Debunking Common DID Misconceptions
hi! this is my first really big post, and itās a topic iām excited to tackle. this post is, of course, dedicated to common misconceptions about DID, including some really absurd and silly ones iāve seen online.
disclaimer: iām 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 DisorderĀ (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. iāve 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 itās 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 itās one even i myself have fallen for). iāve seen quoted statistics as low as 0.01%, which is insanely off-base! the average prevalence rate is around 1.1%-1.5%,Ā 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,Ā estimated prevalence for BPD is 1.6%, and estimated prevalence of OCD is around 2%. DID is often perceived asĀ āsignificantly rarerā 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 ofĀ 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.Ā many psych professionals diagnose DID withoutĀ 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 disorderās 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 ofĀ āDID is not real.ā
Myth 4: DID cannot be diagnosed in any individual under 18.Ā 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,Ā as well as the typical issues present in diagnosing dissociative disorders. however, thereās 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.Ā
the DSM-V also has a clause in the criteria for DID intended to assist in the proper diagnosis of children. should a childās symptoms not be better explained by developmentally typical fantasy play, such as when the childās reported behavior or self-reported identity disturbance is accompanied with amnesia, a diagnosis of DID is indeed possible.Ā
[Image caption: Screenshot of PDF of the DSM-V, listing the diagnostic criteria for DID. A highlighted portion reads,Ā āNote: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.ā]
Myth 5: DID doesnāt develop until the patient is at least 30.Ā 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 disorderās 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, āThe full disorder may first manifest at almost any age (from earliest childhood to late life).ā]
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 doesnāt 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 āstrangeā alters do not appear in legitimate DID cases. while the existence of all these parts may seem rather surprising orĀ āout there,ā the diversity of substitute beliefs in DID, which gives rise to many identity traits in alters, can be quite broad. many varieties of āstrangeā alters are documented in literature concerning DID; in the haunted selfĀ (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 obsessiveācompulsive 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 certainĀ āstrangeā 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.Ā 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 theĀ āhost partā unaware, total ignorance of dissociated parts is not actually typical! the haunted self addresses this very issue.
Most often, the āhostā has some recognition of other parts of the personality, although a degree of amnesia may be involved. However, occasionally, the āhostā 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 āhostā actively denies (active nonrealization) evidence of the existence of other dissociated parts of the personality rather than dissociative parts āhidingā themselves from the host. This nonrealization may be so severe that when presented with evidence of other dissociative parts, the host may āfleeā from treatment.
additionally,Ā āvoices,ā or intrusions from the patientās 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 āownā speech and actions, which they may feel powerless to stop (sense of self). Such individuals may also report perceptions of voices (e.g., a childās 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.Ā
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., āI hear a little girl crying in a closet and an angry man yelling at herā), 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. [ā¦]Ā 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 āenduring pattern of perceiving, relating to, and thinking about the environment and self.ā 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 sameĀ āscale,ā 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! iāve been cautious with my sources, but if youāve noticed any incorrect or badly summarized information here, please donāt 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.
