DID

[thepoopologist]

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As someone working out of a forensic facility, there are moments when I feel like the diagnosis was made up by a group of clinicians whom were completely captivated by a BPD or ASPD presentation and missed the forest for the trees

Have any of you actually come across a case of true DID? Is it a case where the diagnostic criteria are valid but the interrater reliability is poor. Or is the diagnosis even valid.

 

[kopftonmd]

Just a med student but we had an adolescent who presented to the unit w/ a questionable DID diagnosis that some clinician ages ago slapped onto the list but subsequent psychiatrists were less sold on. We ended up feeling that it was really BPD w/ conduct d/o. We did use a cool scale to back up our clinical impression!

 

[wolfvgang22]

99% of the time I see the diagnosis it was made by a social worker. It's almost never DID.

 

[thepoopologist]

Since I'm rolling in confirmation bias so far, the other big peeve of mine is when clinicians start asking someone about their "alters". If they have DID, its not diagnostically or therapeutically helpful. If they start talking in detail about their 25 personalities and then bring up their childhood sexual abuse when it looks like you're doubtful then it speaks to another clinical presentation entirely.

 

[splik]

i guess it depends what you mean by a true case? I believe it is an hysterical diagnosis. As a specialist in hysteria, I see a lot of it. Most of the patients meet diagnostic criteria for borderline personality disorder and PTSD, but I have also seen patients who do not have a personality disorder with such symptoms. Where I trained there was something of a mini epidemic of DID most of which could be traced back to a specific psychiatrist. This psychiatrist would also testify as an expert witness that drunk drivers were in a dissociative state and not intoxicated.

More broadly speaking, dissociation is a recognized phenomenon. It is a hypnotic phenomena and those with a history of trauma are more likely to dissociate. The association works the other way too, as peri-traumatic dissociation is a risk factor for PTSD.

 

[thepoopologist]

I'm not questioning whether dissociation in itself exists, for sure it does. And as for the last comment I do remember reading that long article you uploaded... cognitive model of PTSD? I'm questioning the part where distinct identities form. To clarify, have you or anyone ever come across a case where distinct identities are there, and not because they're trying to avoid a murder charge or because its a maladaptive way of connecting with someone or some other secondary reason. So for example, there is a trauma...they dissociate...separate identities form as a way of coping

 

[thepoopologist]

Also the few cases I've seen in forensics, they have the DID diagnosis, they have a lot of psychopathic traits, and are facing 20 to life for a serious charge. Their argument is the genuine them is a law abiding citizen, but their alter i.e. Bubba is not. And at least 1 out of 3 alienists hedges their bets. "Maybe its DID!" I even saw one that concluded "DID but they're competent to stand trial". What does a judge do with that garbage. I don't know how its even considered in a case like that. Obviously you can tell I'm biased against it and I'm trying to find a more balanced perspective.

 

[Sushirolls]

I had ONE case, wasn't even on my differential for a long time. Outpatient setting.

Enough time has passed details are very rusty now, and probably wrong. Can't fully recall the working diagnosis for most of the months. Schizotypal versus Schizoaffective of all things. Heck I really can't remember anymore, but something that warranted antipsychotic use. At one point patient was on board with antipsychotics, other appointments was like "nope, doing great, don't need meds." Few encounters had moments where patient nodded head for few seconds and demeanor changed just slightly. Got voicemail messages expressing different things from what was expressed at earlier appointments. So many confusing things about treatment course that didn't fit into the usual paradigm of what I've seen in other conditions.

Made the diagnosis with patient and discussed locations of where to seek out treatment, but most clinicians likely had 0 to limited experience with DID. After 1-2 more appointments the more assertive persona terminated care saying everything was well and no issues. I think I observed at least 3 persona.

Wish I still had access to those records where I had charted/seen this patient, to do another review several years later. Nice to see if my post review still passed the muster for charting.

 

[PikminOC]

99% of the time I see the diagnosis it was made by a social worker. It's almost never DID.

Just like when they say it's ADHD..

 

[Crayola227]

i guess it depends what you mean by a true case? I believe it is an hysterical diagnosis. As a specialist in hysteria, I see a lot of it. Most of the patients meet diagnostic criteria for borderline personality disorder and PTSD, but I have also seen patients who do not have a personality disorder with such symptoms. Where I trained there was something of a mini epidemic of DID most of which could be traced back to a specific psychiatrist. This psychiatrist would also testify as an expert witness that drunk drivers were in a dissociative state and not intoxicated.

More broadly speaking, dissociation is a recognized phenomenon. It is a hypnotic phenomena and those with a history of trauma are more likely to dissociate. The association works the other way too, as peri-traumatic dissociation is a risk factor for PTSD.

Would love to hear you explain more about hysteria. I thought that went out with Freud.

 

[Crayola227]

I saw it once in med school, it was pretty convincing and also not terribly dramatic, which probably lent it some credibility in my eyes.

The psychiatrist I was working with who was working with the patient, wasn't totally sure but they felt that in general it might be a real but somewhat rare diagnosis. They didn't feel in most cases it was really essential to figure out or determine if it was "real" for management.

I wouldn't be surprised if most of the time it was super fake, but also really existed rarely.

 

[nexus73]

There was an article I read a few years ago, and I can't remember who wrote it. But the author was a psychiatrist at like Emory or some reasonable academic place. His basic conclusion was, is it real or not? Hard to really say, maybe it is, but there's a lot of controversy, and probably a lot of BPD and PTSD, etc etc. But one thing's for sure, these people who think they have DID, or had some psychiatrist diagnose DID at some point...these people are usually very unhealthy and suffering individuals.

So saying if DID is true or not maybe isn't as important as just supporting these people, making sure they're in therapy and on meds to address the co-morbid anxiety/depression etc. I mean it's not as if a DID diagnosis opens up a different medication treatment pathway...so how important is it. Is it counter therapeutic to argue with someone if they think they truly have DID? Does it actually help if you convince someone it's not DID, it's borderline? Assuming they're going to do DBT therapy anyways?

 

[FlowRate]

Would love to hear you explain more about hysteria. I thought that went out with Freud.

I believe most commonly called FNSD/conversion/somatoform these days but all of that traces back to hysteria.

To maybe elaborate on some of the earlier points. Asking if DID is real is probably like asking if PNES seizures are "real" (ignoring the high comorbidity of actual epilepsy with that diagnosis.)

 

[Stagg737]

Seen multiple cases of "DID", all of which hit criteria for BPD with h/o severe trauma. Even caught someone faking an "alter" once. I personally don't believe in true DID as popularly described, however one of my attendings also previously held this belief but had a close colleague with a case that couldn't be explained otherwise, so who knows.

Realistically, I agree with a lot of the above though, if it's not going to change my treatment plan I don't particularly care what the patient calls it. I'd never document it as a diagnosis though unless I legitimately saw it first had. I'd just say "h/o" or "per patient report".

Also, it probably doesn't help that one of the main coping mechanism/features of BPD is "splitting". I really wish this had a different label, as I hear it being used incorrectly by patients and less educated staff more than I should.

 

[hamstergang]

There was an article I read a few years ago, and I can't remember who wrote it. But the author was a psychiatrist at like Emory or some reasonable academic place.

I've posted this article here before (8 years ago, and I think there was another time too):

I think this is a decent take on the issue: Is dissociative identity disorder real? - CNN.com, by Dr. Charles Raison, a psychiatrist at Emory (I know nothing about him outside this article).

"There is no doubt that some people behave as if they have multiple personalities. And not all of them have been to therapists who have trained them to interpret their dissociative experiences in this way. Does this mean that dissociative identity disorder exists? In my opinion it depends on what we mean by 'exists.' Yes, dissociative identity disorder exists if by exists we mean there are people who complain of its symptoms and suffer its consequences. Do I think that some people have many biologically distinct entities packed into their heads? No. I think that some people dissociate so badly that either on their own or as a result of therapeutic experiences it becomes the case that the most convincing way for them to see their own experience is as if it is happening to multiple people."

I think the important question is, how does it affect treatment if we view DID as it's own entity vs PTSD + BPD? The same author continues from above: "I am personally less sanguine, however, about treatments that proceed as if each of the separate personalities really exists concretely and then work to integrate them again." But I personally don't know much about the treatment issues here so I'll leave that to others.

 

[thepoopologist]

When you think about all the factors that make up an identity: temperament, physical health, the family environment, the social environment, the culture, the educational level, varying experiences that are unique in when and how a person experiences them etc...the idea that someone whom is originally "Brenda the housewife" can also be "Bob the builder" is far-fetched. Or if they become "Brenda the racecar driver" how different does this Brenda have to be to be considered a different identity? I don't see how trauma/dissociation/maladaptive coping can really be the explanation for a different identity when you consider how long it takes for a person to develop their own. Without the dissociation, they are the same identity, just like a person with a type-A personality in a corporate job who goes home and becomes a leather clad gimp covered in peanut butter are the same person.

 

[thepoopologist]

I've posted this article here before (8 years ago, and I think there was another time too):

Wow he beat me to it by 8 years, I totally agree and that would probably be the best way to frame it to a patient.

 

[sloop]

While I certainly believe that there are patients whose subjective experience is consistent with that described by DID, I do not believe that it is a valid diagnosis in the sense of representing a unique psychopathological state. As you have mentioned, generally the presentation seems to be attributable to personality pathology. In a forensic context, the diagnosis also relies too heavily on subjective experiences that are almost impossible to verify.

I do believe that dissociation in the general sense is a real phenomenon, but I also find this to be a problem when defendants claim to have dissociated in the context of a variety of disorders (BPD, PTSD, etc.). How exactly am I supposed to verify that someone actually dissociated, beyond their self report? Most of the defendants who make this claim seem to have acted in goal-directed ways that are indistinguishable from a non-dissociated state. That, and they claim to have rapidly returned to a normal state so that their normal appearance in jail, the hospital, etc. are not strictly relevant to their claim.

 

[clausewitz2]

Worth bearing in mind that the idea of identity in terms of your personal subjective experiences of the world as opposed to some summation of the different kinds of relationships you have with others in your society is a very, very new one and still not the norm in many places. If identity just means whose daughter or father you are, what guild you belong to, your religion, your language, your occupation, your relations etc DID is incomprehensible. Your subjective experience of feeling different is irrelevant to the question of that conception of identity.

 

[calvnandhobbs68]

There was an article I read a few years ago, and I can't remember who wrote it. But the author was a psychiatrist at like Emory or some reasonable academic place. His basic conclusion was, is it real or not? Hard to really say, maybe it is, but there's a lot of controversy, and probably a lot of BPD and PTSD, etc etc. But one thing's for sure, these people who think they have DID, or had some psychiatrist diagnose DID at some point...these people are usually very unhealthy and suffering individuals.

So saying if DID is true or not maybe isn't as important as just supporting these people, making sure they're in therapy and on meds to address the co-morbid anxiety/depression etc. I mean it's not as if a DID diagnosis opens up a different medication treatment pathway...so how important is it. Is it counter therapeutic to argue with someone if they think they truly have DID? Does it actually help if you convince someone it's not DID, it's borderline? Assuming they're going to do DBT therapy anyways?

here’s my issue and the big problem is see with this diagnosis being thrown around. The whole concept that laypeople get from this is that each of these “alters” are totally different consciousnesses that have no idea what the other one is doing. So people will come in and argue that they aren’t responsible for that their “alters” are doing. Then when you try to challenge that in any way or try to approach it as “well other people are still going to view your body as responsible for what these different identities are doing” they throw a fit and insist the left hand doesn’t know what the right is doing. Again, very consistent with a personality disorder. TikTok is the bane of my existence right now…there’s people on there that claim to have like 50 “alters” or whatever. Same reason I’ve started telling my intake that I’m not taking any >12yo ADHD evals from therapists unless it’s coming from a school or parents.

On the face of it it’s a bizarre concept. I saw it put pretty well in a psychiatry group. Think about how much pure wetwork computing power it takes to form an consciousness and how easily it is to screw that up. We know of conditions that alter your personality/conscious self or alter your perception or cause you to dissociate or make your forget parts of yourself but those are all primarily removing/damaging/altering/replacing brain functions.

Then we’re somehow going to state that there’s some condition that “splits” your consciousness into multiple different states that have no verbal/language communication between each other such that were saying you’re essentially replicating multiple conscious persons in the same brain?

 

[Stagg737]

I do believe that dissociation in the general sense is a real phenomenon, but I also find this to be a problem when defendants claim to have dissociated in the context of a variety of disorders (BPD, PTSD, etc.).

I certainly agree with the dissociation in BPD, as this is oftentimes based on subjective patient reports and it's been pretty rare when I've been able to obtain collateral from someone else who could confirm the dissociative state. Typically in those situations, it's more of the derealization/depersonalization where they're still aware of the situation but just do not feel in control (despite whatever level of control they actually have).

I do think that PTSD is different though. Ime, it's pretty common that when a true PTSD patient starts talking about a "dissociative episode" that it's essentially a flashback where others can clearly witness a change in behavior where the patient was either minimally or non-responsive to intervention. I also find that these individuals can usually recall at least some parts of what they were doing but misinterpreted their actions. For example, I had a VA guy who was really pleasant but fairly suddenly entered a flashback and started throwing tele-packs around the medical floor like they were grenades. Afterward he remembered believing he was back in battle and believing he actually was throwing grenades and was able to tell us what he was subjectively experiencing.

When someone reports a period of mental blackout where they became violent or performed some other complex task but don't recall anything they did, I don't attribute it to PTSD. Though PTSD can be a co-morbidity for some other underlying disorder that needs to be addressed like anger disorders or other behavioral disorders (not DID though).

 

[birchswing]

here’s my issue and the big problem is see with this diagnosis being thrown around. The whole concept that laypeople get from this is that each of these “alters” are totally different consciousnesses that have no idea what the other one is doing. So people will come in and argue that they aren’t responsible for that their “alters” are doing. Then when you try to challenge that in any way or try to approach it as “well other people are still going to view your body as responsible for what these different identities are doing” they throw a fit and insist the left hand doesn’t know what the right is doing. Again, very consistent with a personality disorder. TikTok is the bane of my existence right now…there’s people on there that claim to have like 50 “alters” or whatever. Same reason I’ve started telling my intake that I’m not taking any >12yo ADHD evals from therapists unless it’s coming from a school or parents.

On the face of it it’s a bizarre concept. I saw it put pretty well in a psychiatry group. Think about how much pure wetwork computing power it takes to form an consciousness and how easily it is to screw that up. We know of conditions that alter your personality/conscious self or alter your perception or cause you to dissociate or make your forget parts of yourself but those are all primarily removing/damaging/altering/replacing brain functions.

Then we’re somehow going to state that there’s some condition that “splits” your consciousness into multiple different states that have no verbal/language communication between each other such that were saying you’re essentially replicating multiple conscious persons in the same brain?

As a lay person I got the opposite impression. I got the impression this was a fad that flowed from psychiatry to patients, who then enacted the expectations they were given. This gives me like 1980s/90s Oprah-show vibes. I didn't know it was a thing anymore.

 

[sloop]

I certainly agree with the dissociation in BPD, as this is oftentimes based on subjective patient reports and it's been pretty rare when I've been able to obtain collateral from someone else who could confirm the dissociative state. Typically in those situations, it's more of the derealization/depersonalization where they're still aware of the situation but just do not feel in control (despite whatever level of control they actually have).

I do think that PTSD is different though. Ime, it's pretty common that when a true PTSD patient starts talking about a "dissociative episode" that it's essentially a flashback where others can clearly witness a change in behavior where the patient was either minimally or non-responsive to intervention. I also find that these individuals can usually recall at least some parts of what they were doing but misinterpreted their actions. For example, I had a VA guy who was really pleasant but fairly suddenly entered a flashback and started throwing tele-packs around the medical floor like they were grenades. Afterward he remembered believing he was back in battle and believing he actually was throwing grenades and was able to tell us what he was subjectively experiencing.

When someone reports a period of mental blackout where they became violent or performed some other complex task but don't recall anything they did, I don't attribute it to PTSD. Though PTSD can be a co-morbidity for some other underlying disorder that needs to be addressed like anger disorders or other behavioral disorders (not DID though).

I agree that the PTSD dissociative episodes are often more believable, but they are still problematic in a forensic context. Part of the issue is that when a criminal defendant says they killed someone during a flashback, for instance, there is a high suspicion that they might be manufacturing that symptom. That and, in the context of a responsibility evaluation, it’s very difficult to establish whether someone could appreciate the criminality of their conduct or conform their behavior to the requirements of law during an episode that lasts seconds to minutes even if you accept that it happened. It’s very unlikely that you’re going to have enough data around the time of such an event to say, to a reasonable degree of medical certainty, that (a) they dissociated, and (b) they met the legal standard of insanity. Of course if others had noticed changes in behavior consistent with dissociation previously, that would help to diagnose them with the dissociative specifier of PTSD but it doesn’t necessarily give a ton of information for the specific episode you’re focusing on. In fact, someone who has actually dissociated in the past would probably be better at feigning dissociation on an evaluation.

This is different from most psychopathology that might impact a defendant’s responsibility. If someone is psychotic, for instance, their mental state in the days to weeks before and after the offense would be very relevant. If the claim is that they dissociated, it is not. The time period you have to gather information from is much narrower, and that is a real barrier to being able to say someone lacked responsibility to a reasonable degree of medical certainty.

 

[Crayola227]

Well, whether not something is objectively "real" is not the same thing as will it hold up in court. Seems to me we shouldn't let the latter dictate our conclusions on the former (that way madness lies, I tell you). Although I agree that if we do conclude something is "real," it is worth considering how one goes about measuring/proving it and what other consequences there might be.

 

[Jules A]

It makes sense in the context of dissociation and severe trauma however I don't think I have actually seen it in my career. What I have seen is a plethora of patients with significant personality vulnerabilities in conjunction with mood disorder and trauma history who have been given this diagnosis and embrace it like a badge of honor. In my opinion this does the majority a disservice as there doesn't seem to be any motivation to attempt to move past it instead using it as an excuse for chronic, regressive, maladaptive behavior.

 

[Stagg737]

I agree that the PTSD dissociative episodes are often more believable, but they are still problematic in a forensic context. Part of the issue is that when a criminal defendant says they killed someone during a flashback, for instance, there is a high suspicion that they might be manufacturing that symptom. That and, in the context of a responsibility evaluation, it’s very difficult to establish whether someone could appreciate the criminality of their conduct or conform their behavior to the requirements of law during an episode that lasts seconds to minutes even if you accept that it happened. It’s very unlikely that you’re going to have enough data around the time of such an event to say, to a reasonable degree of medical certainty, that (a) they dissociated, and (b) they met the legal standard of insanity. Of course if others had noticed changes in behavior consistent with dissociation previously, that would help to diagnose them with the dissociative specifier of PTSD but it doesn’t necessarily give a ton of information for the specific episode you’re focusing on. In fact, someone who has actually dissociated in the past would probably be better at feigning dissociation on an evaluation.

This is different from most psychopathology that might impact a defendant’s responsibility. If someone is psychotic, for instance, their mental state in the days to weeks before and after the offense would be very relevant. If the claim is that they dissociated, it is not. The time period you have to gather information from is much narrower, and that is a real barrier to being able to say someone lacked responsibility to a reasonable degree of medical certainty.

I agree that PTSD-related dissociative claims would make the situation much murkier unless there were witnesses who could identify the event and knew what they were seeing. Even then, I imagine it would be pretty messy. I was more referencing the idea that people are using dissociation due to BPD as a defense. I feel like claiming a true dissociative episode with BPD that is as severe as some PTSD flashbacks would be a much more difficult defense to make an argument for. I also am personally more skeptical of these claims for the reasons I stated above (depersonalization/derealization vs. a true dissociative episode).

 

[Psych Person]

When you think about all the factors that make up an identity: temperament, physical health, the family environment, the social environment, the culture, the educational level, varying experiences that are unique in when and how a person experiences them etc...the idea that someone whom is originally "Brenda the housewife" can also be "Bob the builder" is far-fetched. Or if they become "Brenda the racecar driver" how different does this Brenda have to be to be considered a different identity? I don't see how trauma/dissociation/maladaptive coping can really be the explanation for a different identity when you consider how long it takes for a person to develop their own. Without the dissociation, they are the same identity, just like a person with a type-A personality in a corporate job who goes home and becomes a leather clad gimp covered in peanut butter are the same person.

I lol’d. I like the way your mind works. Keenly skeptical, deeply curios, and fun-loving.

Given that it’s a bit of a “sexy” diagnosis, fashionable and something that many patients with personality disorders love to brag about having (which means they don’t have it 99.9% of the time), I’ve come to really value the notion that the personas in a DID case should not have a tremendous amount of awareness of one another. It’s my understanding that in the literature this is what is to be expected as well for any genuine case of DID. Just like the old adage “Crazy doesn’t know it’s crazy”, DID doesn’t know it’s DID.

 

[Merovinge]

Well, spoiler alert, but Mr. Robot was a really solid show, so thanks for that DID.

Spilk or someone else with more rings on their tree can correct me, but I believe a big start of DID was related to falsified research out of Rush University where patients were put under hypnosis and suggested to detail alters. Ongoing research on the area tends to be siloed to very specific universities, notably a few in Germany. I have only ever met psychiatrists with particularly strong ties to psychodynamics as well as other mental health professionals wanting a niche that seem to diagnosis or treat DID. It seems to be a historic relic that might be able to be finally put to rest if we can have DSM 6 include complex trauma and have further research in this domain, but given the number of TV shows and movies based on it, I'm not sure we can ever get it out of the zeitgeist.

 

[deleted1100659]

DID is just the primary progressive subtype of BPD.

 

[hallowmann]

I've seen about a couple dozen "DID" diagnosis patients. I suppose one could meet the strict criteria and did not feel easily explained into other diagnoses. All others were in the setting of BPD/ASPD with trauma. I'm not sure what to make of that one case. I tend to agree that in virtually all the cases treatment is the same, so I'm not sure what difference it makes from a clinical standpoint. When we have more treatments of varied efficacy, maybe it will make a bigger difference to actually weed out the strictly DID patients, which if they truly exist are very few in number.

 

[splik]

The first case of the modern era in the English Language was that of Mary Reynolds (for example as described by the father of american neurology S Weir Mitchell here) in the 19th century. Reading this case leaves no doubt that this phenomenon was regarded as an hysterical phenomenon, and should still be regarded as such today. There were odd cases here and there in the 20th century, but it wasn't until the 1950s when Thigpen and Cleckley published their case (later to become Oscar Winning movie The Three Faces of Eve) that the concept of multiple personality entered the collective consciousness. In the 70s there were some other cases reported, and it was at this point it came to be used as a criminal defense by malingerers attempting to evade the death penalty (most famously Kenneth Bianchi). Much of the cases and research being doing was published in hypnosis journals and uncovered in the course of using hypnosis. In the 1980s, the concept of multiple personality disorder became wedded to the recovered memory epidemic where suggestible patients recovered memories of childhood sexual abuse that never happened and told that the formation of alters preventing them from knowing about this abuse. MPD (as it was known back then) was also tied to another hysterical epidemic, that of satanic ritual abuse, and I have certainly seen patients from that era who were led to beleive they were victims of satanic abuse (despite no evidence to support this and much evidence to the contrary) and that they developed MPD in response. In one of my favorite cases, a patient sued a psychiatrist for billing her over $300 000 for group therapy (one patient) for each of her "personalities" one of which was a Duck.

Today the cases seen typically fall into 3 categories: iatrogenic, factitious, and hysterical. Frank malingering is rare today especially since the courts have ruled that it does provide exculpation for criminal responsibility (i.e. if one of your personalities did it, it's still part of you, so you're still responsible). But most cases are probably iatrogenic or factitious.