DID vs. BPD: How to tell them apart, or tell when both are present?

[SpongeBob DoctorPants]

Recently I met a patient who reported a history of dissociative identity disorder. This was the first time I've met a patient who had this as an actual diagnosis. He states this diagnosis was made by another medical professional after they witnessed a dissociative episode. The patient experiences a dramatic change in behavior during these episodes, including changes in his speech and mannerisms, and he becomes very angry, evil, or grandiose; episodes may last minutes to hours, and he denies having any memory of the episode afterward. His mother was present for his first visit with me and confirmed this history.

Looking at the diagnostic criteria alone, it would seem that DID could be present. However, aside from the fact that this is a controversial diagnosis, I am hesitant to make this diagnosis myself because the patient also meets criteria for borderline personality disorder. I understand that DID and BPD can both be diagnosed in the same patient, but given that BPD can present with severe dissociative symptoms, how do you tell when a dissociative episode is part of BPD or due solely to DID?

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[st2205]

Generally, the best way to distinguish them is by recognizing that the latter is real (and common), and the former is just a fancy way to describe that the ‘practitioner’ and patient are colluding, consciously or not (both parties), to avoid the latter.

 

[erg923]

Recently I met a patient who reported a history of dissociative identity disorder. This was the first time I've met a patient who had this as an actual diagnosis. He states this diagnosis was made by another medical professional after they witnessed a dissociative episode. The patient experiences a dramatic change in behavior during these episodes, including changes in his speech and mannerisms, and he becomes very angry, evil, or grandiose; episodes may last minutes to hours, and he denies having any memory of the episode afterward. His mother was present for his first visit with me and confirmed this history.

Looking at the diagnostic criteria alone, it would seem that DID could be present. However, aside from the fact that this is a controversial diagnosis, I am hesitant to make this diagnosis myself because the patient also meets criteria for borderline personality disorder. I understand that DID and BPD can both be diagnosed in the same patient, but given that BPD can present with severe dissociative symptoms, how do you tell when a dissociative episode is part of BPD or due solely to DID?

Parsimony should win here.

 

[splik]

almost every patient I have had with a DID diagnosis met criteria for BPD and often PTSD as well. That said, frequent dissociative symptoms is highly atypical of BPD alone.

 

[Stagg737]

Generally, the best way to distinguish them is by recognizing that the latter is real (and common), and the former is just a fancy way to describe that the ‘practitioner’ and patient are colluding, consciously or not (both parties), to avoid the latter.

I've actually seen 2 patients who carried that diagnosis. One had severe PTSD and his dissociations were in the context of flashbacks. The other carried multiple psychotic disorders in their problems list and stated they didn't actually believe they had DID. Every doc I've talked to who has had a patient with DID on their problem list said it could be better explained by other disorders, and I'm inclined to believe them given my experiences as well (which were really interesting since I was a med student seeing them).

 

[DisorderedDoc417]

Generally, the best way to distinguish them is by recognizing that the latter is real (and common), and the former is just a fancy way to describe that the ‘practitioner’ and patient are colluding, consciously or not (both parties), to avoid the latter.

I am so happy you said this

 

[clausewitz2]

There has been idea of dedoublement in the neurological literature since the 19th century and possibly earlier, but most people who think this was a thing seem to think it is/was also limited to two personalities and is a forme fruste of epilepsy. There is a reason Ian Hacking chose DID as his paradigm case for the self-looping hypothesis of mental "disorders".

 

[lyla]

Just remember DID is BPD+PTSD until proven otherwise. If I was on a computer I’d strike through/crossout “until proven otherwise” as well.

 

[darknecrosforte]

The actual way to do this is the Multidimensional Inventory of Dissociation, which is a 110+ questionnaire that you score with an extremely difficult to find spreadsheet in order to identify the degree to which BPD, PTSD, factitious, schizophrenic, and other factors are playing into what you're seeing. You then are supposed to do a full psych eval on them and guesstimate the probability that the MID + your clinical assessment is enough. The MID spreadsheet is pretty amazing. It even attempts to identify which alters are supposedly present and how dominant each one is in relation to the others.

Also, in my studying of why the MID was the best diagnostic tool, I learned that less than 5% of all "confirmed" DID cases did not have repeated sexual trauma in childhood.

 

[birchswing]

There has been idea of dedoublement in the neurological literature since the 19th century and possibly earlier, but most people who think this was a thing seem to think it is/was also limited to two personalities and is a forme fruste of epilepsy. There is a reason Ian Hacking chose DID as his paradigm case for the self-looping hypothesis of mental "disorders".

I don't know the references but based on the words I understand the sentiment.

I remember a professor in college once telling me that a theory does not have to be true, it only needs to be useful.

That's what I think of when I hear that BPD is real and DID is not*.

Postmodernists would say you can't even describe what you're seeing with any type of replicability over centuries, let alone understand why what you're seeing seems to improve or worsen depending on how you to intervene with it.

BPD seems useful to me of this moment and of this time. I know very little about DID, but that in and of itself makes it less useful. There are, I assume, fewer modalities to address it if it's not accepted as real. In the same way, someone given no diagnosis or no reason to seek one could benefit from the resources used to treat BPD, the same way people adopt the 12-step model for areas outside alcoholism. Again doesn't have to be true to be useful (I know the conversation of the overall usefulness of AA is a separate one, but it can be said to be useful for some people).

*Isn't there an idea that the illnesses people have, especially mental illnesses, are social constructs and that people manifest distress differently over time depending on what is diagnosable at the time? It's almost as if people subconsciously pick up societal cues on how distress "should" manifest even though it's still involuntary.

For example, I have heard (and I don't have a source—just something I heard from an analyst a long time ago) that in the mid 20th century a common feature of neurosis (anxiety) in women would be the loss of control of their hands. But it was a social phenomenon that is now not very commonly associated with anxiety.

Also, more recently diagnoses seem to trend in the direction of whichever medications are available. For a while that was anxiety with benzodiazepines, then the switch to depression with SSRIs, and then more to bipolar disorder with the atypicals. Again it might be more useful to have depression if the doctor has anti-depression medications.

I'm not sure if psychoanalysis was as marketable as pharmaceuticals, but it also reminds me of the very strange example of asthma, which had evidence for a biological basis and biological treatment. Then in the 1930-50s in the US at least and among at least some but not all doctors, the biological understanding was abandoned for a psychoanalytic explanation and treatment.

All this makes it difficult to go back in time and say any historical figure had a particular mental illness by today's standards since the illness of the time was expressed and diagnosed in relation to that time's normative ways of displaying mental health, distress, and mental health treatment. I think it also hopefully points out that today's standards such as BPD are products of everything around us, which isn't to say that the diagnosis can't be therapeutic, but more that it sounds strange to says it exists and DID doesn't.

 

[WisNeuro]

I've seen about 15 patients who carried a diagnosis of DID. I've seen 0 patients with an actual diagnosis of DID.

 

[Agrippa2]

https://www.researchgate.net/profile/Richard_Loewenstein/publication/21210019_An_office_mental_status_examination_for_chronic_complex_dissociative_symptoms_and_multiple_personality_disorder/links/02bfe5115b25a5499b000000/An-office-mental-status-examination-for-chronic-complex-dissociative-symptoms-and-multiple-personality-disorder.pdf

 

[WisNeuro]

https://www.researchgate.net/profile/Richard_Loewenstein/publication/21210019_An_office_mental_status_examination_for_chronic_complex_dissociative_symptoms_and_multiple_personality_disorder/links/02bfe5115b25a5499b000000/An-office-mental-status-examination-for-chronic-complex-dissociative-symptoms-and-multiple-personality-disorder.pdf

I've seen this article before. The questions are somewhat problematic. They are very much leading questions. When you are dealing with patients with high degrees of somatoform/dissociation/suggestibility, open-ended, general questions are preferred. If you give them a laundry list of the symptoms, with very specific details in your questions, you are essentially creating the diagnosis for them to accede to.

 

[LadyHalcyon]

I typically conceptualize DID as a reaction to trauma. Many people with traumatic histories have BPD, but many do not. I think one essential piece is the dissociative factor. How does the person know they have DID? They should "lose time" in a sense, and not be aware of their other personalities.

A major piece of BPD is splitting and an identity that is not fully integrated. I had a case once where I was evaluating a 14-year-old who murdered his step-mother. The prosecution was seeking a second opinion because the first evaluator diagnosed him with DID. Although the kid had developed a separate personality (the other personality is the one who committed the murder), he was also aware when the other personality was present. He described it as feeling like he was in his body, but that the other personality had taken over and was holding him captive in a sense. From my perspective, it seemed he developed this other personality because he saw himself as a "good kid" and, in his mind, good people aren't angry. Therefore, his anger was channeled into a different personality, which allowed him to maintain his belief that he was a "good" person. Clearly, he was more on the BPD spectrum in terms of identity integration.

 

[deleted736562]

I typically conceptualize DID as a reaction to trauma. Many people with traumatic histories have BPD, but many do not. I think one essential piece is the dissociative factor. How does the person know they have DID? They should "lose time" in a sense, and not be aware of their other personalities.

A major piece of BPD is splitting and an identity that is not fully integrated. I had a case once where I was evaluating a 14-year-old who murdered his step-mother. The prosecution was seeking a second opinion because the first evaluator diagnosed him with DID. Although the kid had developed a separate personality (the other personality is the one who committed the murder), he was also aware when the other personality was present. He described it as feeling like he was in his body, but that the other personality had taken over and was holding him captive in a sense. From my perspective, it seemed he developed this other personality because he saw himself as a "good kid" and, in his mind, good people aren't angry. Therefore, his anger was channeled into a different personality, which allowed him to maintain his belief that he was a "good" person. Clearly, he was more on the BPD spectrum in terms of identity integration.

Yeah, I think a key distinguishing feature is pretty much amnesia. Patients don't remember what they do when they are in the "other personality", can't describe this other person and sometimes not even aware of it. We all have "multiple selves"; In patients with BPD there is much less integration and transition between the selves, which is technically "dissociation". In DID the dissociation is more extreme.

I saw one case as a med student and it was quite dramatic.

 

[nitemagi]

I've seen this article before. The questions are somewhat problematic. They are very much leading questions. When you are dealing with patients with high degrees of somatoform/dissociation/suggestibility, open-ended, general questions are preferred. If you essentially give then a laundry list of the symptoms, with very specific details in your questions, you are essentially creating the diagnosis for them to accede to.

This. So much of this. In general dissociation is a poorly taught phenomenon amongst psychiatry, and even worse in the general population.

Dissociation and suggestibility are linked but not identical, so be very careful when working with these patients. This was what led to the DID explosion in the 80s, with false memory syndrome. Beware of leading questions.

I have seen one person who might have had DID, who had a complex dissociative disorder manifesting in conversion symptoms and what eventually got diagnosed as conversion psychiatric symptoms (see DSM handbook of ddx, under symptom tree of hallucinations). But he never, ever seemed borderline. As a matter of fact he was misdiagnosed as schizophrenic for years.

So the likelihood of DID is very very low. Not zero. But low.

 

[whopper]

Add to the confusion with dissociation the person could also be having something else such as catatonia, or a neurological such as an absence seizure, and all of these disorders are one where psychiatrists typically overlook them.

When I ran a geriatric psych unit I'd encounter catatonia every few months while in regular adult inpatient I'd encounter a case less than annually. I never ever saw a study showing it having a higher incidence in older people so I'm still wondering if this was coincidence or if I was noticing something valid.

My last DID patient I terminated her because she was often-times rude and inappropriate to staff members, myself, and came to me already loaded on Adderall and Xanax 8 mg a day that strongly suggested to me her prior psychiatrist just tried to zonk her. I told her if she wanted to be my patient I was going to wean her off of Xanax. By the time I terminated her I lowered her Alprazolam to 4 mg a day. Some inappropriate behaviors included screaming at my assistant, smoking in the waiting area, and never following my recommendations to get a DBT therapist.

I tolerated her inappropriate behavior possibly more than I should. I did consider that some of her inappropriate behaviors were due to some of the alleged identities of her DID but even if this was the case many hold the treatment philosophy that as a treatment approach you hold the person accountable for the behaviors of all their IDs.

 

[thoffen]

DID is real, but what you describe sounds like a patient with dissociative episodes that aren't clearly separately organized identities. That's a diagnostic criteria, but it is not equivalent to BPD.

As to DID, there's a paper out there about a case of a woman with psychogenic blindness and DID who started completely blind with negative visual evoked potentials demonstrating that her occipital cortex did not receive the visual information. In the course of treatment, she had some identity states which could see and some which still could not which still showed negative visual evoked potentials. Eventually, she fully integrated as a sighted person. If that isn't proof that DID is real, I don't know what could be.

But that doesn't mean everyone or even most people who purport to have it do. Unfortunately, there's no clear way to tell.

 

[NickNaylor]

I have only seen a handful of patients with reported history of DID (we have a psychiatrist in our area who is notorious for giving out this diagnosis), and in all cases it wasn't particularly convincing. One patient reported "alters" that seemed to "flare up" with a clear factitious/malingering etiology while the others experienced dissociation which was really more consistent with trauma symptomatology.

I'll stay away from the controversy of whether DID is "real" or not, but in every case that I have seen, the dissociation was really better understood as symptomatology of another disorder rather than DID.

 

[whopper]

but what you describe sounds like a patient with dissociative episodes that aren't clearly separately organized identities. That's a diagnostic criteria, but it is not equivalent to BPD.

She'd occasionally claim she didn't remember some things I told her and claimed she did have other IDs.

I do believe DID exists, but, and I mentioned this before, whenever I have a case where it's brought up I hold a lot of suspicion at least at first. The few times I did think it was going on, there was literally 24-7 observation over the course of several days, or in 1 other case I had a patient with it, she spent the time to go through and understand the existing literature on it and told me upfront she knew meds didn't help so during sessions she didn't bring it up often, and told me she knew it was more for the psychotherapist to address.

 

[nitemagi]

The “personality changes” seen in BPD can more easily be conceptualized in the control mastery model of switching from “passive to active” testing. Which reflects a reenactment of abuse/negative behaviors that were done to them, rather than their usual self who was the victim of that abuse.

See Weiss’s “How Psychotherapy Works.” Ego state therapy references might also be good.

 

[Sushirolls]

This. So much of this. In general dissociation is a poorly taught phenomenon amongst psychiatry, and even worse in the general population.

Dissociation and suggestibility are linked but not identical, so be very careful when working with these patients. This was what led to the DID explosion in the 80s, with false memory syndrome. Beware of leading questions.

I have seen one person who might have had DID, who had a complex dissociative disorder manifesting in conversion symptoms and what eventually got diagnosed as conversion psychiatric symptoms (see DSM handbook of ddx, under symptom tree of hallucinations). But he never, ever seemed borderline. As a matter of fact he was misdiagnosed as schizophrenic for years.

So the likelihood of DID is very very low. Not zero. But low.

An exploration of dissociation can be achieved with CME in hypnotherapy and some of its off shoots.

I have only had one DID patient I believe that may have been a legit diagnosis if time had allowed. It wasn't even a diagnosis of exploration for many visits. It wasn't until the last few visits, that some of the previous behaviors in office and out of office made more sense. A few appointments the patient had switches that were very subtle and not readily apparent until reflecting much later. Patient ultimately stopped all meds and terminated the patient/doctor relationship because of disagreement about a different diagnosis - suspect related to one of the more dominant fractures that drove the decision. Best estimate this patient had 3 splits.

As others have pointed out, those who have come into the office saying by self diagnosis or otherwise they have DID, were actually BPD or BPD+PTSD.