Although the debate around DID is fairly played out and stale, I find the most recent iteration of this clinical presentation to be a new level of ridiculous. I am encountering patients who present in crisis telling me they have 'Alters' who serve the function of being responsible for all their poor choices, and possess an ever-changing set of qualities that fulfill the function of defining the patients problem as being outside of their control and not something they can be expected to change or take ownership of. It is a transparent attempt to permanently occupy the sick role, and communicate distress with the goal of receiving maximal support, complete excusal from obligation, and with no expectation that change can or should occur. I don't feel as empowered as I would like to set limits around these patients as they unfortunately do find a community of therapists who will validate them to the end. But I wonder if others feel comfortable defining these patients as malingerers who aren't interested in recovery and likely shouldn't be offered much in the way of mental health care in the absence of expressed motivation to change.
Alters
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Out of curiosity are these ideas suggested to them by the therapists?
I remember seeing this type of thing on Oprah back in the day and the person was always accompanied by a psychiatrist who seemed to be the Svengali behind it. I thought it had sort of passed. What do you mean by more recent iteration? Just that it's coming into fashion again?
I remember seeing this type of thing on Oprah back in the day and the person was always accompanied by a psychiatrist who seemed to be the Svengali behind it. I thought it had sort of passed. What do you mean by more recent iteration? Just that it's coming into fashion again?
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Lots of therapists validate nonsense
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I haven't seen this personally in my patients (active duty) but I know there is a growing trend on social media stuff with people parading DID as their diagnosis and discussing their "alters". My middle school daughter has showed me tik tok/you tube stuff where people are putting this out there. Thanks social media...
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It used to be that this phenomenon was just seen amongst those with certain personality types (histrionic, borderline etc) but with TikTok now other vulnerable individuals have come to see themselves in this way. In true complete DID patients are not typically aware that they have alters. And even if we accept the concept of alters, and there are different therapies that do recognize we have different parts (e.g. IFS, schema therapy, ego state therapy), those parts are all you and you must take responsibility for them. The criminal courts have also concluded that even if you do have DID, if one of your alters did it, you are criminally responsible. I don't shy away from sharing that latter point with patients.
I think what you are describing is unlikely to be frank malingering, but certainly on the abnormal illness behavior spectrum somewhere from psychoform disorder to factitious disorder. The renewed salience of DID and having alters in the collective consciousness may have some influence on this.
Having treated a lot of patients with dissociative disorders, I will tell you that whatever you want to call it, there are patients who do regress into childlike states for which they have no memory and sometimes this is associated with violent behavior. However, these individuals never talk about having alters and have no recall of these episodes, which you only get from collateral or witnessing said episodes. There seem to be far more people with symptoms influenced by iatrogenesis, or more recently TikTok who are highly suggestible. It's pretty uncommon nowadays for people to feign DID in criminal cases and is ineffective.
I think what you are describing is unlikely to be frank malingering, but certainly on the abnormal illness behavior spectrum somewhere from psychoform disorder to factitious disorder. The renewed salience of DID and having alters in the collective consciousness may have some influence on this.
Having treated a lot of patients with dissociative disorders, I will tell you that whatever you want to call it, there are patients who do regress into childlike states for which they have no memory and sometimes this is associated with violent behavior. However, these individuals never talk about having alters and have no recall of these episodes, which you only get from collateral or witnessing said episodes. There seem to be far more people with symptoms influenced by iatrogenesis, or more recently TikTok who are highly suggestible. It's pretty uncommon nowadays for people to feign DID in criminal cases and is ineffective.
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Then why are they seeing you?
What do you mean? They want me to admit them so they can have a bed on our nice inpatient unit 🙂
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Tik Tok is a blight on the world.
I don't do formal long term therapy (thank goodness), but when I encounter inpatients with the alter stuff...I try my best to ignore and direct on to other topics. It tends to work as much as anything does inpatient. At least the statements aren't re-enforced through positive or negative attention. Maybe this could work for long term therapy too.
With adolescents, I had some luck with a workbook I made called 'managing multiple emotions' and told them the treatment for multiple personalities was to never mention it again but just talk about the emotions they felt when they shifted and come up with strategies for managing those. The adult patients are far more invested and have had their illness concepts reinforced for much longer so are less open to this approach.
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"What insurance does your alter have? "
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Depends, but I think Splik hit the nail. If there's an obvious secondary gain other than treatment or attention for their "condition", then I do feel comfortable calling it malingering. Otherwise factitious works just fine.
Was recently watching a Forensic Files 2 episode about Donna Perry. Previously went by Douglas Perry and murdered 3 women in the Spokane area in 1990, had gender reassignment surgery in 2000, and was arrested in 2014 for those murdered. Tried to claim that she shouldn't be held responsible because she was now a "different person" and that it wasn't really her back then and was eventually convicted.
Relevant because in the episode they showed a clip where she was being interviewed where she was indignant that she was being charged with the crimes when she supposedly wasn't even the same person. The officers response when asked if she was responsible was, "...yes, the body is responsible for the acts it does" which found to be quite a perfect response from someone with undoubtedly limited experience for that situation.
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I do long term therapy and the strategy is the same. Don’t want to reinforce maladaptive patterns. The only addition is that when they say something in a way that is splitting, then my empathic reflection is using more integrative language. Along the lines of “so sometimes you feel this way and at others you feel that way and sometimes it’s so intense that you feel as though it’s two different parts of you.” If they aren’t malingering they will respond well to this.
TheRightMedication
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Love that little phrase there.
As many above have said, if the patient and I can agree we're talking about subjectivity when they use the language of DID, I find it's not an issue. I had only one case when an inpatient insisted it was an objective fact. In that case I left it to them and their therapist, and proceeded on the SmallBird protocol.
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Another potential private clinic gold mine. Cash only, vistaril medication management and "grounding techniques" for those with very affluent "alters".
I can only imagine the number of pt messages youd get a day though
I can only imagine the number of pt messages youd get a day though
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As long as you're not billing insurance, you could even do the time-tested money-bringer of billing each alter for a "group" session. $300/hour for individual or $100/hour for each group member. Let the patients eventually decide they're one person for the discount.
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I think this dynamic can be seen across many clinical settings
-PTSD and avoiding triggers or “it’s my trauma”
-the patient who is too depressed for everything
-pseudo adhd with the convenient excuse for legal speed
-etc.
Like many concepts in mental health treatment, we should be assessing if someone is making progress. If they are not, we need to change our approach. It’s not a new thing that winding back on care can be what is beneficial. As primary gain can indeed entrench the problem. I have a patient with borderline personality and when I decreased frequency of visits, actually do better after we discussed they appeared to be in precontemplation and to reflect on what they are getting out of the appointments.
-PTSD and avoiding triggers or “it’s my trauma”
-the patient who is too depressed for everything
-pseudo adhd with the convenient excuse for legal speed
-etc.
Like many concepts in mental health treatment, we should be assessing if someone is making progress. If they are not, we need to change our approach. It’s not a new thing that winding back on care can be what is beneficial. As primary gain can indeed entrench the problem. I have a patient with borderline personality and when I decreased frequency of visits, actually do better after we discussed they appeared to be in precontemplation and to reflect on what they are getting out of the appointments.
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DID can fall under the umbrella of hysteria related disorders. Tendency towards borderline traits are going to be more suggestible overall and may be drawn to forming a DID-based identity if suggested by influence (social, media, therapists, etc). Approaching it that way can be helpful. DID in itself is not an indication for anything in particular in the acute settings. I've discharged DID from the ED for conditional SI the same way I discharged non DID folks. People these days can identify as slugs - who am I to care?
In crisis centers or ED settings you just need to identify crisis and triage who needs to be admitted and who doesn't. Flush out the concrete behaviors and cut past the narrative like any other patient.
In crisis centers or ED settings you just need to identify crisis and triage who needs to be admitted and who doesn't. Flush out the concrete behaviors and cut past the narrative like any other patient.
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I mean one issue is, which is why I can get behind the policy being "fair," is that if you "KNOW" you have alters and they "do" things outside your control, then what responsibility do you have for that knowledge? To that end, maybe it does make sense that they are seeking to be committed or whatever.
If I know I have a condition I don't have great control over, like narcolepsy or alters, then I have a responsibility to make sure other people don't get hurt because of this thing I know about with potential to cause harm. This could mean not driving or not owning guns, or getting psychiatric care.
My point being, that these people don't seem to understand that the very ability to say "My alters did it" means you have awareness, means you have responsibility.
The only people that would have a rational argument otherwise, can't make the argument because it would only be true if you had an alter you knew nothing of and "they did it," in which case, you would never be able to deny the crime saying "my alter did it."
It's like that silly saying, if you think you're crazy you probably aren't because crazy people by definition don't know they're crazy.
If you know about your alters, then you can't use the defense "but my alters did it" and act like you have no idea, because you can only say that if you did know.
This comes up a bit in the cases where someone goes off their meds and then commits a crime, or does drugs blacks out and commits a crime. Somewhere in this series of events you had some responsibility and control or foreknowledge.
Even in the case of someone with an "actual" alter, how often does the person dissociate to the point they never notice lost time or anything weird? Has no inkling whatsoever help is maybe needed? I'm sure Splik has an example and I know that not being aware of dissociation can itself be part and parcel of said dissociation, but how common is that really and how common is there were no clues to you that there was anything wrong with you, and to the point where serious harm to another person was done?
It doesn't change anything. Sadly, if you have an "alter" and it ****s up your life, you are still left holding that bag. It's no different for the bi-polar patient that has an episode and catches an STD and gives it to their wife. There are consequences despite the best of intentions because of the reality of your life. Sadly harms to others are not always a product of intention.
What's more, if you really were to be believed you had an alter you either knew nothing of or had no control over and it did dangerous things or killed people, wouldn't we even more than the "average" criminal who claims responsibility and agency, need to incarcerate you or whatnot if for no other reason to protect the public from your alter?
As far as what other people owe you, I mean if your alter beats me up, maybe I should in theory forgive your primary personality, but I still can't invite you over for dinner and you're going to have to accept that having a condition doesn't mean other people are not entitled to protecting themselves and this may mean consequences that are not comfortable for you.
Just saying, so much of it even taken at face value doesn't end up being as much of a great excuse as people might seem to think.
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I mean I guess the difference between being found guilty or found innocent by reason of insanity, or say one of these DID defenses "working," becomes less about, do we need to lock you up, because clearly either way there is a "protect the public" interest here in incarceration either way, so let's say, it is more about, whether or not there should be a "punitive" aspect to the incarceration. Which raises a lot of other issues certainly.
Some would argue perhaps all incarceration should not be punitive, others would argue that even commitment to a psychiatric facility is in itself a somewhat punitive experience for the average person. So one could say it's all the same or should all be the same so it makes no real difference as to what the defense is in these cases with clear guilt but unclear mental health status or the role it played in a crime.
I don't really know.
Some would argue perhaps all incarceration should not be punitive, others would argue that even commitment to a psychiatric facility is in itself a somewhat punitive experience for the average person. So one could say it's all the same or should all be the same so it makes no real difference as to what the defense is in these cases with clear guilt but unclear mental health status or the role it played in a crime.
I don't really know.
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It's all because of TikTok. Usually they are a part of communities where everyone has "DID" and thus it becomes a core part of their social experience. Many also see very little value in themselves, and see DID as a way to be more interesting and possibly to achieve fame online. I have had some luck with direct confrontation, as many do not have a therapist supporting this nonsense, and on the occasions I have it always boiled down to someone that admits they are lonely and cultivating a vibrant inner world and supposed alters was a coping mechanism and a way to help them achieve connection with others that are making similar claims. I ask them if they would like to have a diagnosis or a fulfilling life, because such strong identification with and cultivation of their diagnosis does not bode well for their long-term functioning. Their symptoms stopped entirely shortly thereafter.
There are some that clearly would not be receptive to such an approach. I'm very up front with patients that DID is controversial within psychiatry and that, personally, I do not believe it to be a diagnosis that is reasonable based upon my understanding of neurology and memory. I concede to them that there are others that may have a different opinion based upon their understanding of the science and literature. I make it clear that I am not this person, but I am here to help them with whatever else ails them and that I am open to exploring and treating any of their other issues.
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Yeah, "you may not be guilty but "someone" in there is, and that someone needs 4 concrete walls and some steel bars for good measure to keep the public safe" is my take on it.
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TikTok has a lot to answer for, but it also promotes ADHD, Autism, BPD, and PTSD and yet most people would not dismiss out of hand the possibility of those. And yet, PTSD, much like DID, is an hysterical diagnosis with symptoms constrained by cultural scripts of how one might legitimately respond to trauma. As suggestibility is the sine qua non of hysteria, the influence of TikTok can be seen as a symptom, rather than a cause. We are talking about highly disturbed individuals here. Which is not to say that there aren't many cases that are factitious or misattribution (though these individuals tend to be quite disturbed as well with high prevalence of cluster B personality traits/disorders). But across the spectrum of "hysterical" symptoms, whether those symptoms are recognized and have cultural salience determines their ascendance. Those that are dismissed die out for the most part. In the case of DID, there was an explosion of such cases in the 80s and 90s, but the bitter memory wars of the 90s damaged the credibility of clinicians and patients alike, and we saw a lot less of it until recent years when the concept received a hashtag with over 2.7 billion views.
As for the idea that the diagnosis is not reasonable from a neurobiological standpoint, we know a bit about the neurobiology of trauma, dissociation, disorganized attachment, and "hysterical" (now functional neurological) symptoms and this would appear relevant here. While most people have an increased sympathetic response to trauma cues, a subset have a decreased response (essentially parasympathetic overdrive) which is experienced as dissociative. These individuals have difficulty identifying and verbalizing emotion and have deficits in allostasis, interoceptive awareness, and awareness of self-generated actions. For some individuals that might manifest as a non-epileptic seizure, but it can also lead to more complex behaviors and elaboration for which the individual has no awareness/recollection of. There are a range of different therapeutic approaches that recognize different self-states, so it is not a stretch to acknowledge that some people with a lack of coherent self have difficulty integrating and acknowledging certain self-states that may be triggered by particular cues. Like other psychiatric disorders, symptoms are constrained and co-created by the social zeitgeist, ineffective coping, and neurobiological processes shaped by early developmental experiences.
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Dissociation is real. Entirely separate personalities with their own conserved memories, interests, etc are nonsense and I'll never believe otherwise. The other issue is that many of these individuals aren't actually that disturbed and have no significant trauma history to speak of, and furthermore often endorse full memories, conversations with, and extensive inner workings of their supposed alters.
Are there people out there with the FND equivalent of DID? Probably. But the number that are actually just mislabeling symptoms or outright fabricating them are probably 99% of what I've seen and heard about. Honestly, DID should be removed from the DSM in my opinion, because our perpetuation of it as a diagnosis within our very manual has led to iatrogenic harm through individuals developing symptoms they attribute to an illness they otherwise would be unable to functionally develop, in the same manner you don't see most people in the West getting koro or windigo.
That's also the reason even in those patients that I don't feel it worth discussing I focus on their other symptoms- focusing on DID itself, in my opinion, is like focusing on any FND and just perpetuates it.
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Never say never. 😉
I used to feel much the same as yourself and still do to an extent but have had experience with several fascinating cases that made even a skeptic like me see that chronic dissociation and splitting types of defenses can lead to some clinical presentations that get pretty close to completely distinct “personalities” or maybe persona would be a better word. Even a method actor can get a little lost in a persona so why not some of our patients? I do think it is incredibly rare and on the extreme end of a spectrum of trauma and personality dysfunction and that it probably is never really as extreme as the popularized versions.
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DID was initially iatrogenic. It can also be culturally-created phenomenon like the salem witch trials, and in modern times with media and now social media. It falls under the umbrella of hysteria, and we are doing a disservice to these patients.
Hysteria is one of the best supported, independently verified constructs in psychiatry. Additionally, it is treatable, and can have a good prognosis. By breaking it up and allowing the promulgation of different "disorders" was a poor decision by the field. DID is one of the more egregious examples of this.
Edit:
But don't take my word on it. Here is from a Dr. Carol North paper in 2015 --
"A review by Brown and colleagues [72] of studies of dissociative disorder found substantial somatoform and conversion symptom comorbidity. Dissociative identity disorder is especially associated with numerous psychiatric comorbidities. An extensive review of multiple personality disorder by North et al. [14] demonstrated abundant evidence of comorbidity with somatization disorder (33%– 100%), conversion disorder (generally > 50%), and borderline personality disorder (about 50%–70%), with three or four comorbid disorders on average... the authors stated that multiple personality disorder “may be best conceptualized as a polysymptomatic, polysyndromic disorder”"
Polysymptomatic, polysyndromic disorder - I.e. hysteria
Hysteria is one of the best supported, independently verified constructs in psychiatry. Additionally, it is treatable, and can have a good prognosis. By breaking it up and allowing the promulgation of different "disorders" was a poor decision by the field. DID is one of the more egregious examples of this.
Edit:
But don't take my word on it. Here is from a Dr. Carol North paper in 2015 --
"A review by Brown and colleagues [72] of studies of dissociative disorder found substantial somatoform and conversion symptom comorbidity. Dissociative identity disorder is especially associated with numerous psychiatric comorbidities. An extensive review of multiple personality disorder by North et al. [14] demonstrated abundant evidence of comorbidity with somatization disorder (33%– 100%), conversion disorder (generally > 50%), and borderline personality disorder (about 50%–70%), with three or four comorbid disorders on average... the authors stated that multiple personality disorder “may be best conceptualized as a polysymptomatic, polysyndromic disorder”"
Polysymptomatic, polysyndromic disorder - I.e. hysteria
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I think I could agree with your point although I tend to not worry too much about diagnoses as much as they are a part of my case formulation when planning treatment. The problem is that the term hysteria itself is a bit of an issue since I’m pretty sure that the disorder has little to with uteruses wandering around the body.
