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Can DID be caused by therapists? Can DID be caused by seeing it online and in popular media? What about if you know someone who has it - can that make you think you have it?

This post is going to be looking at the article “Iatrogenic and Sociocognitive Models of DID”. It has some cool brain scan pics, but a lot of medical jargon which may be intimidating or confusing.

TLDR; My personal interpretation of this article is that there is no basis for assuming that all DID is “made up” by a patient being convinced they have it by either a therapist or social environments.

Below I have quoted a few key points from the article, and have done my best to explain them a little more.

Firstly let’s start with some definitions:

Iatrogenic = When a therapist or mental health professional accidentally or purposefully convinces a patient that they have a specific issue/disorder. Tumbly user misachips has offered this extra clarification on the definition of Iatrogenic: “In terms of DID and its myth, iatrogenic often implies the condition is pushed onto the patient by a therapist indeed, but the real definition means that the condition was caused because of medical intervention or treatment! so for example, side symptoms of medication are iatrogenic, hairloss due to chemo is iatrogenic, muscle atrophy after a coma too, etc.” Sociocognitive = When a person begins to believe they have a disorder, or starts experiencing symptoms of a disorder, after being exposed to the disorder/symptoms in a social context. Traumagenic = When a disorder is caused by the patient having experienced trauma. In DID this specifically means when DID is caused by long term or repeated childhood trauma.

“Iatrogenic dissociative identity disorder is DID that results from suggestion from or coercion by a mental health professional.”

“Likewise, sociocognitive conditions are those that are caused by internalizing symptoms seen in the media, in friends, in family members, online, or in other social settings.”

“While there are cases of both iatrogenic and sociocognitive DID, most cases of DID are thought to be traumagenic, or the result of long term or repeated childhood trauma.”

- This article seems to be addressing whether DID is caused by trauma, social influences, or by mental health professionals pushing a disorder on a patient.

It states that all of the above may happen, but it goes on to focus on traumagenic DID. *Note: if you are worried that your disorder may be caused by outside influence such as a therapist or social media, please talk to a (different) therapist about these fears. It’s ok to be worried about this, particularly if you are highly suggestible, but you should try to identify whether it is a valid fear or whether it is just denial. Regardless, being open with a trusted and experienced therapist will help you.*

“DID patients have smaller hippocampal and amygdalar glands, something seen in those who were abused as children and have posttraumatic stress disorder (PTSD)”

“… DID cannot be said to be the same as PTSD. Individuals with DID and co-morbid PTSD have larger putamen and pallidum volumes compared to individuals with only PTSD with these volumes being positively correlated with severity of dissociative symptoms.”

- While DID patients and child abuse survivors both exhibit the same physiological differences within the brain, DID is not simply “MEGA PTSD!!!”.

*Disclaimer*: I don’t actually know what putamen and pallidum volumes are, or what they are related to. But the article makes it clear that a patient who has both DID and PTSD will show one result, and a patient who only has PTSD will show a different result.

“There is also evidence that DID is not iatrogenic. Some of the symptoms of DID might become visible only after diagnosis or treatment, but many are present before this point.”

“As well, appropriate DID treatment is unlikely to cause additional or worsened dissociative symptoms as it measurably leads to patient improvement. It lowers self-injurious behaviors, leads to fewer hospitalizations, and increases adaptive functioning.”

- It’s not unusual for patients to only start noticing or start presenting some symptoms after diagnosis/treatment. I personally believe this is mainly due to increased awareness of the symptoms, and the realisation that certain things are actually signs of abnormal mental health or an abnormal childhood. - You may be scared to think that you have DID, scared that things are going to change or get worse. But the studies here show that there is no reason to believe that that is true. In fact it states very clearly that finding out you have DID and then beginning treatment for it with a good therapist, will make your life better, not worse.

So even if it feels like you’re getting worse, it is not likely to be true. If you are feeling overwhelmed, or as though you are taking steps backwards instead of forwards, talk to your therapist about these feelings. Your therapist should work with you to make sure you’re only taking on as much as you can handle. (This is true with all therapy, not just for DID.)

“More evidence that DID is neither iatrogenic nor sociocognitive lies in the blend of underlying symptoms that the disorder contains that one would not learn about through the media, the vast majority of professionals, or casual online resources. Before the publication of the study "A New Model of Dissociative Identity Disorder” by Paul F. Dell in 2006, many of these symptoms were unknown, not associated with DID, or not clinically associated with DID, yet the study finds that a strong majority of individuals with DID experience all of the symptoms tested.“

- This part talks about how if DID were sociocognitive (created by exposure to social media etc), people would only present with the most well known symptoms. But there are many symptoms that people with DID experience which are not addressed in social media or in entertainment (such as movies). It’s basically asking: How could so many different people who don’t know each other, have these same symptoms (which aren’t shown online or in movies etc) if those symptoms weren’t real?

"Finally, it should be noted that some cases of DID are not traumagenic, iatrogenic, or sociocognitive but pseudogenic (factitious or malingered). This final type of "DID” is addressed here. That pseudogenic DID can be distinguished from genuine DID also supports that DID is caused by more than outside influences as it shows that iatrogenic or sociocognitive influences are not enough for an individual to sufficiently feign DID. “

- The article ends by mentioning people who purposefully fake DID. They believe that this further proves that DID is not caused by outside influences (therapist, social media, movies, etc), because someone without DID, who is genuinely trying to fake DID using these sources as a "guide” to faking it, can not fake it well enough. They link another article, which I will link here too. But please note that I have not read this article about “pseudogenic DID”.

Now here are the cool bits about the brain scans:

“In none of these studies are individuals without DID able to match the differences between trauma oriented and non-trauma oriented parts even if the control individuals are highly fantasy prone.”

- This shows that there is a clear difference between people who have DID, and people who are pretending to have DID. Note: This isn’t saying that everyone claiming to have DID should undergo a brain scan to prove it, it is simply stating that they used people without DID who were pretending to have DID in order to see whether the reactions in the brains were the same, or whether there was a fundamental difference between DID and fantasy/acting.

“The same study finds that individuals with DID are not more fantasy prone than the general population, a finding that refutes the idea that DID is caused by fantasy proneness or suggestibility (Reinders, Willemsen, Vos, Boer, & Nijenhuis, 2012).8 ”

- Though it is a common theory that one of the indicators that a child may develop DID/OSDD is an increased imagination, this study did not find that to be true.

All quotes from: https://did-research.org/controversy/iatrogenic.html

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Let's talk about longitudinal studies on dissociation!

First off, what is a longitudinal study? This is a type of academic experiment where researchers study the same group of volunteers over a long period of time, usually several years. It's very effective for seeing how the same things change over time, such as how people might develop dissociative disorders.

The longitudinal study I want to share is "Development and the fragmented self: longitudinal study of dissociative symptomatology in a nonclinical sample" by researchers Ogawa, Sroufe, Weinfield, Carlson, and Egeland. This was a longitudinal study over the span of 19 years, looking to investigate the emergence of pathological dissociation in a person.

Experiencing dissociation is normal to some extent! But pathological dissociation is described as severe & abnormal dissociation such as amnesia, identity confusion, identity fragmentation, and depersonalization & derealization.

Okay, now let's talk about the study. The study followed 168 children from birth to 19 years old. They were in "at-risk" families which experienced things like poverty or a teenage parent. Here's what the study discovered after 19 years:

Trauma is necessary but not sufficient for pathological dissociation. Not every child who experienced trauma ended up dissociative. Every child who did develop pathological dissociation, however, experienced trauma.

Pathological dissociation is predicted by trauma occurring at 0-24 months of age. The older the children got, the less likely pathological dissociation was to develop.

Pathological dissociation is also predicted by trauma that is severe and chronic.

Pathological dissociation is predicted by attachment style. Children with disorganized attachment to their mothers had the highest dissociation scores. Children who had anxious/avoidant attachment with their mothers had higher dissociation scores than children with secure or anxious/ambivalent attachment.

The more integrated a child's sense of self is, the less likely they will develop pathological dissociation.

The environments that produced the most severe trauma also produced the most chronic trauma, while environments that produced the least severe trauma also produced the least chronic trauma. Likewise, the children who experienced the most severe & chronic traumas also experienced them at the earliest ages. "If children are living in chaotic, traumatic environments when they are infants, then it is likely that they will continue to live in such environments as they grow older. All three of these aspects of trauma may be highly related in our society, and are probably not separable in either an analytic sense or a theoretical sense."

Their findings support that pathological dissociation is not a more severe version of normal dissociation. Pathological dissociation actually "represents an extreme deviation from normal development."

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Some points to be learned from this article:

A massive analysis of 1.5k+ studies contrasted the different theoretical models for DD & concluded that DD are posttraumatic in nature. 

There are no clinical studies that support the iatrogenic, sociocognitive, or fantasy models.

DID is a posttraumatic childhood onset disorder.

DD patients are at a huge risk for suicidal and self-destructive behavior.

DD patients have been found to have the highest rates of suicide attempts in many studies. Despite this, they are often overlooked in suicidality studies.

The lack of adequate treatment and recognition for DD is a major public health issue which is leading to substantial human and societal costs.

“By the time many DD patients are correctly diagnosed, they are demoralized and have suffered substantial secondary losses from years of unproductive treatment, hospitalizations, suicide attempts, disfiguring self-harm, disability, and careers as chronic ‘treatment resistant’ patients.”

“A major public health effort is needed to raise awareness about dissociation/DD, including educational efforts in all mental health training programs and increased funding for research.”

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I'm rereading one of Ellert Nijenhuis's books and on page 550 he discusses the fantasy model of dissociative identity disorder and the costs of ignoring DID as a valid, trauma-based disorder. I wanted to share some of these points because I think they are important to hear:

- Biopsychosocial studies show no evidence that DID results from suggestibility, fantasy proneness, or roleplaying.

- Evidence and research consistently and strongly supports that complex dissociative disorders like DID are caused by trauma and respond positively to phase-oriented treatment.

- People with DID are not highly fantasy prone: they are more likely to avoid trauma memories rather than fantasize about them.

- Ignoring the prevalence of childhood trauma and DID is resulting in huge moral and economic costs.

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DID/OSDD or CDD?

"Over the past few decades, it has become increasingly clear that DID is characterized by much more than alter personalities. Persons with DID routinely exhibit a vast array of dissociative symptoms. In other words, DID is more than an alter disorder; it is a chronic complex dissociative disorder. Coons (2001), for example, has argued that DID needs a name that 'truly reflects the polysymptomatic nature of DID' (p. 44). In keeping with this understanding, Dell (2001a) has suggested renaming DID major dissociative disorder and Coons (2001) has suggested pervasive dissociative disorder. Perhaps the most common referent or label for DID (other than MPD or DID) is 'complex dissociative disorder.' To my knowledge, no one has actually proposed that DID be renamed Complex Dissociative Disorder, but variations of this term have been cropping up in the literature with increasing frequency: 'chronic complex dissociative disorders' (Ross, 1990), 'complex chronic dissociative symptoms' (Loewenstein, 1991), 'complex posttraumatic and dissociative disorders' (Chu, 1998), 'chronic, complex dissociative disorder' (Tutkun et al., 1998, p. 804), 'complex dissociative disorders' (Coons, 2001), and 'the taxon of chronic complex dissociative disorder' (Ross, Duffy, & Ellason, 2002, p. 15). Clearly, the authors cited in this paragraph understand DID to be much more than just 'an alter disorder.' They understand DID to be a major, pervasive, complex, chronic, dissociative disorder. Perhaps the DSM should call DID Complex Dissociative Disorder."

Paul F. Dell (2009) on giving DID a new name: complex dissociative disorder. Source (page 392).

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every once in a while i DO remember to think with my brain. this blog isnt dead i promise i just don't always have new stuff to put here

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something to look into more scholarly sources about later, but i thought this was interesting - i see a lot of resources about childhood trauma discuss attachment theory as it was conceived of in the 1970s, and so i had no idea that the dynamic-maturational model existed! i think people could probably benefit from reading more about the updated theories of attachment than the 1970s version. (correction: the initial ABC + D model of attachment theory didn't see significant pushback in favor of the DMM until 2017, apparently.)

i've seen a lot of discussion of DID as related to disorganized attachment in particular, which apparently was a broad and not particularly useful category prior to the DMM, so i'm interested to see how dissociation fits into this model.

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here’s stuff i think i actually want people without did/osdd-1 to understand:

did/osdd-1 are the result of developmental trauma + other factors. it is inextricable from the subject of child abuse and its various forms. regard them as post-traumatic experiences and treat the subject with the care and consideration that deserves.

the “alters” in did/osdd-1 are more often referred to nowadays as dissociated parts of the self or simply “parts.” some people dislike this terminology in reference to themselves and that’s fine. others prefer it.

“switching” is a requirement to be diagnosed with did/osdd-1 but it is not the most commonly experienced symptom - passive influence is often the main way parts (other than who’s fronting) are “active.” some people with did/osdd-1 switch very rarely.

fictional introjects are not the only type of introject and not everyone with did/osdd-1 has any. introjects of abusers are what’s the most common.

did/osdd-1 is not inherently a form of plurality.

not everyone with did/osdd-1 identifies as a “system” and there are plenty of us who are highly uncomfortable being referred to as such as it can be seen as dehumanizing.

respect the boundaries of people with did/osdd-1. not everyone is open about their parts or their experience with it. who’s “fronting” or if a switch has occurred is not information that anyone is entitled to. remember these are post-traumatic diagnoses most heavily associated with being abused long-term as a child.

treating dissociated parts as if they’re their own individual people as a rule can be harmful. at the end of the day they’re dissociated parts of one individual - this doesn’t mean any one part is any more or less “real” than the others or the perceived “host” part.

don’t get your “education” on did/osdd-1 from teenagers and be incredibly careful with what “influencer”-types on social media claim to be true since sensationalizing things works in their favor it but can often be a detriment to the rest of us. also, don’t trust poorly-cited carrds.

( here’s an extensive list of resources for those interested in learning more )

you can rb this, questions are ok, and corrections with actual backing are welcome, but otherwise stupid disagreements with this post come with a mandatory $50 fee <3

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About Polyfragmentation.

Here is a master list of all posts I have made regarding polyfragmentation: Definition of Polyfragmented (in DID)

Polyfragmentation - a breakdown of scientific sources.

Polyfragmentation: DID vs OSDD

Personal experiences of Polyfragmented DID

All posts are tagged with #polyfragmented

  I began looking into this subject because an anon asked me for information about polyfragmented DID. This is a major subject with VERY little concrete information available.

I have been unable to find any information on how common polyfragmentation is, or how it occurs. This is because there is so little information out there from academic resources.

Most information about polyfragmented DID is gleaned from sidenotes - I have not been able to find/access any studies that were specifically focused on polyfragmented DID.

Please feel free to reach out if you have sources which I haven’t addressed in the above posts. My DMs are open, and anon asks are turned on. For accountability, here are the anon asks which led me to post about polyfragmentation: Anon ask 1 Anon ask 2 (follow up)

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Having DID isn't something that's impossible to understand or relate to. Even dissociation specialists remark that it's very easy to relate to DID. Everyone has interconnected parts. People with DID have that same underlying structure. It's just that childhood trauma & dissociation causes some of our parts to become disconnected and develop into alters. We're not aliens. We're survivors.

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https://www.systemspeak.org/blog/2019/9/12/structural-dissociation-discussion

This is a discussion article from System Speak about Power To The Plural’s “structural dissociation is ableist” article. While interviewing a professional, they go over the misinformation in PTTP’s article, and even get input from one of the creators of the structural dissociation theory. They tackle some common myths and misconceptions that the plural community is spreading about dissociative disorders and the theory of structural dissociation.

Some topics include:

OSDD is not a “lesser” version of DID

All alters are equally important & real

You don’t have to be distressed by your alters to be diagnosed with DID or OSDD

Structural dissociation applies to ALL trauma-related disorders, not just DID and OSDD

Final fusion is not the primary treatment goal for DDs; it’s a choice & it should not be forced onto you

This is an important read if you feel like the concept of trauma-related structural dissociation and its treatment somehow invalidates plurality.

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Fully fused with parts?

Let’s talk about full integration / final fusion where the parts are never erased and where being a whole-yet-multifaceted person is the goal of the fusion.

I don’t think I’ve ever seen anyone talk about this. Then again, I don’t think that there are many systems on Tumblr who are at this point in therapy with this particular goal.

Final fusion is usually thought of as the merging of all parts into one self. Before fusion, there are metaphorical walls of dissociation between you and other parts of your mind. Whichever part of the mind is active is perceived as “Me” while the other parts are perceived as “Not Me”. After fusion, those metaphorical walls disappear, allowing all parts of the mind to become “Me”.

In the past, the westernized approach to self often led to therapists pressuring fully fused systems to stop valuing (or even acknowledging) that they had parts. It makes sense to me why those older systems would often compare fusion to death. In the present day, the plurality of self is being valued more. Especially with therapeutic practices like internal family systems, it’s more normalized to acknowledge that everyone has multiple parts to themselves.

When I fused with all of my parts for the first time, we still felt each other. We were one person with full access to each other, but also somehow still parts. We were connected parts and a single person at the same exact time. I thought that maybe I did it wrong, or maybe I wasn’t fully fused yet, but my therapist (who is from a culture where having parts is more normalized) told me that this is just another way that final fusion can be experienced.

So, full integration / final fusion doesn’t mean that parts have to go away. Maybe that’s how some people want to still do it. If someone wants to recover like that, please let them. But this is a type of final fusion that I have never heard talked about before. 

I often felt alone with this experience. I felt like no one would believe me if I brought this to Tumblr, because people can get so aggressive about fusion. Something that can be so beautiful is often shoved aside and attacked. I think it’s important to talk about this, though. Hearing about this can probably really help some people.

I want to share some statements from former DID patients who have fully fused, from this professional study. These statements helped me feel less alone with my experience.

Rebecca:

“Today I feel I am fully aware and present both as the collective of parts and as any individual part. That is, even when a part of me is present, there is a collective awareness of the experience.”

Irene:

“It gradually dawned on me that I could get some relief if I paid enough attention to the voices and their pain. I understood they needed to be heard… . My integration is about being in control, being aware, being able to understand myself. Whenever I’m anxious and I can’t understand why, I turn inside and I ask: What’s going on? I usually get an answer that either helps me deal better with an external problem or guides me as to how to calm myself down… . There is a clear advantage to my situation: I have better access to my subconscious than most people do. I call this ability Creative Disintegration.”

Loraine:

“I think the best way to describe my integration process is as a progressive one. First, there were brief moments of integration; later on I was integrated during some of the time but wasn’t on other occasions. This developed into a period in which I was integrated most of the time and then, into full integration with only momentary periods of disintegration… . It is a process of forward and backward movement on the dissociation continuum, but the general trend is towards a decrease in dissociation… . once you’re integrated, you don’t feel fragmented anymore, but in emergency situations there is a proclivity to utilize the mechanism for brief periods of time to help with coping.”

Some notes from the study:

“It is noteworthy that integration was not always described in terms of a renunciation of dissociative capabilities. Rebecca, Loraine, and even more so, Irene described occasional post-integrational awareness of the old psychological entities that once formed the personality alters… .  Whereas Sara and Tina talked about their lives as ‘one,’ others were clearly continuing to utilize some of the advantages of the dissociative process. It is probable, though, that rather than representing ‘imperfect’ integrations this variance portrays the naturally occurring distribution of dissociative phenomena in the population. It is, perhaps, not only an unreasonable expectation but also an undesirable outcome to have a useful defense mechanism, naturally occurring in society, completely abolished in this particular population.”

I think maybe it’s important to recognize that the boundary between multiplicity and fusion isn’t as clear cut as social media likes to make it out to be.

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one of my favorite pieces of domestic violence language is confabulation: where someone gets triggered by something they can’t identify, finds themselves in a state of fear and distress and rage, spots the closest target, and invents and performs a scenario on the spot that would allow them to discharge their distress at this person and in so doing separate themselves from whatever actually set them off.

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not science i just realized i barely post on here and people are following me now so uh....Sorry i’m not very active. have a cool meme

i should check if asks are open. i will accept those if you want to ask me things

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Debunking Common DID Misconceptions

hi! this is my first really big post, and it’s a topic i’m excited to tackle. this post is, of course, dedicated to common misconceptions about DID, including some really absurd and silly ones i’ve seen online.

disclaimer: i’m a layman, not an expert. please keep this in mind when you read!

Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder (published 2016) is a great review of existing literature about DID, which dispels a number of pervasive myths that exist even in a clinical context. i’ve chosen to kick off this post by summarizing three points from this article which are commonly repeated by the average person - but please refer to the full article, because it’s very thorough, informative, and awesome.

Myth 1: DID is rare. this myth goes first, despite being third in the original article, because it is so incredibly pervasive among laypeople for absolutely no good reason (and it’s one even i myself have fallen for). i’ve seen quoted statistics as low as 0.01%, which is insanely off-base! the average prevalence rate is around 1.1%-1.5%, as reported in a study of a representative sample of 658 individuals from new york state. the DSM-V cites a very similar rate of prevalence overall (1.5% without accounting for gender), likely from the same study.

for perspective, estimated prevalence for BPD is 1.6%, and estimated prevalence of OCD is around 2%. DID is often perceived as “significantly rarer” than these disorders, or rare enough that one is unlikely to ever meet someone with DID, but the evidence hardly bears that out. this is also a dangerous myth for clinicians to buy into, as the belief that one will never encounter a DID patient and subsequent refusal to entertain the notion automatically sets those patients up for failure.

sometimes this runs the other direction, and DID is erroneously stated to be extremely common. higher rates are usually misquotes of studies of specific populations where the expected prevalence is naturally likely to be higher. for example, someone may read this study and believe the general prevalence rate for DID to be 6%, and quote it as such - but in reality, 6% is only the prevalence rate for an already highly traumatized population, and so naturally one would expect to find more DID patients in such a population due to its causation. this is also a mistake i see often, though moreso within the community of people who are diagnosed with or suspect themselves to have DID.

Myth 2: DID is overdiagnosed, and only by DID experts. many psych professionals diagnose DID without specifically specializing in its study or treatment. for example, in an australian study surveying 250 mental health clinicians, 52% had diagnosed DID in a patient before. in addition, DID is more likely to be underdiagnosed than overdiagnosed. studies of dissociative disorders tend to find that participants with DID are often not diagnosed prior to their evaluation in the study, and those with diagnoses are often untreated despite very high levels of functional impairment - in a study of german young adults and adolescents with dissociative disorders, only 16% had even sought treatment despite the severity of their deleterious symptoms.

even clinicians are frequently underinformed or undertrained where dissociative disorders are concerned. when a selection of US clinicians were asked to diagnose a patient based on a case vignette of a patient suffering the symptoms of DID, only around 60% correctly diagnosed DID - the most common misdiagnoses were PTSD, schizophrenia and depression, in descending order. a similar study from northern ireland found discipline also had an impact - when reviewing case vignettes psychologists were most competent, able to correctly identify DID 41% of the time, but psychiatrists correctly identified DID a paltry 7% of the time. unfortunately, skepticism as well as simple lack of training contribute to these poor outcomes for DID patients. people with DID and other dissociative disorders are a neglected demographic, not an inflated one.

Myth 3: DID is not real, and/or induced by therapists. this misconception posits that vulnerable, fantasy-prone patients are influenced by the media, their therapists, or other social influences to believe that they suffer from DID, thus in theory calling into question the disorder’s validity and the traumatic causation usually attributed to DID. it plays into both the iatrogenic and fantasy models of DID, which claim that DID is induced by therapists and is simply due to fantasy proneness, respectively. there is no empirical evidence to support these models anywhere, in any study, and they have been directly challenged and undermined by a number of studies which find DID among participants in cultures where DID is not recognized; in addition, a number of studies have established a strong link between DID and childhood traumatization, which is accordingly the only accepted causation of the disorder. this myth, despite its pervasive influence even in clinical settings, has no basis in reality whatsoever, and is incredibly hurtful to those with dissociative disorders, which as previously discussed are a very vulnerable and neglected psychiatric population. unfortunately, this one is VERY pervasive, and repeated often, especially in the form of “DID is not real.”

Myth 4: DID cannot be diagnosed in any individual under 18. DID is a childhood trauma disorder, and therefore absolutely diagnosable in children. a number of factors are likely to make such a diagnosis difficult, such as ongoing abuse in the home posing obstacles, as well as the typical issues present in diagnosing dissociative disorders. however, there’s no rule against such a diagnosis, and in fact the ISST-D has released guidelines for the treatment of children and adolescents who are diagnosed with dissociative disorders. 

the DSM-V also has a clause in the criteria for DID intended to assist in the proper diagnosis of children. should a child’s symptoms not be better explained by developmentally typical fantasy play, such as when the child’s reported behavior or self-reported identity disturbance is accompanied with amnesia, a diagnosis of DID is indeed possible. 

[Image caption: Screenshot of PDF of the DSM-V, listing the diagnostic criteria for DID. A highlighted portion reads, “Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.”]

Myth 5: DID doesn’t develop until the patient is at least 30. this one is, to be frank, completely stupid. given the disorder is diagnosable in children, professional guidelines exist for the treatment of said children, and it is a disorder associated with childhood traumatization, it is of course safe to say the disorder’s main features can easily develop in childhood. in addition, the DSM-V corroborates this further.

[Image caption: Screenshot of PDF of the DSM-V, in the Development and Course section for DID. A highlighted portion reads, “The full disorder may first manifest at almost any age (from earliest childhood to late life).”]

the basis of this myth is likely due to the usual age of diagnosis - statistically speaking, DID is typically diagnosed between the ages of 29 - 35, often 6 or more years after the first appearance of symptoms. however, the typical age of diagnosis doesn’t necessarily indicate the development and course of a disorder, and the claim that DID does not exist in individuals under 30 is demonstrably false.

Myth 6: Introjected identities such as fictional characters or real-life abusers, non-human alters, child alters, and other “strange” alters do not appear in legitimate DID cases. while the existence of all these parts may seem rather surprising or “out there,” the diversity of substitute beliefs in DID, which gives rise to many identity traits in alters, can be quite broad. many varieties of “strange” alters are documented in literature concerning DID; in the haunted self (not a link to the full text), often considered a seminal work on dissociative disorders and trauma, many such possible alters are listed:

In the literature on DID, various types of dissociative parts of the personality (that are not necessarily mutually exclusive) have been described (e.g., Boon & Van der Hart, 1995; Kluft, 1984, 1996a; Putnam, 1989; Ross, 1997). These include (1) host parts; (2) child parts; (3) protector and helper parts; (4) internal self helpers; (5) persecutor parts, based on introjects of perpetrators; (6) suicidal parts; (7) parts of the opposite sex; (8) promiscuous parts; (9) administrators and obsessive–compulsive parts; (10) substance abuse parts; (11) autistic and handicapped parts; (12) parts with special talents or skills; (13) anesthetic or analgesic parts; (14) imitators and imposters; (15) demons and spirits; (16) animals and objects such as trees; and (17) parts belonging to a different race. Some of these types of parts, such as child, persecutor, and suicidal parts are common, while others are not. All these parts can be regarded as more or less elaborated ANPs or EPs whose characteristics are defined by the action system(s) which mediate their functioning and which involve particular psychological defenses.

while certain “strange” parts may be relatively uncommon, none are impossible, and a wide variety of substitute beliefs can be observed in DID. the existence of strange substitute beliefs in an individual with DID does not negate the validity of their condition.

Myth 7: It is impossible or unusual for an individual with DID to have any awareness of alters. / Internal communication between alters is impossible. this is a very common belief, since it is partially grounded in the diagnostic criteria for DID. surprisingly, however, while amnesia is a diagnostic requirement and such amnesia may very well render the “host part” unaware, total ignorance of dissociated parts is not actually typical! the haunted self addresses this very issue.

Most often, the “host” has some recognition of other parts of the personality, although a degree of amnesia may be involved. However, occasionally, the “host” does not know about the existence of other dissociative parts of the personality, and loses time when others dominate executive control (Putnam, Guroff, Silberman, Barban, & Post, 1986). As C. R. Stern (1984) pointed out, it is more often the case that the “host” actively denies (active nonrealization) evidence of the existence of other dissociated parts of the personality rather than dissociative parts “hiding” themselves from the host. This nonrealization may be so severe that when presented with evidence of other dissociative parts, the host may “flee” from treatment.

additionally, “voices,” or intrusions from the patient’s dissociated parts of the personality, are considered a common aspect of the presentation of DID, as outlined by the DSM-V:

Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their “own” speech and actions, which they may feel powerless to stop (sense of self). Such individuals may also report perceptions of voices (e.g., a child’s voice; crying; the voice of a spiritual being). In some cases, voices are experienced as multiple, perplexing, independent thought streams over which the individual experiences no control. 

these intrusions are mentioned again where differential diagnoses for psychosis are concerned:

Dissociative identity disorder may be confused with schizophrenia or other psychotic disorders. The personified, internally communicative inner voices of dissociative identity disorder, especially of a child (e.g., “I hear a little girl crying in a closet and an angry man yelling at her”), may be mistaken for psychotic hallucinations. Dissociative experiences of identity fragmentation or possession, and of perceived loss of control over thoughts, feelings, impulses, and acts, may be confused with signs of formal thought disorder, such as thought insertion or withdrawal. […]  Persecutory and derogatory internal voices in dissociative identity disorder associated with depressive symptoms may be misdiagnosed as major depression with psychotic features.

Myth 8: It is possible to have DID without prior childhood traumatization. / Childhood traumatization is not the only cause of DID. while some without prior childhood traumatization may perceive themselves as having multiple self-states and compare such an experience with DID, it is outside the scope of this post to prove or disprove the validity of such an assertion, and this is not the focus of myth 7. such an experience is not and should not be confused for DID specifically. the only known cause of DID specifically is childhood traumatization; appropriately, the DSM-V only lists childhood traumatization as a risk factor.

Interpersonal physical and sexual abuse is associated with an increased risk of dissociative identity disorder. Prevalence of childhood abuse and neglect in the United States, Canada, and Europe among those with the disorder is about 90%. Other forms of traumatizing experiences, including childhood medical and surgical procedures, war, childhood prostitution, and terrorism, have been reported.

between interpersonal abuse and other traumatizing experiences, childhood traumatization accounts for 100% of DID cases, and a lack of recall does not constitute a lack of traumatization. such claims are, ultimately, not in keeping with the current scientific understanding of the disorder.

while it is commonly cited that the diagnostic criteria do not include prior traumatization and interpreted to mean that this implies an alternate causation, such an exclusion is intended to account for autobiographical amnesia in many DID patients; many will not recall the trauma responsible for their condition at the time of diagnosis.

furthermore, the central thesis of the haunted self is, to be incredibly simplistic, that such personality divisions as exist in DID are, in fact, due to the same posttraumatic mechanism as in PTSD, that being structural dissociation of the personality.

Dissociative parts are components of a single personality. Even parts that only encompass few experiences still have stable features. In this sense, all dissociative parts have their own “enduring pattern of perceiving, relating to, and thinking about the environment and self.” This is the DSM-IV criterion for dissociative identity or personality state (APA, 1994, p. 487), as well as the definition of personality traits (APA, 1994, p. 630). There is no qualitative principle in the current literature that distinguishes dissociative parts of the personality in DID from dissociative parts of the personality in other trauma-related disorders such as PTSD. We propose the difference is essentially one of degree of complexity and emancipation of the parts of the personality. [emphasis mine.]

while it is differentiated by its complexity in comparison to PTSD, DID is a trauma disorder that exists on the same “scale,” brought into being by the same mechanisms.

in conclusion, DID is often very misunderstood, and sometimes maligned or altogether dismissed. in reality, DID exists, and is a childhood trauma disorder with a number of complex characteristics, which can exist in an individual of any age. hopefully, understanding such misconceptions is helpful to you and any loved ones you may have with DID.

thank you very much for reading this post! i’ve been cautious with my sources, but if you’ve noticed any incorrect or badly summarized information here, please don’t hesitate to point it out - i am very open to making corrections.

EDIT: this post was edited to reflect the fact that the iatrogenic and fantasy models are NOT the same; previously i had erroneously conflated them. a typo in the numbering of myths was also fixed.

[skimmalk]

this is extremely grim but in the wake of the roe v wade decision i really hope that everyone pays a special amount of attention to victims of child sexual abuse. not only is this a difficult time for adult survivors, but in some states this is going to result in extremely dark situations for children who are abused sexually.

i’m not really sure what to say beyond this. please keep this issue in mind and discuss it. it can really feel like no one ever wants to discuss CSA except for survivors because it’s such a dark and uncomfortable topic, but it just results in a lot of traumatized adults and currently endangered children being left without any help or recourse. if you had previously assumed that victims of CSA at any age receive adequate resources and attention, this is me telling you otherwise.

pay special attention to children. pay special attention to adult survivors, many of whom are very distressed right now, and many of whom will similarly be trying to warn you of what happens when victimized children are ignored — and they are almost always ignored.

this repeal does not only endanger the lives and wellbeing of adults. no matter how dark that is, that’s the truth, and i hope people respond accordingly.