Disclosing abuse is one of the most terrifying things that someone can do and, for people with DID, a history of not being believed, listened to, or taken seriously by medical professionals, family members, friends, and teachers is common.
Both their symptoms and their trauma history are dismissed, which serves to reinforce the feelings of self-blame that are typical in people who have experienced interpersonal complex trauma. Dissociated parts need a safe space in which they will not only be heard, but also believed unconditionally. It means accepting that other parts of you exist on a neurological level, created as an adaptive response to hold experiences that were too painful for you to have in your consciousness.
Dissociated parts serve a purpose, and recovery involves uncovering the nature of each one. What has traumatised a toddler part so severely that she can no longer speak? Why is there a carefree fifteen-year-old stuck in the year ? When was the part who smashes her head against the wall until her face is black and blue created?
So — now do you understand why acknowledging the traumatic origin of my disorder is so important? Find out more about Mental Health Today's Teach Me Well campaign to better shape the mental health lessons coming to the national curriculum. For more information about dissociative disorders, see Positive Outcomes for Dissociative Survivors.
Current preferences. Third Party Cookies. This site is intended for healthcare professionals. Email address:. Ok Cancel. The basics of Dissociative Identity Disorder DID Dissociation is the psychological process in which the mind detaches itself from the self or the world, usually in moments of severe stress.
By dissociating, a child is able to compartmentalise the experiences, enabling them to endure what would ordinarily result in severe psychiatric breakdown Despite extensive research supporting the existence of this disorder and the role of trauma in developing it, many still doubt its existence.
Reversing the code of secrecy I suspect that the majority of people who have been abused were told, as young children, not to tell others about what was going on. 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, ; Laddis et al.
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. 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. 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.
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. Although three participants in this study had very high scores in SDQ 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. The voices usually belong to dissociative parts and comment on actions, express needs, likes and dislikes, and encourage self-mutilation.
Dorahy et al. In dissociative patients they are more complex and responsive, and already appear in childhood. None of our participants reported auditory hallucinations although one Dominique said she had imaginary friends from childhood.
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. Sudden switches between dissociative personalities may occur only when the patient is triggered and cannot exercise enough control to hide his or her symptoms.
Contrary to that, dissociative patients experience much shame and fear of disclosing their internal parts Draijer and Boon, If they become aware that switches had occurred, they try to make reasonable explanations for the intrusions of parts and unusual behavior e.
Dell 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.
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. According to Laddis et al. Participants in this study often used clinical jargon e. However, they often had lay understanding of clinical terms.
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. Detachment from feelings and emotions, bodily sensations and external reality is often present in various disorders Simeon and Abugel, While these phenomena have been commonly associated with dissociation, Holmes et al. Allen et al. 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.
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. There are also secondary gains explained in this study, such as receiving attention and care.
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, 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. 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, 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.
Draijer and Boon 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.
While psycho-education is considered a crucial element in the initial treatment of dissociative disorders Van der Hart et al. Subsequently, this may lead to a wrong diagnosis and treatment, which can become iatrogenic. 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, ipietkiewicz swps.
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. 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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Trauma Dissociation 12, — Laddis, A. Trauma Dissociation 18, — Leonard, D. Dissociative disorders: pathways to diagnosis, clinician attitudes and their impact. Psychiatry 39, — Longden, E. Hysteria was seen as primarily dissociative in nature and could involve disturbances of memory, consciousness, affect, identity, and body functions van der Hart, Lierens, Goodwin, , 1 the same symptoms today associated with dissociative disorders and particularly with dissociative identity disorder.
The first person to be officially diagnosed with multiple personality disorder instead of double personality disorder as had eventually come into use in France was Louis Auguste Vivet in His manner, morals, and appetite were different as well. Following additional attacks, the next year, his character would change from impulsive and dangerous to calm and gentle.
In , he had another attack that left him gentle of manner but unable to walk, and yet another attack returned the use of his legs but left him quarrelsome and inclined to steal as he had done as a child in order to survive. Amnesia for intervals spanning episodes was noted. By , he had been recorded as having 10 personality states, each of which were different in character, memory, and somatic symptoms.
Even after DID became a valid diagnosis, it was still often mistaken for other disorders. Additionally, in , Bleuler had introduced the term schizophrenia, and in , the reported number of cases for this disorder rose dramatically, matched by a decrease in the diagnose of DID. One reason for this is that the original description of schizophrenia actually included multiple personalities!
Many of those diagnosed and treated as having schizophrenia should have been diagnosed as having DID, but because schizophrenia was the more popular diagnosis, that was what was officially recognized Rosenbaum, However, at the time, any theory involving the subconscious mind was unpopular, and few paid attention to what Ferenczi had discovered.
As well, the schizophrenia diagnosis still included and dominated over the DID diagnosis. Howell, The Journal of Psychohistory, 24 1. Dissociation, 2 2. In Statistical manual for the use of institutions for the insane. The role of the term schizophrenia in the decline of diagnoses of multiple personality [Abstract]. Archives of General Psychiatry, 37 12 , DOI: In Understanding and treating dissociative identity disorder: A relational approach.
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