DID and were ready to defend their diagnosis. Some planned their future based on it (an academic career, writing a book, or a film). During the interviews, it became clear that some perceived having an exotic diagnosis as an opportunity for seeking attention and feeling unique, exhibiting the drama of an ‘unseen child’ (see section “Theme 4”).

Understanding a few of the symptoms identified in this study can be useful for differential diagnosis: intrusions, voices, switches, amnesia, use of language, depersonalisation. How they are presented by patients and interpreted by clinicians is important.

Triggered by external or internal factors (memories or anything associated with trauma) dissociative patients tend to relive traumatic experiences. In other words, they have intrusive memories, emotions or sensorimotor sensations contained by dissociative parts which are stuck in trauma. In addition to avoidance, this is another characteristic PTSD feature observed in the clinical presentation of DID patients ( Van der Hart et al., 2010 ). Interestingly, participants in this study showed no evidence for intrusions (images, emotions or somatosensory experiences directly related to trauma), but rather problems with emotional regulation (illustrated in sections “Themes 1 and 2”). Asked about intrusive images, emotions or thoughts, some gave examples of distressing thoughts attacking self-image and blaming for their behavior. This, however, was related to attachment problems and difficulties with self-soothing. They also revealed a tendency to indulge themselves in these auto-critical thoughts instead of actively avoiding them, which is often a case in dissociative patients. Some intrusions reported by DID patients are somatoform in nature and connected with dissociative parts stuck in trauma time ( Pietkiewicz et al., 2018 ). Although three participants in this study had very high scores in SDQ-20 indicating that they may have a dissociative disorder (scores of 50–60 are common in DID), further interviews revealed that they aggravated their symptoms and, in fact, had low levels of somatoform dissociation. This shows that tests results should be interpreted with caution and clinicians should always ask patients for specific examples of the symptoms they report.

It is common for DID patients to experience auditory hallucinations ( Dorahy et al., 2009 ; Longden et al., 2019 ). The voices usually belong to dissociative parts and comment on actions, express needs, likes and dislikes, and encourage self-mutilation. Subsequently, there may be conflicts between ‘voices,’ and the relationship with them is quite complex. Dorahy et al., 2009 observe that auditory hallucinations are more common in DID than in schizophrenia. In dissociative patients they are more complex and responsive, and already appear in childhood. Specifically, child voices are also to be expected in DID (97% in comparison to 6% in psychosis). None of our participants reported auditory hallucinations although one (Dominique) said she had imaginary friends from childhood. While this could sound like a dissociative experience, exploring their experiences showed she had a tendency to absorb herself in her fantasy world and vividly imagine characters in her story (see section “Theme 2”).

Literature also shows that it is uncommon for avoidant dissociative patients to present autonomous dissociative parts to a therapist before a good relationship has been established and the phobia for inner experiences reduced ( Steele et al., 2005 ). Sudden switches between dissociative personalities may occur only when the patient is triggered and cannot exercise enough control to hide his or her symptoms. Two participants in this study (Dominique and Karina) tried to present ‘alternate personalities’ and they actually announced this would happen, so that the interviewer did not miss them. Later on, they could relate to what happened during the alleged switch (no amnesia), maintaining the first-person perspective (I was saying/doing). Contrary to that, dissociative patients experience much shame and fear of disclosing their internal parts ( Draijer and Boon, 1999 ). If they become aware that switches had occurred, they try to make reasonable explanations for the intrusions of parts and unusual behavior (e.g., I must have been very tired and affected by the new medicine I am taking).

Dell (2006) mentions various indicators of amnesia in patients with DID. However, losing memory for unpleasant experiences may occur in different disorders, usually for behaviors evoking shame or guilt, or for actions under extreme stress ( Laddis et al., 2017 ). All patients in this study had problems with emotional regulation and some said they could not remember what they said or did when they became very upset. With some priming, they could recall and describe events. For this reason, it is recommended to explore evidence for amnesia for pleasant or neutral activities (e.g., doing shopping or cleaning, socializing). According to Laddis et al. (2017) there are different mechanisms underlying memory problems in personality and dissociative disorders.

Use of Language

Participants in this study often used clinical jargon (e.g., flashbacks, switches, and feeling depersonalized) which indicates they had read about dissociative psychopathology or received psycho-education. However, they often had lay understanding of clinical terms. A good example in this study was having ‘flashbacks’ of neutral or pleasant situations which had once been forgotten. Examples of nightmares did not necessarily indicate reliving traumatic events during sleep (as in PTSD) but expressed conflicts and agitation through symbolic, unrealistic, sometimes upsetting dreams. When talking about behavior of other parts and their preferences, they often maintained a first-person perspective. Requesting patients to provide specific examples is thus crucial.

Depersonalisation

Detachment from feelings and emotions, bodily sensations and external reality is often present in various disorders ( Simeon and Abugel, 2006 ). While these phenomena have been commonly associated with dissociation, Holmes et al. (2005) stress the differences between detachment (which can be experienced by both dissociative and non-dissociative patients) and compartmentalisation, associated with the existence of dissociative parts. Allen et al. (1999) also stress that extreme absorptive detachment can interfere with noticing feelings and bodily sensations, and also memory. Some participants in this study tended to enter trance-like states or get absorbed in their inner reality, subsequently getting detached from bodily sensations. They also described their feeling of emptiness in terms of detachment from feelings. Nevertheless, none of them disclosed evidence for having distinct dissociative parts. Some of their statements might have been misleading; for example, when they attributed anger attacks to other parts, not-me (see: Dominique in section “Theme 2”). One might suspect it could be evidence for autonomous dissociative parts. However, these participants seem to have had unintegrated, unaccepted self-states and used the concept of DID to make meaning of their internal conflicts. In their narrative they maintained the first-person narrative. None of them provided sound evidence for extreme forms of depersonalisation, such as not feeling the body altogether or out-of-body experiences.

There can be many reasons why people develop symptoms which resemble those typical of DID. Suggestions about a dissociative disorder made by healthcare providers can help people justify and explain inner conflicts or interpersonal problems. In this study several clinicians had suggested a dissociative disorder or DID to the patient. Literature on multiple personalities and therapy focused on them, and using expressions such as ‘parts’, ‘dissociating’, ‘switches,’ can also encourage demonstrating such symptoms. There are also secondary gains explained in this study, such as receiving attention and care. Draijer and Boon (1999) observe that people with borderline features justified shameful behavior and avoided responsibility by attributing their actions to ‘alter personalities.’ Such people can declare amnesia for their outbursts of anger, or hitting partners. Others explained their identity confusion and extreme emptiness using the DID model. All their participants reported emotional neglect and felt unseen in their childhood, so they adopted a new DID-patient identity to fill up inner emptiness ( Draijer and Boon, 1999 ). Just like the participants in this study, they were angry when that diagnosis was disconfirmed during the assessment, as if the clinician had taken away something precious from them. This shows that communicating the results should be done with understanding, empathy and care. Patients and clinicians need to understand and discuss reasons for developing a DID-patient identity, its advantages and pitfalls.

In countries where clinicians are less familiar with the dissociative pathology, there may be a greater risk for both false-negative and false-positive DID diagnoses. The latter is caused by the growing popularity of that disorder in media and social networks. People who try to make meaning of their emotional conflicts, attachment problems and difficulties in establishing satisfactory relationships, may find the DID concept attractive. It is important that clinicians who rule out or disconfirm DID, also provide patients with friendly feedback that encourages using treatment for their actual problems. Nevertheless, this may still evoke strong reactions in patients whose feelings and needs have been neglected, rejected or invalidated by significant others. Disconfirming DID may be experienced by them as an attack, taking something away from them, or an indication that they lie.

Limitations and Further Directions

Among the 85 people who participated in a thorough diagnostic assessment, there were six false-positive DID cases, and this study focused on their personal experiences and meaning attributed to the diagnosis. Because IPA studies are highly idiographic, they are by nature limited to a small number of participants. There were two important limitations in this research. Firstly, information about the level of psychoform symptoms has not been given, because the validation of the Polish instrument used for that purpose is not complete. Secondly, TADS-I used for collecting clinical data about trauma-related symptoms and dissociation has not been validated, either. Because there are no gold standards in Poland for diagnosing dissociative disorders, video-recordings of diagnostic interviews were carefully analyzed and discussed by all authors to agree upon the diagnosis. Taking this into consideration, further qualitative and quantitative research is recommended to formulate and validate more specific diagnostic criteria for DID and guidelines for the differential diagnosis.

Clinicians need to understand the complexity of DID symptoms and psychological mechanisms responsible for them in order to differentiate between genuine and imitated post-traumatic conditions. There are several features identified in this study which may indicate false-positive or imitated DID shown in Table 4 , which should be taken into consideration during diagnostic assessment. In Poland, as in many countries, this requires more systematic training in diagnosis for psychiatrists and clinical psychologists in order to prevent under- and over-diagnosis of dissociative disorders, DID in particular. It is not uncommon that patients exaggerate on self-report questionnaires when they are invested in certain symptoms. In this study, all participants had scores above the cut-off score of 28 on the SDQ-20, a measure to assess somatoform dissociation, which suggested it was probable they had a dissociative disorder. However, during a clinical diagnostic interview they did not report a cluster of somatoform or psychoform dissociative symptoms and did not meet criteria for any dissociative disorder diagnosis. Clinicians also need to go beyond the face value of a patient’s responses, ask for specific examples, and notice one’s own countertransference. Draijer and Boon (1999) observed that DID patients were often experienced by clinicians as very fragile, and exploring symptoms with people with personality disorders (who try to aggravate them and control the interview) can evoke tiredness or even irritability. It is important that clinicians understand their own responses and use them in the diagnostic process.

Table 4. Red flags for identifying false-positive or imitated DID.

While psycho-education is considered a crucial element in the initial treatment of dissociative disorders ( Van der Hart et al., 2006 ; Howell, 2011 ; Steele et al., 2016 ), patients whose diagnosis has not been confirmed by a thorough diagnostic assessment should not be encouraged to develop knowledge about DID symptomatology, because this may affect their clinical presentation and how they make meaning of their problems. Subsequently, this may lead to a wrong diagnosis and treatment, which can become iatrogenic.

Data Availability Statement

The datasets generated for this study are not readily available because data contain highly sensitive clinical material, including medical data which cannot be shared according to local regulations. Requests to access the datasets should be directed to IP, [email protected] .

Ethics Statement

The studies involving human participants were reviewed and approved by Ethical Review Board at the SWPS University of Social Sciences and Humanities. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

IP collected qualitative data, performed the analysis, and prepared the manuscript. AB-N transcribed and analyzed the interviews and helped in literature review and manuscript preparation. RT performed psychiatric assessment and helped in data analysis and manuscript preparation. SB helped in data analysis and manuscript preparation. All authors contributed to the article and approved the submitted version.

Grant number 2016/22/E/HS6/00306 was obtained for the study “Interpretative phenomenological analysis of depersonalization and derealization in clinical and non-clinical groups.”

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords : dissociative identity disorder (DID), false-positive cases, personality disorder, dissociation, differential diagnosis

Citation: Pietkiewicz IJ, Bańbura-Nowak A, Tomalski R and Boon S (2021) Revisiting False-Positive and Imitated Dissociative Identity Disorder. Front. Psychol. 12:637929. doi: 10.3389/fpsyg.2021.637929

Received: 04 December 2020; Accepted: 14 April 2021; Published: 06 May 2021.

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Copyright © 2021 Pietkiewicz, Bańbura-Nowak, Tomalski and Boon. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Igor Jacob Pietkiewicz, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Contemplating the Controversies of Dissociative Identity Disorder

By Elements Behavioral Health posted on January 26, 2013 in Mental Health

Dissociative Identity Disorder (DID), the new-ish name for an old label, multiple personality disorder , still has its armies of detractors. Despite reams of controversy littered through the pages of the upcoming revision of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders slated for May of 2013, DID is still likely to be one of the most misunderstood diagnoses in the book. For some time, many in the media and even members of the mental health profession have contended that DID is not a legitimate mental illness-that it is, in essence, a fake.

What is DID?

DID most commonly develops as a result of severe and sustained childhood trauma . The theory is that a child’s fragile psyche dissociates in order to cope with stressors with which no child can possibly contend. Dissociation is a mental process, which produces a lack of connection in a person’s thoughts, memories, feelings, actions, or sense of identity (PsychCentral.com). Dissociating from traumatic experiences allows those experiences to become repressed, so that memory of them does not begin to emerge until later in life-sometime during adulthood-when the individual is more able to emotionally cope with memories of traumatic experiences.

In instances of DID, the experiences are too severe, or the psychology or genetic makeup of a particular child is too fragile to later integrate the traumatic memories in a healthy way. Instead, the individual’s psyche fractures, splitting off from the core self so that independent identities emerge, each with separate characteristics.

The DSM criteria for DID is as follows:

• The presences 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 self).
• At least two of these identities or personality states recurrently take control of the person’s behavior.
• Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
• The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

What are the Controversies?

One component that makes DID difficult for some mental health professionals to swallow is a theory of its causality which pertains to repressed memories. These professionals are dubious of repressed memories and the potential for “remembering” childhood abuse that may never have actually occurred. With the 1980s childhood abuse claims tied to Satanic cult practices, it’s no wonder for these fears. Those claims-largely overblown and sensationalized in the media-turned out to be overwhelmingly unsubstantiated.

But Bethany Brand, PhD, a professor of psychology at Townsend University and an expert in the research and treatment of dissociative disorders explains that most people with DID do not forget their childhood abuse, particularly when it was chronic or severe. “[S]ufferers may forget episodes or aspects of some of their trauma,” Brand has said, but it’s “fairly rare not to remember any trauma at all and suddenly recover memories of chronic childhood abuse.” Those individuals who experience recovery of repressed memories often do so around events or experiences they had maintained some memory of, but which they had dissociated chunks of in order to cope.

Skepticism over false memories and the many myths surrounding DID persist in the mental health field because of a lack of awareness, education, and adequate and updated training on the subject. Brand has explained that one of the beliefs which persists about DID is that there are “different people” inside someone who has DID. This only adds to the notion that the disorder itself and the people who suffer it are unusual or bizarre. Another complicating factor are those mental health professionals outside the mainstream who choose to treat DID patients with strange and unproven methods. The treatment that dissociative experts use for DID patients is similar to the standard methods for treating complex trauma, and these are the treatments with the highest efficacy in helping DID patients recover from their past traumas and to integrate the split “self-states” they perceive and which trouble them even while they have served as a method of coping with insurmountable pain for a time.

Prevailing Myths of DID

The myths surrounding DID and its sufferers are many, and so it’s important to set right at least a couple of facts. Despite media sensationalizing and Hollywood portrayals, DID is a subtle disease; it takes many years for anyone-family, sufferers themselves, and even therapists-to determine what is happening, if they ever do. The “self-states” are generally not so distinct as to be easily spotted, even if they can be. Efficacious treatments for DID do not involve hypnosis in order to “retrieve” past memories. While hypnosis has been proven beneficial in aiding patients in finding a calm, secure state in order to work through anxiety and other emotions, the use of hypnosis to explore repressed memories has been negated by the mental health field as it can produce clients who are too susceptible to producing “memories” which never occurred.

DID sufferers typically share a common childhood history of repeated and severe emotional, physical, or sexual abuse or a combination of these. When their disease strikes, they are confused and uncertain, and many report a lack of awareness or understanding of self. Another feature DIDs often share in common is a new fracturing of self-a new seemingly independent identity emerging-each time a new traumatic experience took place. In this way their central identity (who they truly are) could slip away through dissociation in order to bear the terrible event they were forced to suffer as a child.

The mind is the most complex organ in the known universe, and the human the most adaptable animal. If we can live successfully in the arctic as well as on the equator, can walk on the moon and live months in space, it is no wonder that one mind can trick itself into believing it is many so that it can endure a more hostile terrain than any of these.

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The Controversies Surrounding Dissociative Disorders

Assignment: Controversy Associated With Dissociative Disorders The DSM-5 is a diagnostic tool. It has evolved over the decades, as have the classifications and criteria within its pages. It is used not just for diagnosis, however, but also for billing, access to services, and legal cases. Not all practitioners are in agreement with the content and structure of the DSM-5, and dissociative disorders are one such area. These disorders can be difficult to distinguish and diagnose. There is also controversy in the field over the legitimacy of certain dissociative disorders, such as dissociative identity disorder, which was formerly called multiple personality disorder.

In this Assignment, you will examine the controversy surrounding dissociative disorders. You will also explore clinical, ethical, and legal considerations pertinent to working with patients with these disorders.

The Assignment (3-4 pages) Explain the controversy that surrounds dissociative disorders. Explain your professional beliefs about dissociative disorders, supporting your rationale with at least three scholarly references from the literature. Explain strategies for maintaining the therapeutic relationship with a client that may present with a dissociative disorder. Finally, explain ethical and legal considerations related to dissociative disorders that you need to bring to your practice and why they are important.

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Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder

Dissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.

Dissociative identity disorder (DID) is defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an identity disruption indicated by the presence of two or more distinct personality states (experienced as possession in some cultures), with discontinuity in sense of self and agency, and with variations in affect, behavior, consciousness, memory, perception, cognition, or sensory-motor functioning. 1 Individuals with DID experience recurrent gaps in autobiographical memory. The signs and symptoms of DID may be observed by others or reported by the individual. DSM-5 stipulates that symptoms cause significant distress and are not attributable to accepted cultural or religious practices. Conditions similar to DID but with less-than-marked symptoms (e.g., subthreshold DID) are classified among “other specified dissociative disorders.”

DID is a complex, posttraumatic developmental disorder. 2 , 3 DSM-5 specifically locates the dissociative disorders chapter after the chapter on trauma- and stressor-related disorders, thereby acknowledging the relationship of the dissociative disorders to psychological trauma. The core features of DID are usually accompanied by a mixture of psychiatric symptoms that, rather than dissociative symptoms, are typically the patient’s presenting complaint. 3 , 4 As is common among individuals with complex, posttraumatic developmental disorders, DID patients may suffer from symptoms associated with mood, anxiety, personality, eating, functional somatic, and substance use disorders, as well as psychosis, among others. 3 – 8 DID can be overlooked due to both this polysymptomatic profile and patients’ tendency to be ashamed and avoidant about revealing their dissociative symptoms and history of childhood trauma (the latter of which is strongly implicated in the etiology of DID). 9 – 14

Multiple personality states * have been described by renowned theorists, including Pierre Janet, Sigmund Freud, Alfred Binet, William James, Benjamin Rush, Morton Prince, Boris Sidis, Enrico Morselli, and Sandor Ferenczi. 15 – 20 The first published cases are those of Jeanne Fery, 20 reported in 1586, and a case of “exchanged personality” that dates to Eberhardt Gmelin’s account of 1791. 21 Many of the individuals considered hysterics in the nineteenth century would today be diagnosed with dissociative disorders. Early debates focused upon whether hysteria should be conceptualized as a somatoform condition, a condition of altered states of consciousness, or a condition rooted entirely in suggestion. 16 , 22

Current debates about the validity and etiology of DID echo early debates about hysteria and also other trauma-based phenomena such as dissociative amnesia. Historically, trauma has stirred debate within and outside the mental health field; periods of interest in trauma have been followed by disinterest and disavowal of its prevalence and impact. 6 , 23 , 24 The previous lack of systematic evidence about the relationship between trauma and clinical symptomatology contributed to misconceptions about trauma-related problems (such as attributing these symptoms to psychosis). The absence of systematic documentation of the extent of child abuse further inhibited efforts to identify and define the complex syndromes that were closely associated with it. 6

Additionally, a broadening of the range of conditions subsumed by a diagnosis of schizophrenia moved the etiological focus from trauma and dissociation to a variant of genetic illness/brain pathology. Rosenbaum 25 documented that as the concept of schizophrenia began to gain ascendency among clinicians, the concept of DID markedly decreased—a change that likely occurred because schizophrenia and DID have some similar symptoms. 8 , 26 Yet, early writers on psychoses/schizophrenia (e.g., Kahlbaum, Kraepelin, Bleuler, Meyer, Jung, Schneider, and Bateson) reference cases of “psychosis” that closely resemble, or are seemingly typical of, DID. 27 Bleuler references many such cases, including some in which “the ‘other’ personality is marked by the use of different speech and voice … Thus we have here two different personalities operating side by side, each one fully attentive. However, they are probably never completely separated from each other since one may communicate with both.” 28(p 147)

Social, scientific, and political influences have since converged to facilitate increased awareness of dissociation. These diverse influences include the resurgence of recognition of the impact of traumatic experiences, feminist documentation of the effects of incest and of violence toward women and children, continued scientific interest in the effects of combat, and the increasing adoption of psychotherapy into medicine and psychiatry. 18 , 29 The increased awareness of trauma and dissociation led to the inclusion in DSM-III of posttraumatic stress disorder (PTSD), dissociative disorders (with DID referred to as multiple personality disorder), and somatoform disorders, and to the discarding of hysteria. 30 Concurrently, traumatized and dissociative patients with severe symptoms (e.g., suicidality, impulsivity, self-mutilation) gained greater attention as psychiatry began to treat more severe psychiatric conditions with psychotherapy, and as some acutely destabilized DID patients required psychiatric hospitalization. 31 These developments facilitated a climate in which researchers and clinicians could consider how a traumatized child or adult might psychologically defend himself or herself against abuse, betrayal, and violence. Additionally, the concepts of identity, alongside identity crisis, identity confusion, and identity disorder, were introduced to psychiatry and psychology, thereby emphasizing the links between childhood, society, and epigenetic development. 32 , 33

In this climate of renewed receptivity to the study of trauma and its impact, research in dissociation and DID has expanded rapidly in the 40 years spanning 1975 to 2015. 14 , 34 Researchers have found dissociation and dissociative disorders around the world. 3 , 12 , 35 – 45 For example, in a sample of 25,018 individuals from 16 countries, 14.4% of the individuals with PTSD showed high levels of dissociative symptoms. 35 This research led to the inclusion of a dissociative subtype of PTSD in DSM-5. 1 Recent reviews indicate an expanding and important evidence base for this subtype. 14 , 36 , 46

Notwithstanding the upsurge in authoritative research on DID, several notions have been repeatedly circulated about this disorder that are inconsistent with the accumulated findings on it. We argue here that these notions are misconceptions or myths. We have chosen to limit our focus to examining myths about DID, rather than dissociative disorders or dissociation in general. Careful reviews about broader issues related to dissociation and DID have recently been published. 47 – 49 The purpose of this article is to examine some misconceptions about DID in the context of the considerable empirical literature that has developed about this disorder. We will examine the following notions, which we will show are myths:

• belief that DID is a “fad”
• belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder
• belief that DID is rare
• belief that DID is an iatrogenic disorder rather than a trauma-based disorder
• belief that DID is the same entity as borderline personality disorder
• belief that DID treatment is harmful to patients

MYTH 1: DID IS A FAD

Some authors opine that DID is a “fad that has died.” 50 – 52 A “fad” is widely understood to describe “something (such as an interest or fashion) that is very popular for a short time.” 53 As we noted above, DID cases have been described in the literature for hundreds of years. Since the 1980 publication of DSM-III, 30 DID has been described, accepted, and included in four different editions of the DSM. Formal recognition as a disorder for over three decades contradicts the notion of DID as a fad.

To determine whether research about DID has declined (which would possibly support the suggestion that the diagnosis is a dying fad), we searched PsycInfo and MEDLINE using the terms “multiple personality disorder” or “dissociative identity disorder” in the title for the period 2000–14. Our search yielded 1339 hits for the 15-year period. This high number of publications speaks to the level of professional interest that DID continues to attract.

Recent reviews attest that a solid and growing evidence base for DID exists across a range of research areas:

• DID patients can be reliably and validly diagnosed with structured and semistructured interviews, including the Structured Clinical Interview for Dissociative Disorders–Revised (SCID-D-R) 54 and Dissociative Disorders Interview Schedule (DDIS) 55 , 56 (reviewed in Dorahy et al. [2014]). 14 DID can also be diagnosed in clinical settings, where structured interviews may not be available or practical to use. 57
• DID patients are consistently identified in outpatient, inpatient, and community samples around the world. 12 , 37 – 45
• DID patients can be differentiated from other psychiatric patients, healthy controls, and DID simulators in neurophysiological and psychological research. 58 – 63
• DID patients usually benefit from psychotherapy that addresses trauma and dissociation in accordance with expert consensus guidelines. 64 – 66

An expanding body of research examines the neurobiology, phenomenology, prevalence, assessment, personality structure, cognitive patterns, and treatment of DID. This research provides evidence of DID’s content, criterion, and construct validity. 14 , 55 The claim that DID is a “fad that has died” is not supported by an examination of the body of research about this disorder.

MYTH 2: DID IS PRIMARILY DIAGNOSED IN NORTH AMERICA BY DID EXPERTS WHO OVERDIAGNOSE THE DISORDER

Some authors contend that DID is primarily a North American phenomenon, that it is diagnosed almost entirely by DID experts, and that it is overdiagnosed. 50 , 67 – 69 Paris 50(p 1076) opines that “most clinical and research reports about this clinical picture [i.e., DID] have come from a small number of centers, mostly in the United States that specialize in dissociative disorders.” As we show below, the empirical literature indicates not only that DID is diagnosed around the world and by clinicians with varying degrees of experience with the disorder, but that DID is actually under diagnosed rather than overdiagnosed.

Belief That DID Is Primarily Diagnosed in North America

According to some authors, DID is primarily diagnosed in North America. 50 , 52 , 70 We investigated this notion in three ways: by examining the countries in which prevalence studies of DID have been conducted; by inspecting the countries from which DID participants were recruited in an international treatment-outcome study of DID; and by conducting a systematic search of published research to determine the countries where DID has been most studied.

First, our results show that DID is found in prevalence studies around the world whenever researchers conduct systematic assessments using validated interviews. Table ​ Table1 1 lists the 14 studies that have utilized structured or semistructured diagnostic interviews for dissociative disorders to assess the prevalence of DID. 80 These studies have been conducted in seven countries: Canada, Germany, Israel, the Netherlands, Switzerland, Turkey, and the United States. 37 – 39 , 44 , 45 , 71 – 79

Dissociative Disorder Prevalence Studies

Second, in addition to the prevalence studies, a recent prospective study assessed the treatment outcome of 232 DID patients from around the world. The participants lived in Argentina, Australia, Belgium, Brazil, Canada, Germany, Israel, the Netherlands, New Zealand, Norway, Singapore, Slovakia, South Africa, Sweden, Taiwan, and the United States. 81 That is, the participants came from every continent except Antarctica.

Third, we conducted a systematic search of published, peer-reviewed DID studies. Using the search terms “dissociative identity disorder” and “multiple personality disorder,” we conducted a literature review for the period 2005–13 via MEDLINE, PsycInfo, and the Journal of Trauma and Dissociation . This search yielded 340 articles. We selected empirical research studies in which DID or multiple personality disorder had been diagnosed in patients. We recorded authors’ countries and institutions, and whether structured interviews were used to diagnose DID. Over this nine-year period, 70 studies included DID patients. Significantly, these studies were conducted by authors from 48 institutions in 16 countries. In 28 (40%) of studies, structured interviews (SCID-D or DDIS) were administered to diagnose DID.

In summary, all three methods contradicted the claim that DID is diagnosed primarily in North America.

Belief That DID Is Primarily Diagnosed by DID experts

Lynn and colleagues 69(p 50) argue that “most DID diagnoses derive from a small number of therapy specialists in DID.” Other critics voice similar concerns. 50 , 82 , 83 Research does not substantiate this claim. For example, 292 therapists participated in the prospective treatment-outcome study of DID conducted by Brand and colleagues. 81 The majority of therapists were not DID experts. Similarly, a national random sample of experienced U.S. clinicians found that 11% of patients treated in the community for borderline personality disorder (BPD) also met criteria for comorbid DID. 84 None of the therapists were DID experts. In an Australian study of 250 clinicians from several mental health disciplines, 52% had diagnosed a patient with DID. 85 These studies show that DID is diagnosed by clinicians around the world with varying degrees of expertise in DID.

Belief That DID Is Overdiagnosed

A related myth is that DID is overdiagnosed. Studies show, however, that most individuals who meet criteria for DID have been treated in the mental health system for 6–12 years before they are correctly diagnosed with DID. 4 , 86 – 89 Studies conducted in Australia, China, and Turkey have found that DID patients are commonly misdiagnosed. 78 , 89 , 90 For example, in a study of consecutive admissions to an outpatient university clinic in Turkey, 2.0% of 150 patients were diagnosed with DID using structured interviews confirmed by clinical interview. 74 Although 12.0% were assessed to have one of the dissociative disorders, only 5% of the dissociative patients had been diagnosed previously with any dissociative disorder. Likewise, although 29% of the patients from an urban U.S. hospital-based, outpatient psychiatric clinic were diagnosed via structured interviews with dissociative disorders, only 5% had a diagnoses of dissociative disorders in their medical records. 37 Similar results have been found in consecutive admissions to a Swiss university outpatient clinic 91 and consecutive admissions to a state psychiatric hospital in the United States 45 when patients were systematically assessed with structured diagnostic interviews for dissociative disorders. This pattern is also found in nonclinical samples. Although 18.3% of women in a representative community sample in Turkey met criteria for having a dissociative disorder at some point in their lives, only one-third of the dissociative disorders group had received any type of psychiatric treatment. 78 The authors concluded, “The majority of dissociative disorders cases in the community remain unrecognized and unserved.” 78(p 175)

Studies that examine dissociative disorders in general, rather than focusing on DID, find that this group of patients are often not treated despite high symptomatology and poor functioning. A random sample of adolescents and young adults in the Netherlands showed that youth with dissociative disorders had the highest level of functional impairment of any disorder studied but the lowest rates (2.3%) of referral for mental health treatment. 92 Those with dissociative disorders in a nationally representative sample of German adolescents and young adults were highly impaired, yet only 16% had sought psychiatric treatment. 93 These findings point to the conclusion that dissociative disorder patients are underrecognized and undertreated, rather than being overdiagnosed.

Why is DID so often underdiagnosed and undertreated? Lack of training, coupled with skepticism, about dissociative disorders seems to contribute to the underrecognition and delayed diagnosis. Only 5% of Puerto Rican psychologists surveyed reported being knowledgeable about DID, and the majority (73%) had received little or no training about DID. 94 Clinicians’ skepticism, about DID increased as their knowledge about it decreased. Among U.S. clinicians who reviewed a vignette of an individual presenting with the symptoms of DID, only 60.4% of the clinicians accurately diagnosed DID. 95 Clinicians misdiagnosed the patient as most frequently suffering from PTSD (14.3%), followed by schizophrenia (9.9%) and major depression (6.6%). Significantly, the age, professional degree, and years of experience of the clinician were not associated with accurate diagnosis. Accurate diagnoses were most often made by clinicians who had previously treated a DID patient and who were not skeptical about the disorder. It is concerning that clinicians were equally confident in their diagnoses, regardless of their accuracy. A study in Northern Ireland found a similar link between a lack of training about DID and misdiagnosis by clinicians. 96 Psychologists more accurately detected DID than did psychiatrists (41% vs. 7%, respectively). Australian researchers found that misdiagnosis was often associated with lack of training about DID and with skepticism regarding the diagnosis. 85 They concluded, “Clinician skepticism may be a major factor in under-diagnosis as diagnosis requires [dissociative disorders] first being considered in the differential. Displays of skepticism by clinicians, by discouraging openness in patients, already embarrassed by their symptoms, may also contribute to the problem.” 85(p 944)

In short, far from being overdiagnosed, studies consistently document that DID is underrecognized. When systematic research is conducted, DID is found around the world by both experts and nonexperts. Ignorance and skepticism about the disorder seem to contribute to DID being an underrecognized disorder.

MYTH 3: DID IS RARE

Many authors, including those of psychology textbooks, argue that DID is rare. 70 , 97 – 99 The prevalence rates found in psychiatric inpatients, psychiatric outpatients, the general population, and a specialized inpatient unit for substance dependence suggest otherwise (see Table ​ Table1). 1 ). DID is found in approximately 1.1%–1.5% of representative community samples. Specifically, in a representative sample of 658 individuals from New York State, 1.5% met criteria for DID when assessed with SCID-D questions. 77 Similarly, a large study of community women in Turkey (n = 628) found 1.1% of the women had DID. 78

Studies using rigorous methodology, including consecutive clinical admissions and structured clinical interviews, find DID in 0.4%–6.0% of clinical samples (see Table ​ Table1). 1 ). Studies assessing groups with particularly high exposure to trauma or cultural oppression show the highest rates. For example, 6% of consecutive admissions in a highly traumatized, U.S. inner city sample were diagnosed with DID using the DDIS. 37 By contrast, only 2.0% of consecutive psychiatric inpatients received a diagnosis of DID via the SCID-D in the Netherlands. 38 The difference in prevalence may partially stem from the very high rates of trauma exposure and oppression in the U.S. inner-city, primarily minority sample.

Possession states are a cultural variation of DID that has been found in Asian countries, including China, India, Iran, Singapore, and Turkey, and also elsewhere, including Puerto Rico and Uganda. 46 , 100 – 102 For example, in a general population sample of Turkish women, 2.1% of the participants reported an experience of possession. 102 Two of the 13 women who reported an experience of possession had DID when assessed with the DDIS. Western fundamentalist groups have also characterized DID individuals as possessed. 102 Such findings are inconsistent with the claim that DID is rare.

MYTH 4: DID IS AN IATROGENIC DISORDER RATHER THAN A TRAUMA-BASED DISORDER

One of the most frequently repeated myths is that DID is iatrogenically created. Proponents of this view argue that various influences—including suggestibility, a tendency to fantasize, therapists who use leading questions and procedures, and media portrayals of DID—lead some vulnerable individuals to believe they have the disorder. 52 , 69 , 83 , 103 – 107 Trauma researchers have repeatedly challenged this myth. 48 , 49 , 108 – 111 Space limitations require that we provide only a brief overview of this claim.

A recent and thorough challenge to this myth comes from Dalenberg and colleagues. 48 , 49 They conducted a review of almost 1500 studies to determine whether there was more empirical support for the trauma model of dissociation—that is, that antecedent trauma causes dissociation, including dissociative disorders—or for the fantasy model of dissociation. According to the latter (also known as the iatrogenic or sociocognitive model), highly suggestible individuals enact DID following exposure to social influences that cause them to believe that they have the disorder. Thus, according to the fantasy model proponents, DID is not a valid disorder; rather, it is iatrogenically induced in fantasy-prone individuals by therapists and other sources of influence.

Dalenberg and colleagues 48 , 49 concluded from their review and a series of meta-analyses that little evidence supports the fantasy model of dissociation. Specifically, the effect sizes of the trauma-dissociation relationship were strong among individuals with dissociative disorders, and especially DID (i.e., .54 between child sexual abuse and dissociation, and .52 between physical abuse and dissociation). The correlations between trauma and dissociation were as strong in studies that used objectively verified abuse as in those relying on self-reported abuse. These findings strongly contradict the fantasy model hypothesis that DID individuals fantasize their abuse. Dissociation predicted only 1%–3% of the variance in suggestibility, thereby disproving the fantasy model’s notion that dissociative individuals are highly suggestible.

Despite the concerns of fantasy model theorists that DID is iatrogenically created, no study in any clinical population supports the fantasy model of dissociation . A single study conducted in a “normal” sample of college students showed that students could simulate DID. 112 That study, by Spanos and colleagues, documents that students can engage in identity enactments when asked to behave as if they had DID. Nevertheless, the students did not actually begin to believe that they had DID, and they did not develop the wide range of severe, chronic, and disabling symptoms displayed by DID patients. 3

The study by Spanos and colleagues 112 was limited by the lack of a DID control group. Several recent controlled studies have found that DID simulators can be reliably distinguished from DID patients on a variety of well-validated and frequently used psychological personality tests (e.g., Minnesota Multiphasic Personality Inventory–2), 113 , 114 forensic measures (e.g., Structured Interview of Reported Symptoms), 61 , 115 , 116 and neurophysiological measures, including brain imaging, blood pressure, and heart rate.

Two additional lines of research challenge the iatrogenesis theory of DID: first, prevalence research conducted in cultures where DID is not well known, and second, evidence of chronic childhood abuse and dissociation in childhood among adults diagnosed with DID. Three classic studies have been conducted in cultures where DID was virtually unknown when the research was conducted. Researchers using structured interviews found DID in patients in China, despite the absence of DID in the Chinese psychiatric diagnostic manual. 117 The Chinese study and also two conducted in central-eastern Turkey in the 1990s 78 , 118 —where public information about DID was absent—contradict the iatrogenesis thesis. In one of the Turkish studies, 118 a representative sample of women from the general population (n = 994) was evaluated in three stages: participants completed a self-report measure of dissociation; two groups of participants, with high versus low scores, were administered the DDIS by a researcher blind to scores; and the two groups were then given clinical examinations (also blind to scores). The researchers were able to identify four cases of DID, all of whom reported childhood abuse or neglect.

The second line of research challenging the iatrogenesis theory of DID documents the existence of dissociation and severe trauma in childhood records of adults with DID. Researchers have found documented evidence of dissociative symptoms in childhood and adolescence in individuals who were not assessed or treated for DID until later in life (thus reducing the risk that these symptoms could have been suggested). 11 , 13 , 119 Numerous studies have also found documentation of severe child abuse in adult patients diagnosed with DID. 10 , 13 , 120 , 121 For example, in their review of the clinical records of 12 convicted murderers diagnosed with DID, Lewis and colleagues 11 found objective documentation of child abuse (e.g., child protection agency reports, police reports) in 11 of the 12, and long-standing, marked dissociation in all of them. Further, Lewis and colleagues 11(p 1709) noted that “contrary to the popular belief that probing questions will either instill false memories or encourage lying, especially in dissociative patients, of our 12 subjects, not one produced false memories or lied after inquiries regarding maltreatment. On the contrary, our subjects either denied or minimized their early experiences. We had to rely for the most part on objective records and on interviews with family and friends to discover that major abuse had occurred.” Notably, these inmates had already been sentenced; they were all unaware of having met diagnostic criteria for DID; and they made no effort to use the diagnosis or their trauma histories to benefit their legal cases.

Similarly, Swica and colleagues 13 found documentation of early signs of dissociation in childhood records in all of the six men imprisoned for murder who were assessed and diagnosed with DID during participation in a research study. During their trials, the men were all unaware of having DID. And since their sentencing had already occurred, they had nothing to gain from DID being diagnosed while participating in the study. Their signs and symptoms of early dissociation included hearing voices (100%), having vivid imaginary companions (100%), amnesia (50%), and trance states (34%). Furthermore, evidence of severe childhood abuse has been found in medical, school, police, and child welfare records in 58%–100% of DID cases. 11 , 13 , 121 These studies indicate that dissociative symptoms and a history of severe childhood trauma are present long before DID is suspected or diagnosed.

Perhaps the “iatrogenesis myth” exists because inappropriate therapeutic interventions can exacerbate symptoms if used with DID patients. The expert consensus DID treatment guidelines warn that inappropriate interventions may worsen DID symptoms, although few clinicians report using such interventions. 66 , 122 No research evidence suggests that inappropriate treatment creates DID. The only study to date examining deterioration of symptoms among DID patients found that only a small minority (1.1%) worsened over more than one time-point in treatment and that deterioration was associated with revictimization or stressors in the patients’ lives rather than with the therapy they received. 123 This rate of deterioration of symptoms compares favorably with those for other psychiatric disorders.

MYTH 5: DID IS THE SAME ENTITY AS BORDERLINE PERSONALITY DISORDER

Some authors suggest that the symptoms of DID represent a severe or overly imaginative presentation of BPD. 124 The research described below, however, indicates that while DID and BPD can frequently be diagnosed in the same individual, they appear to be discrete disorders. 125 , 126

One of the difficulties in differentiating BPD from DID has been the poor definition of the dissociation criterion of BPD in the DSM’s various editions. In DSM-5 this ninth criterion of BPD is “transient, stress-related paranoid ideation or severe dissociative symptoms.” 1 The narrative text in DSM-5 defines dissociative symptoms in BPD (“e.g., depersonalization”) as “generally of insufficient severity or duration to warrant an additional diagnosis.” DSM-5 does not clarify that when additional types of dissociation are found in patients who meet the criteria for BPD—especially amnesia or identity alteration that are severe and not transient (i.e., amnesia or identity alteration that form an enduring feature of the patient’s presentation)—the additional diagnosis of a dissociative disorder should be considered, and that additional diagnostic assessment is recommended.

On the surface, BPD and DID appear to have similar psychological profiles and symptoms. 124 , 127 Abrupt mood swings, identity disturbance, impulsive risk-taking behaviors, self-harm, and suicide attempts are common in both disorders. Indeed, early comparative studies found few differences on clinical comorbidity, history, or psychometric testing using the Minnesota Multiphasic Personality Inventory and the Millon Clinical Multiaxial Inventory. 124 , 127 However, recent clinical observational studies, as well as systematic studies using structured interview data, have distinguished DID from BPD. 59 , 128 Brand and Loewenstein 59 review the clinical symptoms and psychosocial variables that distinguish DID from BPD: clinically, individuals with BPD show vacillating, less modulated emotions that shift according to external precipitants. 59 In addition, individuals with BPD can generally recall their actions across different emotions and do not feel that those actions are alien or so uncharacteristic as to be disavowed. 59 , 128 By contrast, individuals with DID have amnesia for some of their experiences while they are in dissociated personality states, and they also experience a marked discontinuity in their sense of self or sense of agency. 1 Thus, the dissociated activity and intrusion of personality states into the individual’s consciousness may be experienced as separate or different from the self that they identify with or feel they can control. Accordingly, using SCID-D structured interview data, Boon and Draijer 128 demonstrated that amnesia, identity confusion, and identity alteration were significantly more severe in individuals with DID than in cluster B personality disorder patients, most of whom had BPD. However, DID and BPD patients did not differ on the severity of depersonalization and derealization. Both groups had experienced trauma, although the DID group had much more severe and earlier trauma exposure.

BPD and DID can also be differentiated on the Rorschach inkblot test. Sixty-seven DID patients, compared to 40 BPD patients, showed greater self-reflective capacity, introspection, ability to modulate emotion, social interest, accurate perception, logical thinking, and ability to see others as potentially collaborative. 58 A pilot Rorschach study found that compared to BPD patients, DID patients had more traumatic intrusions, greater internalization, and a tendency to engage in complex contemplation about the significance of events. 129 The DID group consistently used a thinking-based problem-solving approach, rather than the vacillating approach characterized by shifting back and forth between emotion-based and thinking-based coping that has been documented among the BPD patients. 129 These personality differences likely enable DID patients to develop a therapeutic relationship more easily than many BPD patients.

With regard to the frequent comorbidity between DID and BPD, studies assessing for both disorders have found that approximately 25% of BPD patients endorse symptoms suggesting possible dissociated personality states (e.g., disremembered actions, finding objects that they do not remember acquiring) 126 and that 10%–24% of patients who meet criteria for BPD also meet criteria for DID. 75 , 126 , 130 , 131 Likewise, a national random sample of experienced U.S. clinicians found that 11% of patients treated in the community for BPD met criteria for comorbid DID, 84 and structured interview studies have found that 31%–73% of DID subjects meet criteria for comorbid BPD. 12 , 72 , 132 Thus, about 30% or more of patients with DID do not meet full diagnostic criteria for BPD. In blind comparisons between non-BPD controls and college students who were interviewed for all dissociative disorders after screening positive for BPD, BPD comorbid with dissociative disorder was more common than was BPD alone (n = 58 vs. n = 22, respectively). 130 It is important to note that despite its prevalence in patients with DID, BPD is not the most common personality disorder that is comorbid with DID. More common among individuals with DID are avoidant (76%–96%) and self-defeating (a proposed category in the appendix of DSM-III-R; 68%–94%) personality disorders, followed by BPD (53%–89%). 132 , 133

When the comorbidity between BPD and DID is evaluated specifically, the patients with comorbid BPD and DID appear to be more severely impaired than individuals with either disorder alone. For example, the participants who had both disorders reported the highest level of amnesia and had the most severe overall dissociation scores. 130 Similarly, individuals who meet criteria for both disorders have more psychiatric comorbidity and trauma exposure than individuals who meet criteria for only one, 134 and they also report higher scores of dissociative amnesia. 135

In the future, the neurobiology of BPD and DID might assist in their comparison. Preliminary imaging research in BPD suggests the prefrontal cortex may fail to inhibit excessive amygdala activation. 136 By contrast, two patterns of activation that correspond to different personality states have been found in DID patients: neutral states are associated with overmodulation of affect and show corticolimbic inhibition, whereas trauma-related states are associated with undermodulation of affect and activation of the amygdala on positron emission tomography. 62 Similarly, recent fMRI studies in DID found that the neutral states demonstrate emotional underactivation and that the trauma-related states demonstrate emotional overactivation. 137 , 138 Perhaps BPD might be thought of as resembling the trauma-related state of DID with amygdala activation, whereas the dissociative pattern found in the neutral state in DID appears to be different from what is found in BPD. 139 Additional research comparing these disorders is needed to further explore the early findings of neurobiological similarities and differences.

What remains open for debate is whether a personality disorder diagnosis may be given to DID patients, because attribution of a clinical phenomenon to a personality disorder is not indicated if it is related to another disorder—in this instance, DID. Hence, the DSM-5 criteria for BPD may be insufficient to diagnose a personality disorder because DID is not excluded. In this regard, some DID researchers have concluded that unmanaged trauma symptoms—including dissociation—may account for the high comorbidity of BPD in DID patients. 75 , 131 For example, one study found that only a small group of DID patients still met BPD criteria after their trauma symptoms were stabilized. 140 Resolution of this debate may hinge on whether patients diagnosed with BPD are conceptualized as having a severe personality disorder rather than a trauma-based disorder that involves dissociation as a central symptom.

Yet to be studied is the possibility that several overlapping etiological pathways—including trauma, 4 , 141 attachment disruption, 142 – 144 and genetics 145 – 149 —may contribute to the overlap in symptomatology between BPD and DID. In order to clarify which variables increase risk for one or both developmental outcomes, research that carefully screens for both DID and BPD is needed. The apparent phenomenological overlap between the two psychopathologies does not create an insurmountable obstacle for research, because distinct influences may be parsed out via statistical analysis. 135 , 150 Screening for both disorders would prevent BPD and DID from constituting mutually confounding factors in research specifically about one or the other. 150

The benefit of accurately diagnosing (1) BPD without DID, (2) DID without BPD, and (3) comorbid DID BPD is that treatment can be individualized to meet patients’ needs. A diagnosis of BPD without DID can lead clinicians to use empirically supported treatment for BPD. By contrast, the treatment of DID is different from the treatment of BPD and comprises three phases: stabilization, trauma processing, and integration (discussed below). 66 Given the severity of illness found in individuals with comorbid BPD/DID, clinicians should emphasize skills acquisition and stabilization of trauma-related symptoms in an extended stabilization phase. Early detection of comorbid DID and BPD alerts the therapist to avoid trauma-processing work until the stabilization phase is complete. The trauma-processing phase should be approached cautiously in highly dissociative individuals, and only after they have developed the capacity both to contain intrusive trauma material and to use grounding techniques to manage dissociation.

In summary, DID and BPD appear to be separate, albeit frequently comorbid and overlapping, disorders that can be differentiated on validated structured and semistructured interviews, as well as on the Rorschach test. While the symptoms of DID and BPD overlap, preliminary indications are that the neurobiology of each is different. It is also possible that differences between DID and BPD may emerge regarding the respective etiological roles of trauma, attachment disruption, and genetics.

MYTH 6: DID TREATMENT IS HARMFUL TO PATIENTS

Some critics claim that DID treatment is harmful. 52 , 69 , 151 – 153 This claim is inconsistent with empirical literature that documents improvements in the symptoms and functioning of DID patients when trauma treatment consistent with the expert consensus guidelines is provided. 65 , 66

Before reviewing the empirical literature, we will present an overview of the DID treatment model. The first DID treatment guidelines were developed in 1994, with revisions in 1997, 2005, and 2011. The current standard of care for DID treatment is described in the International Society for the Study of Trauma and Dissociation’s Treatment Guidelines for Dissociative Identity Disorder in Adults. 66 The DID experts who wrote the guidelines recommend a tri-phasic, trauma-focused psychotherapy. In the first stage, clinicians focus on safety issues, symptom stabilization, and establishment of a therapeutic alliance. Failure to stabilize the patient or a premature focus on detailed exploration of traumatic memories usually results in deterioration in functioning and a diminished sense of safety. In the second stage of treatment, following the ability to regulate affect and manage their symptoms, patients begin processing, grieving, and resolving trauma. In the third and final stage of treatment, patients integrate dissociated self-states and become more socially engaged.

Early case series and inpatient treatment studies demonstrate that treatment for DID is helpful, rather than harmful, across a wide range of clinical outcome measures. 64 , 140 , 154 – 158 A meta-analysis of eight treatment outcome studies for any dissociative disorder yielded moderate to strong within-patient effect sizes for dissociative disorder treatment. 64 While the authors noted methodological weaknesses, current treatment studies show improved methodology over the earlier studies. One of the largest prospective treatment studies is the Treatment of Patients with Dissociative Disorders (TOP DD) study, conducted by Brand and colleagues. 159 The TOP DD study used a naturalistic design to collect data from 230 DID patients (as well as 50 patients with dissociative disorder not otherwise specified) and their treating clinicians. Patient and clinician reports indicate that, over 30 months of treatment, patients showed decreases in dissociative, posttraumatic, and depressive symptomatology, as well as decreases in hospitalizations, self-harm, drug use, and physical pain. Clinicians reported that patient functioning increased significantly over time, as did their social, volunteer, and academic involvement. Secondary analyses also demonstrated that patients with a stronger therapeutic alliance evidenced significantly greater decreases in dissociative, PTSD, and general distress symptoms. 160

Crucial to discussion of whether DID treatment is harmful is the importance of dissociation-focused therapy. A study of consecutive admissions to a Norwegian inpatient trauma program found that dissociation does not substantially improve if amnesia and dissociated self-states are not directly addressed. 161 The study, by Jepsen and colleagues, compared two groups of women who had experienced childhood sexual abuse—one without, and one with, a dissociative disorder (DID or dissociative disorder not otherwise specified). None of the dissociative disorder patients had been diagnosed or treated for a dissociative disorder, and dissociative disorder was not the focus of the inpatient treatment. Thus, the methods of this study reduce the possibility of therapist suggestion. Although both groups had some dissociative symptoms, the dissociative disorder group was more severely symptomatic. Both groups showed improvements in symptoms, although the effect sizes for change in dissociation were smaller for the dissociative disorder group than for the non–dissociative disorder group ( d = .25 and .69, respectively). As a result of these findings, the hospital developed a specialized treatment program, currently being evaluated, for dissociative disorder patients (Jepsen E, personal communication, June 2013).

Large, diverse samples, standardized assessments, and longitudinal designs with lengthy follow-ups were utilized in the studies by Brand and colleagues 159 and Jepsen and colleagues. 161 However, neither study used untreated control groups or randomization. Additionally, Brand and colleagues’ TOP DD study 159 had a high attrition rate over 30 months (approximately 50%), whereas Jepsen and colleagues 161 had an impressive 3% patient attrition rate during a 12-month follow-up.

DID experts uniformly support the importance of recognizing and working with dissociated self-states. 65 Clinicians in the TOP DD study reported frequently working with self- states. 122 While it is not possible to conclude that working with self-states caused the decline in symptoms, these improvements occurred during treatment that involved specific work with dissociated self-states. This finding of consistent improvement is another line of research that challenges the conjecture that working with self-states harms DID patients. 69 , 152

Brand and colleagues 47 reviewed the evidence used to support claims of the alleged harmfulness of DID treatment. They did not find a single peer-reviewed study showing that treatment consistent with DID expert consensus guidelines harms patients . In fact, those who argue that DID treatment is harmful cite little of the actual DID treatment literature; instead, they cite theoretical and opinion pieces. 52 , 69 , 151 – 153 In their review—from 2014—Brand and colleagues 47 concluded that claims about the alleged harmfulness of DID treatment are based on non-peer-reviewed publications, misrepresentations of the data, autobiographical accounts written by patients, and misunderstandings about DID treatment and the phenomenology of DID.

In short, claims about the harmfulness of DID treatment lack empirical support. Rather, the evidence that treatment results in remediation of dissociation is sufficiently strong that critics have recently conceded that increases in dissociative symptoms do not result from DID psychotherapy. 104 To the same effect, in a 2014 article in Psychological Bulletin , Dalenberg and colleagues 49 responded to critics, noting that treatment consistent with the expert consensus guidelines benefits and stabilizes patients.

THE COST OF MYTHS AND IGNORANCE ABOUT DID

As we have shown, current research indicates that while approximately 1% of the general population suffers from DID, the disorder remains undertreated and underrecognized. The average DID patient spends years in the mental health system before being correctly diagnosed. 4 , 71 , 72 , 76 , 79 These patients have high rates of suicidal and self-destructive behavior, experience significant disability, and often require expensive and restrictive treatments such as inpatient and partial hospitalization. 64 , 162 , 163 Studies of treatment costs for DID show dramatic reductions in overall cost of treatment, along with reductions in utilization of more restrictive levels of care, after the correct diagnosis of DID is made and appropriate treatment is initiated. 164 – 166

Delay in recognition and adequate treatment of DID likely prolongs the suffering and disability of DID patients. Younger DID patients appear to respond more rapidly to treatment than do older adults, 167 which suggests that years of misdirected treatment exact a high personal cost from patients. 166 Needless to say, if clinicians do not recognize the disorder, they cannot provide treatment consistent with expert guidelines for DID.

The myths we have dispelled also have substantial economic costs for the health care system and, more broadly, for society. For example, the myths may deter clinicians and researchers from seeking training in the assessment and treatment of DID, thereby compounding the problems of misunderstanding, lack of recognition, and inappropriate treatment, as we have discussed. The misconception that DID is a rare or iatrogenic disorder may lead to the conclusion that this disorder is one on which resources should not be expended (whereas we have shown the opposite to be the case). In combination, these myths may discourage scholars from pursuing research about DID and also inhibit funding for such research, which exacerbates, in turn, the lack of understanding about, and the currently inadequate clinical services for, DID.

An enduring interest in DID is apparent in the solid and expanding research base about the disorder. DID is a legitimate and distinct psychiatric disorder that is recognizable worldwide and can be reliably identified in multiple settings by appropriately trained researchers and clinicians. The research shows that DID is a trauma-based disorder that generally responds well to treatment consistent with DID treatment guidelines.

Our findings have a number of clinical and research implications. Clinicians who accept as facts the myths explored above are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve . 161 , 168 The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients, but for the whole support system in which they live (e.g., loved ones, health systems, and society). Empirically derived knowledge about DID has replaced outdated myths, and for this reason vigorous dissemination of the knowledge base about this complex disorder is warranted.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

*Prior to being renamed dissociative identity disorder, DID was referred to as “multiple personality disorder.” Dissociated personality states are referred to by various names, including identities, dissociated self-states, parts, and alters.

Assignment: Controversy Associated With Dissociative Disorders

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NURS 6665 Assignment: Controversy Associated with Dissociative Disorders

Dissociative Disorders (DD) are characterized by disruption in the normal integration of memory, consciousness, perceptions, emotion, identity, motor control, body representation, and behavior. They are thought to develop after an individual undergoes an overwhelming, stressful event (Rafiq et al., 2018). The stress may be a result of traumatic events or unbearable inner conflict. DD is associated with trauma and stressor-related disorders, resulting in dissociative symptoms. The purpose of this paper is to discuss the controversy surrounding DD, professional views about DD, and ethical and legal considerations for the disorders.

The Controversy That Surrounds Dissociative Disorders

According to Loewenstein (2018), there has been controversy surrounding dissociation and DD since the start of modern psychiatry and psychology. Although DD is associated with a history of trauma, particularly childhood trauma, some professionals argue that there is no evidence supporting this. For instance, there are rare incidences of DD diagnosed in children with a history of abuse. Furthermore, some healthcare professionals argue that DD is not a real disorder and does not exist even though it is included in the DSM-V. They propose that the disorder should be removed from the DSM-V manual. In addition, there has been an argument that diagnosing and treating DD trigger memories of childhood abuse in individuals, which causes more harm than good (Loewenstein, 2018). Lastly, there have been arguments that criminals use DD as an excuse to escape responsibility for their criminal actions.

Professional Beliefs about Dissociative Disorders

My professional view of DD is that it is more of a coping mechanism for past trauma than a mental disorder. People dissociate from their memory and consciousness to block the intrusive painful memories of their childhood abuse. Rafiq et al. (2018) found that individuals who experienced childhood trauma had the highest levels of dissociation among persons with severe mental conditions. The study also identified significant positive relations between certain childhood difficulties and dissociation.

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I believe that this form of coping is quite intense and negatively affects not only the individual but also those around them. Rinker (2019) explains that an individual’s vivid and broad imagination occurs mostly in childhood. The imagination is often used to cope with stress through a calm internalization. Besides, instead of a person having a single personality with diverse thoughts and emotions, the mind splits into sections, each with new ideas and attitudes that the person may agree or disagree with. Subramanyam et al. (2020) explain that dissociation is a means that allows the mind to sort out memories and thoughts from the normal consciousness. This explains my belief that DD occurs in the same way individuals usually detach themselves from an unpalatable or distressing event.

Strategies for Maintaining a Therapeutic Relationship

Creating and sustaining a therapeutic relationship with patients with DD and a history of trauma is often difficult due to distrust from the patient. Therefore, the provider should identify approaches that will help build trust with the patient to maintain the therapeutic relationship. The PMHNP or mental health provider should explain to the patient that a strong working relationship is crucial to help them return to normal functioning (Firestone, 2018). Another strategy is for the provider to collaborate with the client to identify their health needs , set therapy goals, and identify the interventions necessary to achieve these goals. The therapeutic relationship becomes stronger and lasts longer when the provider and the client have the same beliefs on treatment goals and consider the therapeutic interventions that will be used to meet these goals as appropriate and effective (Firestone, 2018). Active listening by the provider is essential in maintaining a therapeutic relationship. The provider should also be empathetic when interacting with the client to make the patient feel that their concerns have been understood.

Ethical and Legal Considerations Related to Dissociative Disorders

Ethical and legal factors that should be considered by mental health providers when dealing with patients with dissociative disorders include informed consent, privacy and confidentiality, beneficence, and nonmaleficence. In my future PMHNP practice, I will need to always obtain informed consent from the patient before starting assessment and treatment to avoid legal consequences. I will also need to maintain the privacy and confidentiality of patients’ information and always seek consent before sharing patient information to avoid legal consequences (Deshpande et al., 2020). Furthermore, I will need to assess interventions provided to patients to ensure they promote the best possible outcomes with no potential harm to the client.

Controversies in Dissociative disorders include a lack of evidence supporting their association with childhood trauma, beliefs that the disorder is inexistent, and that its diagnosis causes more harm than good. I believe that DD is more of a coping mechanism than a mental disorder and occurs when individuals want to detach themselves from painful past experiences. The provider can collaborate with the client in setting goals and identifying interventions to maintain a therapeutic relationship.

Deshpande, S. N., Mishra, N. N., Bhatia, T., Jakhar, K., Goyal, S., Sharma, S., Sachdeva, A., Choudhary, M., Shah, G. D., Lewis-Fernandez, R., & Jadhav, S. (2020). Informed consent in psychiatry outpatients.  The Indian journal of medical research ,  151 (1), 35–41. https://doi.org/10.4103/ijmr.IJMR_1036_18

Firestone, L. (2018). Dissociation and Therapeutic Alliance. In  Phenomenology of Suicide  (pp. 167-186). Springer, Cham.

Loewenstein, R. J. (2018). Dissociation debates: everything you know is wrong.  Dialogues in clinical neuroscience ,  20 (3), 229–242. https://doi.org/10.31887/DCNS.2018.20.3/rloewenstein

Rafiq, S., Campodonico, C., & Varese, F. (2018). The relationship between childhood adversities and dissociation in severe mental illness: a meta-analytic review.  Acta Psychiatrica Scandinavica ,  138 (6), 509–525. https://doi.org/10.1111/acps.12969

Rinker, K. (2019). Treatment of Trauma: Imaginative Minds of Dissociative Identify Disorder.  Journal of Humanistic Psychology , 0022167819877038. https://doi.org/10.1177/0022167819877038

Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., & Ghildiyal, R. (2020). Psychological Interventions for Dissociative disorders.  Indian journal of psychiatry ,  62 (Suppl 2), S280–S289. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_777_19

Dissociative disorders include conditions where an individual disconnects from their thoughts, feelings, memories, or sense of identity. Dissociative disorders include dissociative amnesia, depersonalization disorder, and dissociative identity disorder. The purpose of this paper is to describe the controversy, professional beliefs, ethical and legal considerations, and how to maintain a therapeutic relationship with patients with this disorder.

Diagnosis of dissociative disorders has been challenging as the disorder is complex, and the symptoms have been found in other mental health conditions. Psychiatrists have found that head trauma and brain tumors, especially in the cognition centers, have caused cognitive problems, resulting in personality disorders and amnesia (Agarwal et al., 2019). Psychiatrists have also recognized symptoms of dissociative disorder in mental illnesses such as obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder, disputing the diagnosis. Some psychiatrists have disputed the diagnosis and argued that the diagnosis may result from the use of psychoactive substances such as marijuana (Kedare et al 2023). Lastly, the diagnosis has been disputed as it has been argued as an adaptation to certain conditions such as depression, bipolar, and schizophrenia.

Most mental health professionals believe that the underlying cause of dissociative disorders is chronic trauma in childhood. Childhood trauma such as physical, emotional, or sexual abuse and neglect often cause affected children to disconnect their thoughts and feelings from reality (Kedare et al., 2023). As a result, the child’s inability to develop and maintain a unified sense of self results in isolation and loneliness with eventual dissociation. Additionally, adults may experience traumatic events such as war, torture, or a natural disaster, resulting in the disorder (Agarwal et al., 2019). Mental health professionals have noted the role of the community and cultural beliefs as the origin and facilitator of such kind of trauma (Boyer et al., 2022). As a result, the affected community is characterized by denial, boundary violations, reality distortions, oppression, paranoia, narcissism, and dramatic posturing.

Developing rapport and trust is vital to establishing a therapeutic relationship. Rapport and trust help build a connection between the patient and the therapist. To create a rapport, you must show interest in the patient’s symptoms and ensure consistency and confidentiality in all sessions with the patient (Lavik et al., 2022). In addition, it is vital to demonstrate empathy as it reassures the patient that the concerns about the condition are understood. Additionally, therapists can promote effective communication by actively listening and asking patients open-ended questions about their disorder.  Open-ended questions allow patients to express themselves actively without feeling judged. Lastly, the therapist should encourage collaboration and shared decision-making while respecting the patient’s autonomy.

Patients with dissociative disorders should be treated equally. It is thus crucial to establish whether they can make the appropriate clinical decisions and respect their autonomy. Additionally, one may consider involving the family when the patient is mentally unstable to make appropriate clinical decisions or when they are underage (Rocchio, 2020). Additionally, some patients with dissociative disorder may pose harm to themselves and others, making it crucial for the nurse to admit the patients without consent. In such scenarios, the therapists must warn others while maintaining medical confidentiality. Dissociative disorders have posed a challenge in the legal process of determining whether they are fit to stand trial or even be sentenced. As a result, a forensic psychiatrist has to establish whether the patient was mentally stable or not while committing the crime.

Dissociative disorders have raised controversies in diagnosis due to the overlapping mental conditions associated with them. An essential etiology of the disorder has been childhood and adult trauma. It is thus crucial for a therapist to understand these patients and treat them just like other patients.

Agarwal, V., Sitholey, P., & Srivastava, C. (2019). Clinical Practice Guidelines for the management of Dissociative disorders in children and adolescents. Indian journal of psychiatry, 61(Suppl 2), 247–253. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_493_18

Boyer, S. M., Caplan, J. E., & Edwards, L. K. (2022). Trauma-Related Dissociation and the Dissociative Disorders:: Neglected Symptoms with Severe Public Health Consequences. Delaware journal of public health, 8(2), 78–84. https://doi.org/10.32481/djph.2022.05.010

Kedare, J. S., Baliga, S. P., & Kadiani, A. M. (2023). Clinical Practice Guidelines for Assessment and Management of Dissociative Disorders Presenting as Psychiatric Emergencies. Indian journal of psychiatry, 65(2), 186–195. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_493_22

Lavik, K. O., McAleavey, A. A., Kvendseth, E. K., & Moltu, C. (2022). Relationship and Alliance Formation Processes in Psychotherapy: A Dual-Perspective Qualitative Study. Frontiers in psychology, 13, 915932. https://doi.org/10.3389/fpsyg.2022.915932

Rocchio L. M. (2020). Ethical and Professional Considerations in the Forensic Assessment of Complex Trauma and Dissociation. Psychological injury and law, 13(2), 124–134. https://doi.org/10.1007/s12207-020-09384-9