Dissociative Identity Disorder Cases: Famous and Amazing

Famous cases of dissociative identity disorder include those seen in court and in books. Check these out, plus DID case studies.

There are many famous dissociative identity disorder (DID) cases, probably because people are so fascinated by the disorder. While DID is rare, detailed reports of DID have existed since the 18th century. Famous cases of dissociative identity disorder have been featured on the Oprah Winfrey show, in books and have been seen in criminal trials. (See Real Dissociative Identity Disorder Stories and Videos and Celebrities and Famous People with DID )

A Dissociative Identity Disorder Case in Court: Billy Milligan

In 1977, Billy Milligan was arrested for kidnapping, robbing and raping three women around Ohio State University. After being arrested, he saw a psychiatrist who diagnosed him with DID (See how DID is diagnosed ). It was argued in court that Milligan wasn't guilty as, at the time of the crimes, two other personalities were in control -- Ragen, a Yugoslavian man and Adalana, a lesbian ( Understanding Dissociative Identity Disorder Alters ).

The jury agreed with the defense and Milligan became the first person ever to be found not guilty due to dissociative identity disorder . Milligan was confined to a mental hospital until 1988 when psychiatrists felt that all the personalities had melded together.

An upcoming film, The Crowded Room , will be based on his famous case of dissociative identity disorder.

Famous Cases of DID: Kim Noble

Kim Noble was born in 1960 and, from a young age, was physically abused. As a teenager, she suffered many mental problems and overdosed several times.

It wasn't until her 20s that other personalities began to appear. "Julie" was a very destructive personality that ran Noble's van into a bunch of parked cars. "Hayley," another personality, was involved in a pedophile ring.

In 1995, Noble received a DID diagnosis and has been getting psychiatric help ever since. It's not known how many personalities Noble has as she goes through four or five personalities a day, but it is thought to be around 100. "Patricia" is Noble's most dominant personality and she is a calm and confident woman.

Noble (as Patricia) and her daughter appeared on The Oprah Winfrey Show in 2010. In 2012, she published a book about her experiences: All of Me: How I Learned to Live with the Many Personalities Sharing My Body.

A Dissociative Disorder Case Study

In 2005, a dissociative identity disorder case study of a woman named "Kathy" (not her real name) was published in Journal of the Islamic Medical Association of North America.

Kathy's traumas began when she was three. At that age, she would have terrible nightmares during which her parents would often entertain leaving the child to cry for hours before falling asleep only to awake a few hours later frightened and screaming.

At age four, Kathy found her father in bed with a five-year-old neighbor. At that time, her father convinced her to join in on the sexual activity. Kathy felt guilty and cried for several hours only stopping once she began to attribute what had happened to an alternate personality, Pat. Kathy would insist on being called Pat during the abuse the father committed for the next five years.

At age nine, Kathy's mother discovered Kathy and her father in bed together. Her mother insisted on the child sleeping in her bed every night thereafter leading to a sexual relationship with the child. Kathy could not accept this and created another identity, Vera, who continued the relationship for another five years.

At age 14, Kathy was raped by her father's best friend and began calling herself Debbie. At that time, she became very depressed and mute and was admitted to a hospital (read why some go to dissociative identity (DID) treatment centers ).

According to the case study, "she showed a mixture of depression, dissociation and trance-like symptoms, with irritability and extensive manipulation which caused confusion and frustration among the hospital staff."

At age 18, Kathy became very attached to her boyfriend but her parents forbid her to see him. Kathy then ran away from home to a new town. However, she could not find a job and her need of money drove her to prostitution. She began to call herself Nancy at this point.

The alternate personality Debbie rejected Nancy and forced her to overdose on sleeping pills. It was then that Kathy was admitted to a psychiatric hospital and given the diagnosis of multiple personality disorder (as it was known at the time). (More on the history of dissociative identity disorder here.)

Kathy is now 29, married, and continues to struggle with mental health problems including dissociative episodes.

article references

APA Reference Tracy, N. (2022, January 4). Dissociative Identity Disorder Cases: Famous and Amazing, HealthyPlace. Retrieved on 2024, February 15 from https://www.healthyplace.com/abuse/dissociative-identity-disorder/dissociative-identity-disorder-cases-famous-and-amazing

Medically reviewed by Harry Croft, MD

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ORIGINAL RESEARCH article

Revisiting false-positive and imitated dissociative identity disorder.

\r\nIgor Jacob Pietkiewicz*

  • Research Centre for Trauma & Dissociation, SWPS University of Social Sciences and Humanities, Katowice, Poland

ICD-10 and DSM-5 do not provide clear diagnosing guidelines for DID, making it difficult to distinguish ‘genuine’ DID from imitated or false-positive cases. This study explores meaning which patients with false-positive or imitated DID attributed to their diagnosis. 85 people who reported elevated levels of dissociative symptoms in SDQ-20 participated in clinical assessment using the Trauma and Dissociation Symptoms Interview, followed by a psychiatric interview. The recordings of six women, whose earlier DID diagnosis was disconfirmed, were transcribed and subjected to interpretative phenomenological analysis. Five main themes were identified: (1) endorsement and identification with the diagnosis. (2) The notion of dissociative parts justifies identity confusion and conflicting ego-states. (3) Gaining knowledge about DID affects the clinical presentation. (4) Fragmented personality becomes an important discussion topic with others. (5) Ruling out DID leads to disappointment or anger. To avoid misdiagnoses, clinicians should receive more systematic training in the assessment of dissociative disorders, enabling them to better understand subtle differences in the quality of symptoms and how dissociative and non-dissociative patients report them. This would lead to a better understanding of how patients with and without a dissociative disorder report core dissociative symptoms. Some guidelines for a differential diagnosis are provided.

Introduction

Multiple Personality Disorder (MPD) was first introduced in DSM-III in 1980 and re-named Dissociative Identity Disorder (DID) in subsequent editions of the diagnostic manual ( American Psychiatric Association, 2013 ). Table 1 shows diagnostic criteria of this disorder in ICD-10, ICD-11, and DSM-5. Some healthcare providers perceive it as fairly uncommon or associated with temporary trends ( Brand et al., 2016 ). Even its description in ICD-10 ( World Health Organization, 1993 ) starts with: “This disorder is rare, and controversy exists about the extent to which it is iatrogenic or culture-specific” (p. 160). Yet, according to the guidelines of the International Society for the Study of Trauma and Dissociation ( International Society for the Study of Trauma and Dissociation, 2011 ), the prevalence of DID in the general population is estimated between 1 and 3%. The review of global studies on DID in clinical settings by Sar (2011) shows the rate from 0.4 to 14%. However, in studies using clinical diagnostic interviews among psychiatric in-patients, and in European studies these numbers were lower ( Friedl et al., 2000 ). The discrepancies apparently depend on the sample, the methodology and diagnostic interviews used by researchers.

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Table 1. Diagnostic criteria for dissociative identity disorder.

Diagnosing complex dissociative disorders (DID or Other Specified Dissociative Disorder, OSDD) is challenging for several reasons. Firstly, patients present a lot of avoidance and rarely report dissociative symptoms spontaneously without direct questioning ( Boon and Draijer, 1993 ; International Society for the Study of Trauma and Dissociation, 2011 ; Dorahy et al., 2014 ). In addition, standard mental state examination does not include these symptoms and healthcare professionals do not receive appropriate training in diagnosing dissociative disorders ( Leonard et al., 2005 ). Secondly, complex dissociative disorders are polysymptomatic, and specialists would rather diagnose these patients with disorders more familiar to them from clinical practice, e.g., anxiety disorders, eating disorders, schizophrenia, or borderline personality disorder ( Boon and Draijer, 1995 ; Dell, 2006 ; Brand et al., 2016 ). For these reasons, complex dissociative disorders are underdiagnosed and often mis-diagnosed. For example, 26.5–40.8% of DID patients would already have been diagnosed and treated for schizophrenia ( Putnam et al., 1986 ; Ross et al., 1989 ). On the other hand, because there is so much information about DID in the media (Hollywood productions, interviews and testimonies published on YouTube, blogs), people who are confused about themselves and try to find an accurate diagnosis for themselves may learn about DID symptoms on the Internet, identify themselves with the disorder, and later (even unintentionally) report core symptoms in a very convincing way ( Draijer and Boon, 1999 ). This presents a risk of making a false positive diagnosis, which is unfavorable for the patient, because using treatment developed for DID with patients without autonomous dissociative parts may be inefficient or even reinforce their pathology.

Authors who wrote about patients inappropriately diagnosed with this disorder used terms such as ‘malingering’ or ‘factitious’ DID ( Coons and Milstein, 1994 ; Thomas, 2001 ). According to Draijer and Boon (1999) , both labels imply that patients intentionally simulate symptoms, either for external gains (financial benefits or justification for one’s actions in court) or for other forms of gratification (e.g., interest from others), while in many cases their motivation is not fully conscious. Getting a DID diagnosis can also provide structure for inner chaos and incomprehensible experiences, and be associated with hope and belief it is real. On the other hand, diagnostic errors often result in inappropriate treatment plans and procedures.

Already in 1995 Boon and Draijer stressed that a growing number of people self-diagnosed themselves based on information from literature and the Internet, and reported symptoms by the book during psychiatric or psychological assessment. Based on their observation of 36 patients in whom DID had been ruled out after applying the structured clinical interview SCID-D, these clinicians identified differences between genuine and imitated DID. They classified their participants into three groups: (1) borderline personality disorder, (2) histrionic personality disorder, or (3) persons with severe dissociative symptoms but not DID. Participants in that study reported symptoms similar to DID patients, including: amnesia (but only for unacceptable behavior), depersonalisation, derealisation, identity confusion, and identity alteration. However, they presented themselves and interacted with the therapist in very different ways. While DID patients are usually reluctant to talk about their symptoms and experience their intrusions as shameful, people who imitated DID were eager to present their problems, sometimes in an exaggerated way, in an attempt to convince the clinician that they suffered from DID ( Boon and Draijer, 1995 ; Draijer and Boon, 1999 ). Similar observations were expressed by Thomas (2001) saying that people with imitated DID can present their history chronologically, using the first person even when they are highly distressed or allegedly presenting an altered personality, and are comfortable with disclosing information about experiences of abuse. They can talk about intrusions of dissociative parts, hearing voices or difficulties controlling emotions, without shame.

Unfortunately, ICD-10, ICD-11, and DSM-5 offer no specific guidelines on how to differentiate patients with personality disorders and dissociative disorders by the manner in which they report symptoms. There are also limited instruments to distinguish between false-positive and false-negative DID. From the clinical perspective, it is also crucial to understand the motives for being diagnosed with DID, and disappointment when this diagnosis is disconfirmed. Accurate assessment can contribute to developing appropriate psychotherapeutic procedures ( Boon and Draijer, 1995 ; Draijer and Boon, 1999 ). Apart from observations already referred to earlier in this article, there are no qualitative analyses of false-positive DID cases in the past 20 years. Most research was quantitative and compared DID patients and simulators in terms of cognitive functions ( Boysen and VanBergen, 2014 ). This interpretative phenomenological analysis is an idiographic study which explores personal experiences and meaning attributed to conflicting emotions and behaviors in six women who had previously been diagnosed with DID and referred to the Research Centre for Trauma and Dissociation for re-evaluation. It explores how they came to believe they have DID and what had led clinicians to assume that these patients could be suffering from this disorder.

Materials and Methods

This study was carried out in Poland in 2018 and 2019. Rich qualitative material collected during in-depth clinical assessments was subjected to the interpretative phenomenological analysis (IPA), a popular methodological framework in psychology for exploring people’s personal experiences and interpretations of phenomena ( Smith and Osborn, 2008 ). IPA was selected to build a deeper understanding of how patients who endorsed and identified with dissociative identity disorder made sense of the diagnosis and what it meant for them to be classified as false-positive cases during reassessment.

Interpretative phenomenological analysis uses phenomenological, hermeneutic, and idiographic principles. It employs ‘double hermeneutics,’ in which participants share their experiences and interpretations, followed by researchers trying to make sense and comment on these interpretations. IPA uses small, homogenous, purposefully selected samples, and data are carefully analyzed case-by-case ( Smith and Osborn, 2008 ; Pietkiewicz and Smith, 2014 ).

This study is part of a larger project examining alterations in consciousness and dissociative symptoms in clinical and non-clinical groups, held at the Research Centre for Trauma & Dissociation, financed by the National Science Centre, and approved by the Ethical Review Board at the SWPS University of Social Sciences & Humanities. Potential candidates enrolled themselves or were registered by healthcare providers via an application integrated with the website www.e-psyche.eu . They filled in demographic information and completed online tests, including: Somatoform Dissociation Questionnaire (SDQ-20, Pietkiewicz et al., 2018 ) and Trauma Experiences Checklist ( Nijenhuis et al., 2002 ). Those with elevated SDQ-20 scores (above 28 points) or those referred for differential diagnosis were consulted and if dissociative symptoms were confirmed, they were invited to participate in an in-depth clinical assessment including a series of interviews, video-recorded and performed at the researcher’s office by the first author who is a psychotherapist and supervisor experienced in the dissociation field. In Poland, there are no gold standards for diagnosing dissociative disorders. The first interview was semi-structured, open-ended and explored the patient’s history, main complaints and motives for participation. It included questions such as: What made you participate in this study? What are your main difficulties or symptoms in daily life? What do you think caused them? Further questions were then asked to explore participants’ experiences and meaning-making. This was followed by the Trauma and Dissociation Symptoms Interview (TADS-I, Boon and Matthess, 2017 ). The TADS-I is a new semi-structured interview intended to identify DSM-5 and ICD-11 dissociative disorders. The TADS-I differs in several ways from other semi-structured interviews for the assessment of dissociative disorders. Firstly, it includes a significant section on somatoform dissociative symptoms. Secondly, it includes a section addressing other trauma-related symptoms for several reasons: (1) to obtain a more comprehensive clinical picture of possible comorbidities, including symptoms of PTSD and complex PTSD, (2) to gain a better insight into the (possible) dissociative organization of the personality: patient’s dissociative parts hold many of these comorbid symptoms and amnesia, voices or depersonalisation experiences are often associated with these symptoms; and (3) to better distinguish between complex dissociative disorders, personality disorders and other Axis I disorders and false positive DID. Finally, the TADS-I also aims to distinguish between symptoms of pathological dissociation indicating a division of the personality and symptoms which are related to a narrowing or a lowering of consciousness, and not to the structural dissociation of the personality. Validation testing of the TADS-I is currently underway. TADS interviews ranging from 2 to 4 h were usually held in sessions of 90 min. Interview recordings were assessed by three healthcare professionals experienced in the dissociation field, who discussed each case and consensually came up with a diagnosis based on ICD-10. An additional mental state examination was performed by the third author who is a psychiatrist, also experienced in the differential diagnosis of dissociative disorders. He collected medical data, double-checked the most important symptoms, communicated the results and discussed treatment indications. Qualitative data collected from six patients out of 85 were selected for this interpretative phenomenological analysis, based on the following criteria for inclusion, which could ensure a homogenous sample expected of IPA studies – (a) female, (b) previously diagnosed or referred to rule in/out DID, (c) endorsement and identification with DID, (d) dissociative disorder disconfirmed in the assessment. Interviews with every participant in this study ranged from 3 h 15 min to 7 h 20 min (mean: 6 h).

Participants

Participants of this IPA were six female patients aged between 22 and 42 years who were selected out of 86 people examined in a larger study exploring dissociation and alterations in consciousness in clinical and non-clinical groups. (Participants in the larger study met criteria of different diagnoses and seven among them had ‘genuine’ DID). These six patients did not meet DID criteria on the TADS-I interview but believed themselves that they qualified for that diagnosis. Four of them had higher education, two were secondary school graduates. All of them registered in the study by themselves hoping to confirm their diagnosis but two (Olga and Katia) were referred by psychiatrists, and the others by psychotherapists. All of them traveled from far away, which showed their strong motivation to participate in the assessment. Four had previously had psychiatric treatment and five had been in psychotherapy due to problems with emotional regulation and relationships. In the cases of Victoria and Dominique, psychotherapy involved working with dissociative parts. None of them recalled any physical or sexual abuse, but three (Dominique, Victoria, and Mary), following therapists’ suggestions, were trying to seek such traumatic memories to justify their diagnosis. They all felt emotionally neglected by carriers in childhood and emotionally abused by significant others. None of them reported symptoms indicating the existence of autonomous dissociative parts. None had symptoms indicating amnesia for daily events, but four declared not remembering single situations associated with conflicting emotions, shame, guilt, or conversations during which they were more focused on internal experiences rather than their interlocutors. None experienced PTSD symptoms (e.g., intrusive traumatic memories and avoidance), autoscopic phenomena (e.g., out-of-body experiences), or clinically significant somatoform symptoms. None had auditory verbal hallucinations but four intensely engaged in daydreaming and experienced imagined conversations as very real. All of them had been seeking information about DID in literature and the Internet. For more information about them see Table 2 . Their names have been changed to protect their confidentiality.

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Table 2. Study participants.

The Researchers

The principal investigator (IJP) is a psychotherapist, supervisor, and researcher in the field of community health psychology and clinical psychology. The second co-investigator (RT) is a psychiatrist, psychotherapist, and supervisor. The third co-investigator (SB) is a clinical psychologist, psychotherapist, supervisor, and a consulting expert in forensic psychology, who also developed the TADS-I. They are all mentors and trainers of the European Society for Trauma and Dissociation, with significant expertise in the assessment of post-traumatic conditions. The first co-investigator (AB) has a master’s degree in psychology and is a Ph.D. candidate. She is also a psychotherapist in training. All authors coded and discussed their understanding of data. Their understanding and interpretations of symptoms reported by participants were influenced by their background knowledge and experience in diagnosing and treating patients with personality disorders and dissociative disorders.

Data Analysis

Verbatim transcriptions were made of all video recordings, which were analyzed together with researchers’ notes using qualitative data-analysis software – NVivo11. Consecutive analytical steps recommended for IPA were employed in the study ( Pietkiewicz and Smith, 2014 ). For each interview, researchers watched the recording and carefully read the transcript several times. They individually made notes about body language, facial expressions, the content and language use, and wrote down their interpretative comments using the ‘annotation’ feature in NVivo10. Next, they categorized their notes into emergent themes by allocating descriptive labels (nodes). The team then compared and discussed their coding and interpretations. They analyzed connections between themes in each interview and between cases, and grouped themes according to conceptual similarities into main themes and sub-themes.

Credibility Checks

During each interview, participants were encouraged to give examples illustrating reported symptoms or experiences. Clarification questions were asked to negotiate the meaning participants wanted to convey. At the end of the interview, they were also asked questions to check that their responses were thorough. The researchers discussed each case thoroughly and also compared their interpretative notes to compare their understanding of the content and its meaning (the second hermeneutics).

Participants in this study explained how they concluded they were suffering from DID, developed knowledge about the syndrome and an identity of a DID patient, and how this affected their everyday life and relationships. Five salient themes appeared in all interviews, as listed in Table 3 . Each theme is discussed and illustrated with verbatim excerpts from the interviews, in accordance with IPA principles.

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Table 3. Salient themes identified during the interpretative phenomenological analysis.

Theme 1: Endorsement and Identification With the Diagnosis

All six participants hoped to confirm they had DID. They read books and browsed the Internet seeking information about dissociation, and watched YouTube videos presenting people describing multiple personalities. Dominique, Victoria, Mary, and Karina said that a mental health professional suggested this diagnosis to them. Dominique remembers consulting a psychiatrist when she was 15, because she had problems controlling anger at home or in public places. She initially found descriptions of borderline personality captured her experiences well enough, but a psychiatrist refuted the idea and recommended further diagnostics toward a dissociative disorder. However, the girl refused to go to hospital for observation.

During an argument with my mother I felt as if some incredible force took control and I smashed the glass in the cabinet with my hand. It was like being under control of an alien force. I started reading about borderline and I thought I had it. I found a webpage about that and told my mother I should see a psychiatrist. I went for a consultation and told her my story. This lady said: “Child, you don’t have borderline, but multiple personality.” She wanted to keep me in the psychiatric unit but I did not agree to stay for observation. (Dominique).

This led Dominique to research the new diagnosis. Karina also said she was encouraged to seek information about DID, when a doctor suggested she might be suffering with it.

When I was 11, I had problems at school and home. Other children made fun of me. My mom took me to a doctor and he said I had borderline, but later I was diagnosed with an anxiety disorder. That doctor also suggested I had DID and told me that I should read more about this diagnosis. (Karina).

Victoria and Mary shared similar stories about psychotherapists suggesting the existence of dissociative parts, having readily accepted this new category as a good explanation for aggressive impulses or problems with recalling situations evoking guilt or shame. Dominique and Victoria stressed, however, that, apart from feeling emotionally abandoned, they could not trace any significant traumas in their early childhoods, although therapists maintained that such events must be present in dissociative patients.

I have no idea why I have this [DID]. My therapist looked for evidence of childhood trauma, which sounds like the easiest explanation, but I don’t feel I had any horrific memories which I threw out of my consciousness. (Victoria).

Katia and Olga had used psychiatric treatment for anxiety and depression for years. After exploring information about different mental disorders they concluded they had DID. They thought there was a similarity between their personal experiences and those of people publishing testimonials about multiple personalities.

I tried to understand this battle inside, leading me to stagnation. I didn’t know how to describe that but I recently bought a book Healing the fragmented selves of trauma survivors , and everything was explained there. Some of these things I have discovered myself and some were new to me. (Olga).

Subsequently, Katia presented to her doctor a review of literature about DID, trying to persuade him that she had this disorder.

Theme 2: Using the Notion of Dissociative Parts to Justify Identity Confusion and Conflicting Ego-States

Once participants had embraced the idea of having multiple personalities, they seemed to construct inner reality and justify conflicting needs, impulses or behaviors as an expression of dissociative parts. They referred to being uncertain about who they were and having difficulties recognizing personal emotions, needs or interests. Some of them felt it was connected to a negative cognition about themselves as worthless, unimportant, and not deserving to express what they felt or wanted. Victoria said she would rather define herself through the eyes of others:

My therapist asked what I wanted or needed. It turned out that without other people’s expectations or preferences to which I normally adjust, I wouldn’t know who I am or what I want. I usually engage in my friends’ hobbies and do what I think gives them pleasure. Otherwise, I think they will not like me and reject me, because I have nothing to offer. (Victoria).

Since a young age, Dominique tended to immerse herself in a fantasy world, developing elaborated scenarios about people living in a youth center administered by a vicious boss. Different characters in her ‘Story’ represented specific features, interests and plans she had.

Well, there is John who is a teacher and researcher. He teaches mathematics. I have no skills in maths at all. Tim is a philosopher and would like to train philosophers, enroll doctoral studies. He would like me to study philosophy but the rest of the system wants me to be a worrier. Ralf is a caring nurse and would like to become a paramedic. It is difficult to reconcile all these different expectations. Whoever comes up front, then I have these ideas. (Dominique).

Dominique neither had amnesia nor found evidence for leading separate lives and engaging herself in activities associated with her characters. She maintained her job as a playwright, and merely imagined alternative scenarios of her life, expressed by her inner heroes. In other parts of the interview, she referred to them as ‘voices inside,’ but admitted she never heard them acoustically. They were her own vivid thoughts representing different, conflicting opinions or impulses.

Katia said she felt internally fragmented. There were times when she engaged in certain interests, knowledge and skills, but she later changed her goals. Fifteen years ago she gave up her academic career and went on sickness benefit when she became disabled due to medical problems; she experienced this as a great loss, a failure, which affected her sense of identity and purpose.

In recent years I have a growing sense of identity fragmentation. I have problems with defining my identity because it changes. I used to feel more stable in the past. I had these versions of myself which were more dominating, so I had a stronger sense of identity. For example, 20 years ago there was this scientist. I was studying and felt like a scientist, attending conferences. Now I don’t have that and I don’t know who I am. […] I also have changing interests and hobbies because of different personalities. Long ago I liked certain music, played the guitar, sang songs. I don’t do that anymore, I suddenly lost interest in all that. (Katia).

She described changes in her professional and social lives in terms of switches between dissociative parts. Although she maintained the first person narrative (“I was studying,” “I played,” or “I sang”), indicating some sense of continuity, she thought it proved the existence of two or more distinct personalities.

Participants also reported thoughts, temptations, impulses or actions which seemed to evoke conflicting feelings. Attributing them to ‘something inside that is not-me’ could free them from guilt or shame, so they used a metaphor of someone taking over, logging in, or switching. Dominique thought it was inappropriate to express disappointment or anger, but she accepted the thought that her dissociative parts were doing this.

When I’m angry at my therapist, it is not really me but somebody inside who gets angry easily. Greg often switches on in such situations and says: “Tell her this and this”. […] I went to a shop once and discovered that the price on the label was not for a whole package of batteries but a single one. And suddenly Greg switched on and had a row with the cashier. I mean, I did it, but wound up by his anger. This is so weird, I wouldn’t react like that. They just charged incorrectly and I would normally ignore that but Greg said: “I give a shit about their mistakes. I won’t accept that.” What a failure! (Dominique).

Mary said she had parts that expressed anger, sadness, and needs associated with attachment. She observed them and allowed them to step in, when situations required.

There were situations in my life when the teenager must have been active. She protected me. She is ready to fight; I am not like that at all. I hate violence, and that teenager likes using force to protect me. […] My therapist suggested I call her after this interview if I do not feel well. I didn’t accept that but the [inner] girls got upset and told me I needed her help. They made me comply, so I agreed to call her if I do not feel well. It has always been like this. (Mary).

During assessment, no participant provided evidence for the existence of autonomous dissociative parts. It seems that the inner characters described by them personified unintegrated ego-states which used to evoke conflicting feelings.

Theme 3: Exploring Personal Experiences via the Lens of Dissociation

Reading books, websites and watching videos of people who claimed to have DID, encouraged them to compare themselves, talk about and express ‘multiple personalities.’ The participants became familiar with specialist terms and learned about core symptoms mentioned in psychiatric manuals.

I read First person plural which helped me understand what this is all about. The drama of the gifted child and The body keeps the score . More and more girls started to appear. There is a 6-month old baby which showed up only 2 months ago, a sad 11-year old teenager, and a 16-year old who thinks I am a loser. I was a teenager like that. Now she is having problems and becoming withdrawn there are fewer switches, because she knows we need to help the little one first. (Mary).

Olga was also inspired by books. Not only did she find similarities to trauma survivors but she made new discoveries and thought there were other experiences she had been unaware of earlier. Victoria started using techniques which literature recommended for stabilization in dissociative disorders. She said these books helped her understand intense emotions and improve concentration.

This explains everything that happens to me, why I get so angry. I also found anchors helpful. I focus on certain objects, sounds or smells which remind me where I am, instead of drifting away into my thoughts. (Victoria).

It seemed that exploring information about DID encouraged changes in participants’ clinical presentation. At first, they merely struggled with emotional liability or detachment, internal conflicts, and concentration problems. Later, they started reporting intrusions of dissociative parts or using clinical terms (e.g., flashback) for experiences which were not necessarily clinical symptoms. Dominique said that the characters of her story would often ‘log in’ and take control. She demonstrated that during the interview by changing her voice and going into a ‘trance.’ She created her own metaphors, explaining these experiences and comparing them with those described in literature. She stressed that she never had amnesia and remained aware of what was happening during her ‘trance.’

I think it is a form of dissociation on the emotional level. I read a lot… The minds of Billy Milligan or First person plural . For sure, I do not have an alteration of personality. I have co-consciousness. My theory is, we are like a glove, we all stem from one trunk, but we are like separate fingers. (Dominique).

While participants maintained they had flashbacks, they understood them as sudden recollections of past memories but not necessarily related to trauma. Katia said she recently remembered the picture of the house and garden where she played as a child and associated these experiences with moments of joy. Karina also exemplified her flashbacks with ‘intrusions of happy memories’ which belonged to other personalities:

Sometimes I begin to laugh but this is not my laughter, but the laughter of sheer joy. Someone inside me is very happy and wants to talk about happy childhood memories, make jokes. (Karina).

Mary said a child part of her was responsible for flashbacks and making comments about current situations. However, she later denied hearing voices or having any other Schneider’s symptoms.

I can hear her comments, that she does not like something. I can be flooded by emotions and have flashbacks associated with that child. For example, there is a trigger and I can see things that this child has seen. She is showing me what was happening in her life. (Mary).

Participants discussed their dissociative parts, their names and features, exhibiting neither avoidance nor fear or shame. On the contrary, they seemed to draw pleasure by smiling, showing excitement and eagerness to produce more examples of their unusual experiences. At the beginning of the interview, Karina was very enthusiastic and said, “My heart is beating so fast, as if I were in fight-or-flight mode.”

Theme 4: Talking About DID Attracts Attention

Not only were multiple personalities a helpful metaphor for expressing conflicting feelings or needs (already mentioned in Theme 2), but they also became an important topic of conversations with family or friends.

My husband says sometimes: “I would like to talk to the little girl.” He then says that I start behaving differently. I also talk to my therapist using different voices. Sometimes, she addresses them asking questions. If questions are asked directly, they respond, but there are times I do not allow them to speak, because the teenager part can be very mean and attacks people. (Mary).

It may have been easier for Mary to express her needs for dependency and care by ascribing them to a little girl and, because she felt awkward about feeling angry with the therapist, attributing hostile impulses to a teenager could give her a sense of control and reduce guilt. Karina decided to create a video-blog for documenting dissociative parts, and shared her videos with people interested in DID. She said she was surprised to find clips in which she looked dreadful, having her make-up smeared all over the face, because she had no memory of doing that. However, she showed no signs that it bothered her. She discussed the videos with her best friend, a DID fan who had encouraged her to enroll in the study in order to confirm her diagnosis. They were collecting evidence to support the idea that she had a dissociative disorder, which she presented one by one, before being asked about details.

Mark [her friend] reads a lot about DID. He says I sometimes talk in a high voice which is not the way I usually talk. He refers to us as plural. […] In some of these videos I do not move or blink for a minute. I look at some point and there is no expression on my face. I can remember things until this moment, and later I discover myself looking like something from Creepypastas. I am so sorry for people who have to see this… and I found my diary. I have been writing diaries since I was seven. I sometimes have no memory for having written something. I need to find these notes because I would like to write a book about a fantasy world and inner conflicts. (Karina).

Dominique and Katia also wrote journals to record dissociative experiences. Katia hoped to be recognized as an expert-by-experience and develop her career in relation to that. She brought with her a script of a book she hoped to publish 1 day.

Theme 5: Ruling Out DID Leads to Disappointment or Anger

Four participants were openly disappointed that their DID diagnosis was not confirmed. They doubted if their descriptions were accurate enough, or they challenged the interviewer’s understanding of the symptoms. Katia also suggested that she was incapable of providing appropriate answers supporting her diagnosis due to amnesia and personality alterations.

Do you even consider that I might give different answers if you had asked these questions 2 or 5 years ago? I must have erased some examples from my memory and not all experiences belong to me. I know that people can unconsciously modify their narratives and that is why I wanted an objective assessment. […] Nobody believed I was resistant to anesthetics until I was diagnosed with some abnormalities. It was once written in my medical report that I was a hypochondriac. One signature and things become clear to everyone. Sometimes it is better to have the worst diagnosis, but have it. (Katia).

She expected that the diagnosis would legitimize her inability to establish satisfactory relationships, work, and become financially independent. For this reason, she also insisted that the final report produced for her should contain information about how she felt maltreated by family or doctors, and revealed her hopes to claim damages for health injury. Mary and Karina were also upset that the interviewers did not believe they had DID.

Can you try to imagine how hard it is? I am not making things up? You don’t believe me. I am telling you things and you must be thinking, from the adult perspective: “You are making this up.” Nothing pisses me off more than someone who is trying to prove to others that they have just imagined things. They [dissociative parts] feel neglected again, as always! (Mary).

Karina tried to hide her disappointment and claimed she was glad she didn’t have a severe mental illness. However, she thought she would need to build another theory explaining her symptoms. After the interview, she sent more videos trying to prove the assessment results were not accurate.

What about my problems then? I am unable to set boundaries, I have anxiety, I fear that a war might break out. If this is not dissociation, then what? I had tests and they ruled out any neurological problems. I came here and ruled out another possibility. It is some information but I have not heard anything new. (Karina).

Only Victoria seemed relieved that her DID diagnosis was not confirmed. She was happy to discuss how attachment problems or conflicts with expressing emotions and needs affected her social life and career, and receive guidelines for future treatment. She felt liberated from having to uncover childhood traumas that her therapist expected her to have as a dissociative patient.

I was hoping that you would find another explanation for my problems… for what is wrong with me, why I feel so sensitive or spaced out, because it is annoying. I would like to know what is going on. I don’t think I’ve had any severe trauma but everybody wants to talk about trauma all the time. (Victoria).

ICD-10 and DSM-5 provide inadequate criteria for diagnosing DID, basically limited to patients having distinct dissociative identities with their own memories, preferences and behavioral patterns, and episodes of amnesia ( American Psychiatric Association, 2013 ; World Health Organization, 1993 ). Clinicians without experience of DID may therefore expect patients to present disruptions of identity during a consultation and spontaneously report memory problems. However, trauma specialists view DID as a ‘disorder of hiddenness’ because patients often find their dissociative symptoms bizarre and confusing and do not disclose them readily due to their shame and the phobia of inner experiences ( Steele et al., 2005 , 2016 ; Van der Hart et al., 2006 ). Instead, they tend to undermine their significance, hide them and not report them during consultations unless asked about them directly. Dissociative patients can also be unaware of their amnesia and ignore evidence for having done things they cannot remember because realizing that is too upsetting. Contrary to that, this study and the one conducted in 1999 in the Netherlands by Draijer and Boon, show that some people with personality disorders enthusiastically report DID symptoms by the book, and use the notion of multiple personalities to justify problems with emotional regulation, inner conflicts, or to seek attention. As with Dutch patients, Polish participants were preoccupied with their alternate personalities and two tried to present a ‘switch’ between parts. Their presentations were naïve and often mixed with lay information on DID. However, what they reported could be misleading for clinicians inexperienced in the dissociation field or those lacking the appropriate tools to distinguish a genuine dissociative disorder from an imitated one.

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, 1993 ; Laddis et al., 2017 ). 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. Therapists’ observations and countertransference may help in assessing the quality of avoidance: How openly or easily do patients report symptoms or adverse life experiences? 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). During the interviews, it became clear that some perceived having an exotic diagnosis as an opportunity for seeking attention and feeling unique, exhibiting the drama of an ‘unseen child’ (see section “Theme 4”).

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. In addition to avoidance, this is another characteristic PTSD feature observed in the clinical presentation of DID patients ( Van der Hart et al., 2010 ). Interestingly, participants in this study showed no evidence for intrusions (images, emotions or somatosensory experiences directly related to trauma), but rather problems with emotional regulation (illustrated in sections “Themes 1 and 2”). 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., 2018 ). Although three participants in this study had very high scores in SDQ-20 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., 2009 ; Longden et al., 2019 ). The voices usually belong to dissociative parts and comment on actions, express needs, likes and dislikes, and encourage self-mutilation. Subsequently, there may be conflicts between ‘voices,’ and the relationship with them is quite complex. Dorahy et al., 2009 observe that auditory hallucinations are more common in DID than in schizophrenia. In dissociative patients they are more complex and responsive, and already appear in childhood. Specifically, child voices are also to be expected in DID (97% in comparison to 6% in psychosis). None of our participants reported auditory hallucinations although one (Dominique) said she had imaginary friends from childhood. While this could sound like a dissociative experience, exploring their experiences showed she had a tendency to absorb herself in her fantasy world and vividly imagine characters in her story (see section “Theme 2”).

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., 2005 ). Sudden switches between dissociative personalities may occur only when the patient is triggered and cannot exercise enough control to hide his or her symptoms. Two participants in this study (Dominique and Karina) tried to present ‘alternate personalities’ and they actually announced this would happen, so that the interviewer did not miss them. Later on, they could relate to what happened during the alleged switch (no amnesia), maintaining the first-person perspective (I was saying/doing). Contrary to that, dissociative patients experience much shame and fear of disclosing their internal parts ( Draijer and Boon, 1999 ). If they become aware that switches had occurred, they try to make reasonable explanations for the intrusions of parts and unusual behavior (e.g., I must have been very tired and affected by the new medicine I am taking).

Dell (2006) 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., 2017 ). 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.g., doing shopping or cleaning, socializing). According to Laddis et al. (2017) there are different mechanisms underlying memory problems in personality and dissociative disorders.

Use of Language

Participants in this study often used clinical jargon (e.g., flashbacks, switches, and feeling depersonalized) which indicates they had read about dissociative psychopathology or received psycho-education. However, they often had lay understanding of clinical terms. A good example in this study was having ‘flashbacks’ of neutral or pleasant situations which had once been forgotten. 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.

Depersonalisation

Detachment from feelings and emotions, bodily sensations and external reality is often present in various disorders ( Simeon and Abugel, 2006 ). While these phenomena have been commonly associated with dissociation, Holmes et al. (2005) stress the differences between detachment (which can be experienced by both dissociative and non-dissociative patients) and compartmentalisation, associated with the existence of dissociative parts. Allen et al. (1999) also stress that extreme absorptive detachment can interfere with noticing feelings and bodily sensations, and also memory. 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. Some of their statements might have been misleading; for example, when they attributed anger attacks to other parts, not-me (see: Dominique in section “Theme 2”). 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. Literature on multiple personalities and therapy focused on them, and using expressions such as ‘parts’, ‘dissociating’, ‘switches,’ can also encourage demonstrating such symptoms. There are also secondary gains explained in this study, such as receiving attention and care. Draijer and Boon (1999) observe that people with borderline features justified shameful behavior and avoided responsibility by attributing their actions to ‘alter personalities.’ Such people can declare amnesia for their outbursts of anger, or hitting partners. 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, 1999 ). 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.

Limitations and Further Directions

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-20, 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. Clinicians also need to go beyond the face value of a patient’s responses, ask for specific examples, and notice one’s own countertransference. Draijer and Boon (1999) 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.

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Table 4. Red flags for identifying false-positive or imitated DID.

While psycho-education is considered a crucial element in the initial treatment of dissociative disorders ( Van der Hart et al., 2006 ; Howell, 2011 ; Steele et al., 2016 ), patients whose diagnosis has not been confirmed by a thorough diagnostic assessment should not be encouraged to develop knowledge about DID symptomatology, because this may affect their clinical presentation and how they make meaning of their problems. Subsequently, this may lead to a wrong diagnosis and treatment, which can become iatrogenic.

Data Availability Statement

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, [email protected] .

Ethics Statement

The studies involving human participants were reviewed and approved by Ethical Review Board at the SWPS University of Social Sciences and Humanities. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

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.

Grant number 2016/22/E/HS6/00306 was obtained for the study “Interpretative phenomenological analysis of depersonalization and derealization in clinical and non-clinical groups.”

Conflict of Interest

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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Keywords : dissociative identity disorder (DID), false-positive cases, personality disorder, dissociation, differential diagnosis

Citation: Pietkiewicz IJ, Bańbura-Nowak A, Tomalski R and Boon S (2021) Revisiting False-Positive and Imitated Dissociative Identity Disorder. Front. Psychol. 12:637929. doi: 10.3389/fpsyg.2021.637929

Received: 04 December 2020; Accepted: 14 April 2021; Published: 06 May 2021.

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Copyright © 2021 Pietkiewicz, Bańbura-Nowak, Tomalski and Boon. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Igor Jacob Pietkiewicz, [email protected]

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Three Cases of Dissociative Identity Disorder and Co-Occurring Borderline Personality Disorder Treated with Dynamic Deconstructive Psychotherapy

  • Susan M. Chlebowski , M.D. ,
  • Robert J. Gregory , M.D.

SUNY Upstate Medical University, Syracuse, NY.

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E-mail Address: [email protected]

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

Introduction

Dissociative Identity Disorder (DID) is a relatively common disorder, especially in clinical populations. Johnson and colleagues found the prevalence to be 1.5% in a population of 658 adults in a community-based longitudinal study ( Johnson, Cohen, Kasen, & Brook, 2006 ). Foote and colleagues (2006) noted the prevalence of DID to be 6% in a study of inner city, psychiatric outpatients. Among adult psychiatric inpatients, estimates of prevalence have varied from 0.9 to 5% ( Gast, Rodewald, Nickel, & Emrich, 2001 ; Rifkin, Ghisalbert, Dimatou, Jin, & Sethi, 1998 ; Ross, 1991 ).

Figure 1.

Figure 1. DISSOCIATIVE EXPERIENCES SCALE SCORES OF 3 PATIENTS WITH DISSOCIATIVE IDENTITY DISORDER

The conceptualization and treatment of DID has been rife with controversy, reflecting in part a dearth of empirical research. A PsychINFO search using the terms dissociative identity disorder and clinical trials indicated no published randomized controlled trials. Various treatment models have been applied to clients with DID, including psychodynamic psychotherapy, cognitive behavioral therapy (CBT), hypnosis, group therapy and family therapy. However, there is little empirical support for any model. In 1986, Putnam and colleagues published the results of a questionnaire given to 92 clinicians treating 100 cases of DID. Thirty six percent of the therapists asked to speak with specific alters, 32% awaited for alters to announce themselves, and 20% used hypnosis to elicit alters. Employing a survey of clinicians treating 305 clients with DID, Putnam and Lowenstein (1993) reported that individual therapy with hypnosis was the most common form of treatment. The average client was seen twice a week for an average of 3.8 years.

Many therapists utilize techniques that include speaking directly with the different alters. ( Caul, 1984 ; Congdon, Hain, & Stevenson, 1961 ; Fine, 1991 ; Kluft, 1987 ; Putnam, 1989 ; Ross et al., 1990 ; Ross and Gahan, 1988 ). Other therapists warn against attending to alters ( Gruenewald, 1971 ; Horton & Miller, 1972 ). There is concern that any acknowledgement of alters can result in “mutual shaping” of present or additional personalities. ( Greaves, 1980 ; Spanos, 1985; Sutcliffe & Jones, 1962 ; Taylor and Martin, 1944 ).

Although hypnosis is a commonly used modality, evidence supporting its use is based primarily on case reports and a single case series ( Coons, 1986 ). When using hypnosis, the therapist attempts to uncover and resolve traumatic experiences linked to specific alters. Coons (1986) reported on the outcomes of 20 clients treated with hypnosis and psychodynamic therapy. Based on global impressions by the treating clinicians, 5 of 20 clients with DID were reported to have “complete integration” over a 3-year period of treatment.

Another approach with preliminary empirical support is cognitive analytic therapy (CAT). In CAT practice, descriptions of dysfunctional relationship patterns and of transitions between them are worked out by therapist and client at the start of therapy and are used by both throughout its course ( Ryle & Fawkes, 2007 ). Employing a single-case experimental design, Kellet (2005) utilized the dissociative experiences scale (DES) to measure the effectiveness of CAT during 16 months with one client. The client received the standard CAT design of 24 sessions with four follow-up sessions. The client developed insight, had reduced fragmentation, and improved self-manageability, but did not establish integration.

The model with the largest empirical basis has been Kluft’s (1999) individualized and multi-staged treatment. It involves making contact and agreement among alters to work towards integration, accessing and processing trauma with occasional use of hypnosis, learning new coping skills, and eventually fusion among the alters and the self. Using this model, Kluft (1984) describes treatment of 123 DID clients over a decade of observation. Of the clients, 83 (67%) achieved fusion, including 25 who sustained fusion over at least a 2-year-follow-up period without any residual or recurrent dissociative symptoms. Kluft noted that individuals with borderline personality traits were less likely to achieve stable fusion. A major limitation of his study was the lack of valid outcome measures or formalized assessment of adherence to the treatment protocol.

Dissociative symptoms commonly co-occur with borderline personality disorder (BPD) and the prevalence of DID among outpatients with borderline personality disorder (BPD) was 24% in two separate studies that employed structured diagnostic interviews ( Korzekwa, Dell, Links, Thabane, & Fougere, 2009 ; Sar et al., 2003 ). Two treatment models targeting borderline personality disorder have been shown to be effective for reducing dissociative phenomena in randomized controlled trials. Koons and colleagues (2001) randomized 20 female clients who had BPD to either dialectical behavior therapy (DBT) or to treatment as usual. At 6 months, participants receiving DBT had a greater reduction in DES scores than those receiving usual care. However, in a shorter 12-week randomized controlled trial, 20 participants receiving DBT demonstrated no improvement in DES scores ( Simpson et al., 2004 ).

The other treatment modality shown effective for dissociative phenomena with BPD is dynamic deconstructive psychotherapy (DDP). Gregory and colleagues (2008) randomized 30 participants with borderline personality disorder and co-occurring alcohol use disorders to either DDP or to optimized community care. Over 12 months of treatment, DES scores were significantly reduced among those receiving DDP, but not among those receiving optimized community care.

Although DBT and DDP have shown promise in reducing dissociative symptoms among clients with BPD, it is unclear whether they would be effective in treating DID. To our knowledge there are no reported cases of any treatment modality for DID complicated by co-occurring BPD employing validated, quantifiable outcome measures. The present observational study attempts to fill that gap in the literature by describing three cases of co-occurring DID and BPD treated with 12 months of DDP, using the DES as an outcome measure.

Participants

Participants include three consecutive cases of DID who had been provided treatment with DDP. All of them were young adult women who had been diagnosed with co-occurring BPD. They were administered the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986 ) at baseline, 6 months, and 12 months into treatment with DDP. The DSM-IV diagnoses of DID and BPD were assigned clinically in each case by the treating therapist. Identifying information has been removed or modified within the case reports to protect the privacy of the participants.

Dissociative Experience Scale

The DES is a 28-item self-report measure assessing a wide array of dissociative phenomena, and it has become the most commonly used and extensively researched scale for measuring the severity of dissociation. Internal consistency has ranged from .83 to .93 and test-retest reliability from .79 to .96 for 4-to-8 week periods ( Carlson et al., 1993 ). There are no differences in scores associated with gender, race, religion, education, and income.

Clients rate their endorsement to each item on a continuum from 0% to 100%, and the mean score is calculated across items. The average DES score in clients with DID has ranged from 41 to 58 across studies, as compared to a median score of 11 for adults without mental disorders ( Bernstein & Putnam, 1986 ; Ross et al., 1990 ). Steinberg, Rounsaville, and Cicchetti ( 1991 ), comparing the DES to diagnosis from structured interviews, found a cutoff score of 15 to 20 yielded good sensitivity and specificity for DID, whereas Ross, Joshi, and Currie (1991) used a cutoff score of 30 in their epidemiological study.

Treatment Intervention

Dynamic Deconstructive Psychotherapy structure is manual based and time limited, involving weekly individual therapy sessions over 12 to 18 months. In a 12-month randomized controlled trial with 30-month follow up, DDP significantly improved interpersonal functioning and reduced self-harm, suicide attempts, alcohol and drug misuse, depression, and dissociation among clients with co-occurring BPD and alcohol use disorders ( Gregory et al., 2008 ; Gregory, Delucia-Deranja, & Mogle, 2010 ). Adherence to DDP techniques correlate strongly with positive outcomes ( r = .64), supporting the effectiveness and specificity of DDP interventions ( Goldman & Gregory, 2009 ).

Dynamic Deconstructive Psychotherapy theory combines the translational neuroscience of emotion processing with object relations theory and deconstruction philosophy ( Gregory & Remen, 2008 ). Through therapy, the individual attempts to remediate the connection between self and one’s experiences and to deconstruct attributions that interfere with authentic and fulfilling relationships.

The practice of DDP targets three purported neurocognitive functions: association , attribution , and alterity. Association is the ability to verbalize coherent narratives of interpersonal episodes, including identification and acknowledgement of specific emotions within each episode. Association techniques involve facilitating discussion of a recent interpersonal episode, helping the client to form a complete narrative sequence and to identify and label specific emotions within the episode.

Attribution is the ability to form complex and integrated attributions of self and others. Attributions of clients with BPD are often distorted and polarized, described in black and white terms ( Gregory, 2007 ). Attribution techniques involve deconstructing distorted, polarized attributions by exploring alternative meanings and motives within narratives.

Alterity is the ability to form realistic and differentiated attributions of self and others. Included within this function are self-awareness, empathic capacity, mentalization, individuation, and self-other differentiation. Alterity techniques are experiential within the client-therapist relationship; they attempt to disrupt the client’s stereotyped expectations by providing acceptance or challenge at key times.

Within the DDP model, DID is conceived primarily as an adaptation to severe trauma and as an end point along a continuum with other dissociative phenomena. Dissociation provides a mechanism for diminishing the emotional impact of trauma by splitting off awareness of feelings, perceptions, and memories from consciousness. However, once dissociation becomes established as a coping mechanism, even minor stresses can trigger it.

Given that clients with DID are often highly hypnotizable and may, therefore, be very suggestible ( Braun, 1984 ), the concern within DDP theory is that alters may become reified as they are individually named and characterized. A DDP therapist explicitly refrains from hypnosis and refrains from exploring the various alters or calling them by name; but insists on addressing the client by his/her legal name. These aspects of DDP differ from expert consensus treatment guidelines of DID, which emphasize negotiation and cooperation between alters, including the occasional use of hypnosis for calming and exploration ( International Society for the Study of Trauma and Dissociation, 2011 ). Also unlike the consensus guidelines, DDP explicitly avoids work on early trauma until later stages of therapy given the difficulty clients with BPD have in adaptively processing intense emotional experiences ( Ebner-Priemer et al., 2008 ) and instead emphasizes narration of recent interpersonal encounters.

The DDP therapist reframes alters as “different parts of you that need to be integrated” while not favoring one aspect of the self over another. This aspect of DDP is largely consistent with the expert consensus DID guidelines emphasizing awareness and resolution of conflict between competing identities, rather than suppressing or ignoring them ( International Society for the Study of Trauma and Dissociation, 2011 ). DDP theory and technique are summarized by Gregory and Remen (2008) and within the training manual (at http://www.upstate.edu/ddp ).

For the present study, the therapists included the founder of DDP (RG; cases 2 and 3) and a senior psychiatry resident (SC; case 1). Training for the senior resident involved several didactic sessions in DDP, reading the training manual, and ongoing weekly case supervision by the founder to ensure treatment fidelity.

Ms. A. was a 33-year-old Caucasian female with a history of chronic major depression, severe dissociation, and narcissistic and borderline personality disorders. She started DDP with a psychiatric resident trainee after several years of recurrent psychiatric admissions for depression, suicidal attempts, and self-mutilation. She would whip herself with chains and used torture devices with religious/medieval themes. She had twice required cardiac resuscitation after overdoses.

Ms. A. also described multiple dissociative symptoms that occurred on a frequent basis. These included flashbacks of traumatic experiences, psychogenic amnesia of important events, derealization, depersonalization, and lapses in time. In addition, the patient described having three separate alters, each having a different name, age, and characteristics. On admission her DES score was 57.

Ms. A. stated her childhood was saddened by her father leaving home when she was about 3 years old; she spent most of her childhood awaiting his return. She vividly recalls feeling alone and spending hours in a rocking in a chair staring at a wall.

Her mother remarried a man who sexually abused Ms. A.’s younger brother and older sister and physically abused Ms. A. When the children revealed the abuse to their mother, she sought counseling at their church, which recommended therapy and that he remain in the home. Ms. A. felt betrayed by her mother for allowing the terror in the home to continue. Ms. A. could not recall feeling loved by her mother, who was a nurse and busy portraying herself a caring individual for others.

Ms. A. did well in school despite having chronic dissociative symptoms, she described as “spacing out” and feeling detached from the world. She enjoyed writing, and she pursued her interest in literature.

Ms. A. became pregnant during her senior year of high school, married, and had a second child. She had difficulties recalling most of her married life, but remembered her husband as being demanding and unloving. Eventually, her husband left her for her best friend.

Initially Ms. A. took on raising the two children on her own, but she was unable to work or even to talk on the telephone due to anxiety. Because of her prolonged periods of dissociation, she was unable to provide adequate and safe care for her children; Child Protective Services eventually removed them from her custody. They went to live with their father in another state. Ms. A. lost contact with her children because they refused to communicate with her.

Ms. A. engaged well in treatment with DDP, attending weekly sessions and developing a therapeutic alliance over the first few months. Much of her early treatment focused on her relationship with her mother, with whom she was living. The predominant theme was, “Do I have a right to be angry?”

She was angry at her mother for her behaviors and attitudes; her mother sympathized with Ms. A.’s ex-husband, insisted that Ms. A. use bed sheets and clothing stained with blood from Ms. A.’s prior cutting episodes, and discouraged her from attending psychotherapy.

At 6 months of therapy, Ms. A. had developed a strongly positive and somewhat dependent transference with the therapist, and she was much better at identifying and articulating feelings of anger, guilt, and shame. She also felt much less need to punish herself, and self-mutilating episodes became less frequent and less severe. Her DES score had decreased from 57 at baseline to 29 at 6 months. However, during therapist vacations, feelings of abandonment would surface in Ms. A., and these sometimes resulted in an exacerbation of self-mutilation and/or severe depression needing hospitalization.

During the final 6 months of therapy, Ms. A. focused a great deal on the preset planned termination of treatment. Vacations and the pending termination were reminders of the limitations of the therapist as an all-caring idealized object. On the one hand, Ms. A. felt as if she had a more integrated self, and she was beginning to expand her functional capacity through the formation of friendships and returning to school part-time. On the other hand, she felt abandoned by the therapist, and this was accompanied with exacerbations of depression, as Ms. A. redirected the anger towards her therapist onto herself. Ms. A. expressed worries about the future and she devalued treatment and the therapist’s role. The therapist struggled to remain empathic with Ms. A.’s worries (without giving false reassurance) and to tolerate the devaluation without becoming defensive.

By the end of treatment, Ms. A. appeared to have a more balanced view of her treatment and of herself. She could express anger with less internal hatred. Depression and suicide ideation markedly improved and 12-month DES score was 12. At termination, she gave the therapist a drawing of a Celtic knot to symbolize the integration of her disconnected self. She was transferred to the care of another therapist; the exact nature of her treatment and course is unknown. However, a chance encounter with the DDP therapist 5 years later revealed that Ms. A. was generally doing well and participating in part-time college coursework.

Ms. B. was a married Caucasian female in her 30s with a long history of severe psychopathology. She delineated five alters, each with a separate name, gender, and age. She was unable to control unexpectedly switching between alters. Ms. B. also described frequent disruptive and embarrassing time lapses. On two occasions, these lapses occurred while she was in the changing room of a Department store: she would become aware of her surroundings after the store had closed and locked its doors.

In addition to dissociative symptoms, the client met criteria for multiple Axis I and II disorders, including BPD, Bipolar I, alcohol and drug dependence, post traumatic stress disorder, obsessive compulsive disorder, and anorexia nervosa, bingeing/purging type. She had a history of six psychiatric hospitalizations beginning in her early twenties; she was treated for suicide attempts, manic episodes, and/or psychosis.

Over the course of her illness, Ms. B. had tried multiple classes of psychotropic medications none successes in treatment, but she has some improvement with mood stabilizers and antipsychotic medications. She had been treated for 5 years in twice-weekly supportive psychotherapy, which had involved a progressively pathological and regressive client-therapist relationship, including cuddling and playing with blocks on the floor. As the client regressed, she also became intrusively demanding of her therapist’s time, which eventually led to the therapist terminating treatment and subsequent deterioration in the client’s condition.

Ms. B. began to see demons in her house, and develop paranoid delusions necessitating psychiatric hospitalization. Following hospitalization, the client was referred for a trial of DDP. At that time, her DES score was 62. Initial sessions focused on establishing clear parameters of treatment, boundary limitations within the client-therapist relationship, and psycho-education regarding the importance of avoiding boundary violations. The client repeatedly brought up interactions with her prior therapist, including her feeling abandoned by the therapist. She was able to work through conflicts regarding agency, i.e. if she or her therapist was to blame for various incidents. As the client gradually worked through her issues she had with her prior therapist, the focus shifted to her marital relationship. Her husband was extremely physically and emotionally abusive. He had prostituted her to his friends and acquaintances. Episodes of physical abuse would be followed by increased psychiatric symptoms, including dissociation. The DDP therapist helped the client identify, label, and acknowledge her emotions in interactions with her husband, and to work through her conflict of agency in that relationship, i.e. whether or not she provoked him to attack her. As Ms. B. worked this through, she decided to terminate the relationship with her husband. She temporarily lived with her parents and eventually lived independently. There was a mourning process involving de-idealization of her husband and of her parents, who pressured her to return to her husband.

Her symptoms of Axis I disorders steadily improved during the course of treatment, despite diminishing dosages of antipsychotic and mood stabilizer medications. Her symptoms of dissociation also improved and her DES score decreased to 45 by 6 months of treatment and to 35 by 12 months. Ms. B. described time lapses as less frequent and of shorter duration, and she began to sense an increased ability to control them. Shifts in personality style became less frequent and pronounced, and Ms. B. no longer described herself as having independent personalities, but rather described “parts of herself” that emerged at different times. She also described herself as “waking up” and feeling “more whole.”

As termination approached, the last phase of weekly treatment was difficult and involved working through feelings of abandonment. After 18 months of weekly sessions, monthly maintenance treatment, which was primarily supportive in nature, was initiated. Despite discontinuing all medications against advice 6 months after termination of weekly DDP, Ms. B. displayed gradual improvement in symptoms at 8-year post-treatment, however, she continued monthly supportive psychotherapy sessions.

During the follow-up period, Ms. B. decided to pursue a professional degree while on social security disability, which supported her efforts through Vocational and Educational Services for Individuals with Disabilities. She successfully completed her courses, came off disability, and has worked full time for the last 3 years of her follow-up period in a responsible professional position.

Ms. C. was a divorced African American woman in her 30s, having a history of alcohol and cocaine dependence. She had moved to the area to “get clean” and leave negative influences. She heard about the study for co-occurring BPD and alcohol use disorders ( Gregory et al., 2008 ), and subsequently enrolled and was randomized to DDP.

Ms. C. described lifelong difficulties with sudden shifts in mood and personality combined with impulsive behaviors, including misuse of alcohol, cocaine, and cannabis. Significant dissociative symptoms included frequent episodes of derealization, feelings of spaciness, fugue episodes, and three distinct personalities, each with a specific name. One of her alters was called “Sunlight.” Sunlight had been the primary alter in Ms. C.’s life for the past few years. Sunlight enjoyed dominating and manipulating men as a drug dealer and prostitute. Unlike Ms. C., Sunlight felt no emotional pain and saw no need for treatment.

Ms. C. was diagnosed with cocaine, alcohol and cannabis dependence, DID, and BPD at evaluation. An 18-month course of DDP therapy was planned. Her initial DES score was 41. Throughout treatment, the therapist addressed the client by her legal name, and reframed the different personalities as different being parts of Ms. C. that were poorly integrated. The focus in early treatment was an exploration of a series of tumultuous relationships with boyfriends. These men had histories of imprisonment and tended to be manipulative or threatening. Her relational pattern was initially to idealize the men. This was followed by disappointment, anger, and fear. She would then engage in manipulating or controlling them. In therapy, the client was able to identify, label, and acknowledge conflicting feelings towards them and to describe a core conflict between her desire to be taken care of by a strong man versus her desire to be independent and in control.

By 6 months in treatment, dissociative episodes were much improved; DES score was 34. Ms. C. was maintaining abstinence and she was able to avoid harmful relationships with men. She began to develop female friendships for the first time in her life and to pursue educational courses leading up to a professional degree.

By 9 months, Ms. C. began to take responsibility for her life but was felt overwhelmed by responsibilities. She became less committed to treatment and recovery, and she began to have increased cravings for substances along with drug dreams. She would speak glowingly about times in the past when she felt in control and without emotional pain in the role of Sunlight. Much of the remaining 6 months of treatment involved bringing Ms. C.’s ambivalence about recovery to consciousness and helping her to mourn the loss of grandiose fantasies. Ms. C. also had to mourn the loss of the therapy relationship. She left treatment 3 months before the scheduled termination so that she “wouldn’t have to say goodbye.” As part of the BPD and alcohol use disorder study, Ms. C. met with the research assistant for follow-up 30 months after enrollment ( Gregory et al., 2010 ). She remained abstinent during the follow-up period despite lack of further treatment, finished her course work for a professional degree, and had been working fulltime during the last 12 months of the follow-up period.

The three cases of DID with co-occurring BPD appeared to respond well to time-limited treatment with DDP. Average DES scores decreased from 53 to 25 over 12 months, indicating an average reduction of 54%. Long-term follow-up for Cases 2 and 3 indicated further improvement in symptoms and function occurred after termination of weekly DDP treatment. These findings are consistent with a randomized controlled trial of DDP for disorders that demonstrated significant improvement in DES scores over time (individuals with BPD and alcohol use Gregory et al., 2008 ).

A theoretical principal of DDP is that individuals with BPD have deficits in association, which involves a dis -association between emotional experience and verbal symbolic capacity ( Gregory & Remen, 2008 ). Individuals are often unable to verbally describe, label, and sequence specific emotional experiences. Association deficits are manifested by incoherent narratives of emotionally charged interpersonal episodes and there is difficulty identifying and appropriately expressing emotions within such episodes.

Dissociation has been linked in prior studies to aberrant processing of emotional experiences. Deficits in the ability to identify and express emotions (as assessed by the Toronto Alexithymia Scale [TAS]), have been noted in traumatized populations, and have been linked to dissociative symptoms, as measured by the DES ( Frewen, Pain, Dozois, & Lanius, 2006 ; McLean, Toner, Jackson, Desrocher, & Stuckless, 2006 ). Clients with DID have been noted to have a slowed response time to negative emotions on the Flanker test ( Dorahy, Middleton, & Irwin, 2005 ). In large, population-based studies ( Elzinga, Bermond, & van Dyck, 2002 ; Maaranen et al., 2005 ; Sayar, Kose, Grabe, & Topbas, 2005), the TAS and DES scores have been correlated with one another even when dissociative symptoms are severe enough to be pathological ( Grabe, Rainermann, Spitzer, Gansicke, & Freyberger, 2000 ; Maaranen et al., 2005 ).

Dynamic Deconstructive Psychotherapy specifically targets association deficits by helping clients to develop coherent narratives of recent interpersonal episodes and to identify, label, and acknowledge emotions within such episodes. Given that deficits in emotion processing have been linked to dissociative symptoms, targeting these deficits should theoretically be helpful for dissociation. This hypothesis was supported by recent research demonstrating a strong and statistically significant correlation (r = .79) between the use of association techniques, as assessed by independent raters, and improvement in DES scores ( Goldman & Gregory, 2010 ). It is, therefore, likely that the use of association techniques was a critical component of treatment response among the reported three cases of DID.

Since DBT also targets association deficits through helping clients to identify emotions associated with maladaptive behaviors, it is perhaps not surprising that this modality has been shown to be helpful in reducing dissociative symptoms ( Koons et al., 2001 ). Whether DBT can be helpful for DID per se, remains to be seen.

Limitations of the present case series include the observational nature of the study, exclusive reliance on clinical diagnoses, and restriction of the study sample to clients with co-occurring BPD. It is unclear whether DDP would be effective for DID clients who are free from this severe personality pathology. The small number of cases also limits the ability to generalize findings. Large controlled trials are needed to better evaluate the efficacy of DDP and other treatment modalities for individuals who suffer from DID.

Conclusions

Dissociative Identity Disorder is a common and under-researched disorder. Borderline Personality Disorders frequently co-occurs with DID and has been noted to worsen its course. DDP is a treatment modality previously found effective for dissociative symptoms of BPD. The active component of DDP for dissociative symptoms may be the use of association techniques, whereby verbal symbolic capacity is linked to emotional experiences within narratives. The three cases presented in this report suggest that DDP can be an effective treatment for clients suffering from DID complicated by co-occurring BPD.

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Famous Cases Of Dissociative Identity Disorder

Christopher Myers

Think back to a time where you had a bit too much to drink. The next day, could you remember what your drunken self had done? Now, remove the alcohol. If you still drew a blank, you would have something in common with these famous cases of dissociative identity disorder .

Dissociative identity disorder (DID), formerly referred to as multiple personality disorder, is when a person manifests two or more distinct personalities that switch off controlling the body. The "blackout" periods are where the dissociative part comes in. Often the personalities have no memory of what went on when other personalties were in charge. In other words, the individual may have no clue that the other personalities even exist.

Usually, there is a dominant personality and one or more "alters." Which personality is dominant can actually change over the years. Sometimes the alternate personalities appear as hostile, foreign invaders to the dominant personality, and can be mistaken for cases of demonic possession. Real cases of DID are extremely rare, and are almost always the result of extreme trauma or abuse. The disorder serves as a psychological coping mechanism in which the psyche compartmentalizes the trauma. Ultimately, the disorder is a failure to integrate various memories, personality traits, identity, and consciousness into a single, multidimensional persona.

These are real people with dissociative identity disorder. All of their stories are true, and well documented. Beyond the sensationalism of tales like Dr. Jekyll and Mr. Hyde is a very real psychological concern that, while rare, can be extremely difficult to live with.

Juanita Maxwell's Alter Committed Murder

Juanita Maxwell's Alter Committed Murder

Juanita Maxwell has no memory of beating 73-year-old Inez Kelly to death with a lamp in 1979. Wanda Weston, however, remembers the incident with glee. She admitted as much during the murder trial . The catch: Juanita and Wanda happen to occupy the same person.

Maxwell had been working as a maid at the hotel where Kelly was staying. According to Wanda, Kelly had borrowed her pen, but refused to give it back. Wanda went into Kelly's room, and when the older woman asked her to leave, killed her.

After Maxwell's alter was coaxed out during her trial, the judge ruled that she was not guilty due to insanity. Maxwell was committed to a mental institution.

Herschel Walker Has A Personality That Excels At Football

Herschel Walker Has A Personality That Excels At Football

Former NFL running back Herschel Walker wrote about his struggle managing multiple personalities in his book, Breaking Free . As a child, Walker was overweight and had a speech impediment. He thinks that he first began developing DID as a coping mechanism . The highly motivated "warrior" was one of Walker's alters who drove his physical fitness and football ability. Another alter, "the hero," was his public face. For years, he managed the disorder without really understanding what it was. He doesn't even remember receiving the Heisman Trophy.

After Walker retired from football, his different personalities started to become jumbled. He fell into depression, at one point playing Russian Roulette with himself. Walker's wife, Cindy Grossman, left him after an episode where he pointed a gun at her head. It was at this point that Walker sought psychiatric help and was diagnosed with DID.

The Real "Three Faces Of Eve"

The Real "Three Faces Of Eve"

The book and 1957 film  The Three Faces of Eve were based on the real case of Chris Costner Sizemore . Sizemore, who died in 2016, actually had 22 distinct personalities. In the book and film, she was portrayed as having only three: Eve White, Eve Black, and Jane.

In reality, Jane's emergence was not the end of Sizemore's suffering . Jane, like Eve White and Eve Black, died, being replaced by ever more personalities . There was the Banana Split Girl, who would only eat said dessert, the Spoon Lady, who collected spoons, and many more. The personalities also ranged in skill sets; some could drive, and others couldn't.

It wasn't until four years of therapy with her eighth doctor, Tony Tsitos, that Sizemore was able to start integrating her personalities. She once said she had a dream where "the personalities were in a kind of Greek arena. They all joined hands and then walked behind a screen and then everything disappeared. They have never come back."

Karen Overhill

Karen Overhill

Is it possible to cure DID? In the case of the patient known as Karen Overhill , the answer was yes. When she was 29 years old, Overhill was referred to Dr. Richard Baer for treatment for her depression. Throughout their sessions, she began revealing how she had been abused by both her father and her grandfather. Dr. Baer treated Overhill for over 20 years as he slowly discovered the truth: she had 17 different personalities.

By using hypnosis and visualization, Dr. Baer was able to help Overhill reintegrate her personalities into one functioning whole. He wrote about her fascinating case in Switching Time: A Doctor's Harrowing Story of Treating a Woman With 17 Personalities . Overhill contributed some of her letters, journal entries, and art to the book. 

Kim Noble Has Four Switches Per Day

Kim Noble Has Four Switches Per Day

Imagine keeping over 100 different personalities straight. That is the life of Kim Noble , told in the autobiographical book All Of Me .

Noble was born in 1960 to two unhappily married factory workers in England. Her childcare was outsourced to friends and family, and at some point between the age of one and three she suffered from extreme and repeated abuse. It was at this point that her psyche splintered, completely compartmentalizing the trauma.

Her condition went undiagnosed through adolescence, even when she was put on suicide watch in a psychiatric hospital after frequent overdosing. In her 20s, a sudden switch resulted in her plowing a van into a line of parked cars. This resulted in another mental health examination, and the diagnosis of schizophrenia.

After being released from the mental hospital, Noble somehow ended up caught up with a pedophile ring. When she reported it to the police, she started receiving threats of retaliation. A man threw acid in her face, someone lit her bed on fire with her in it, and while she escaped, her house was completely gutted. She has no recollection of the incident.

In 1995, Noble was finally diagnosed with DID. Her dominant personality is named Patricia, and under her care, Noble has become an artist and lives with her daughter.

Shirley Mason Made Up Her DID

Shirley Mason Made Up Her DID

One of the most famous cases of DID ever recorded is likely a lie , according to a new book, Sybil Exposed , by Debbie Nathan. The book and miniseries  Sybil  - starring Sally Fields - follows the life of a woman who has DID. It was supposedly a true story, but it seems that the real-life Sybil, Shirley Mason, faked her condition.

Mason initially sought psychiatric attention because she was emotionally unstable. She became attached to her physician, Dr. Connie Wilbur, who had a fascination with multiple personality disorder (as DID used to be called). To get more attention, Mason came in one day and starting claiming to be a different person, talking in a childish voice and changing her mannerisms.

On one occasion, Mason tried to admit that she was faking it, but her confession was dismissed as part of her psychosis. Interestingly, therapist Herbert Spiegel, who saw Mason from time to time, also said that she was probably malingering (faking it) in 1997.

Louis Vivet's Alter Couldn't Walk

Louis Vivet's Alter Couldn't Walk

Louis Vivet was one of the most extensively studied cases of DID in the early days of psychiatry. Vivet lived in the latter part of the 19th century. His youth was marked by abuse and neglect, and at eight years old, he was sent to a house of correction.

By the age of 17, Vivet was a functioning and intelligent man. While working in the field one day, a viper wound itself around his arm. This event frightened him so much that he lost consciousness and began having violent convulsions that evening. These attacks returned several times, eventually resulting in the paralysis of his legs.

Vivet was sent to Bonneval Asylum in 1880. On April 23, he suffered a severe bout of epileptic fits, losing consciousness at times. When he recovered about 50 hours later, he had regained his ability to use his legs. His mannerisms completely changed as well. He was then released as healthy. He eventually wound up in another asylum, where he continued to have epileptic fits, and alternated between being able to walk and not being able to.

Doctors studied him extensively, performing experiments and hypnosis to try and draw out the different personalities he manifested. In total, Vivet manifested at least three and up to ten different personality states.

Truddi Chase Had 92 Personalities

Truddi Chase Had 92 Personalities

When Truddi Chase was just two years old, she moved out to the country with her mother and stepfather. At this time, she was sexually abused by her stepfather, and the trauma ultimately caused her DID.

For years, Chase was able to suppress her memories by holding them in alternate personalities that rarely came to the surface. Each of her 92 personalties served different roles and held different memories. One personality named Black Catherine held most of her rage. Another personality, Rabbit, held the pain.

Chase wrote a book about her life, When Rabbit Howls . Her life was also turned into a made-for-TV movie called The Voices Within: The Lives of Truddi Chase starring Shelly Long, and Chase was interviewed by Oprah as well.

The Strange Case Of Mary Reynolds

The Strange Case Of Mary Reynolds

Mary Reynolds  was born in 1785 and moved from England to Pennsylvania as a child. She had a solemn and melancholy demeanor and spent a lot of time in religious devotion.

At the age of 19, she became blind and deaf for six weeks. Three months after that, she suddenly forgot how to read and write, though she eventually taught herself again. Then, Reynolds's demeanor changed, and was described as "buoyant, witty, fond of company and a lover of nature." After five months, she changed back to her original self, and alternated between the two types for 16 years. When Reynolds reached her mid-30s, the second personality took over once again, and she remained "buoyant and witty" until her death at age 61.

Reynolds was studied by Dr. Samuel Latham Mitchel, who published an account of her " double consciousness " in the 19th century.

Eberhardt Gmelin's Diagnosis Of "Exchanged Personality"

Eberhardt Gmelin's Diagnosis Of "Exchanged Personality"

The first well-documented case of what would later become known as DID was studied by Eberhardt Gmelin in 1791. The case involved a 20-year-old woman living in Stuttgart, Germany. She was divided into two personalities, the "French Woman" and the "German Woman." The French Woman spoke perfect French, behaved like a French aristocrat, and knew about the German Woman.

The German Woman, in contrast, had no idea of the French Woman's existence, and spoke German with a French accent.

Robert Oxnam Didn't Know He Had DID

Robert Oxnam Didn't Know He Had DID

In the 1980s, the scholar Robert Oxnam suffered from alcoholism, bulimia, and blackouts, and his marriage was failing. In 1990, during one routine session with his psychiatrist, Dr. Jeffery Smith, Oxnam's entire demeanor changed. Suddenly, it was not Oxnam in front of Dr. Smith, but an angry little boy named Tommy.

As a young boy, Oxnam suffered sexual and physical abuse and from that he developed DID. He has identified 11 distinct personalities, including Tommy; Bobby, a troublemaker who enjoys rollerblading; The Witch, a frightening presence; and Baby, who holds the memories of Oxnam's childhood trauma. Oxnam wrote a book about his experience called A Fractured Mind .

Ansel Bourne Had Dissociative Fugue

Ansel Bourne Had Dissociative Fugue

One day in the mid-19th century, a man named A.J. Brown arrived in Norristown, PA, and opened a small shop. Around two months later, Brown woke up and had no idea where he was. It turns out that Brown was really one Ansel Bourne , a preacher from Rhode Island.

Bourne had dissociative fugue, a condition similar to DID. It's a condition in which a person loses all memory of his identity and personal past, but essentially goes on functioning in an automatic state. Dissociative fugue can last a few months, or a lifetime.

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Schema therapy for Dissociative Identity Disorder (DID): rationale and study protocol

Terapia de esquema para el trastorno de identidad disociativo (did): justificación y protocolo de estudio, 解离身份障碍(did)的图式疗法:原理和研究方案, rafaële j. c. huntjens.

a Department of Experimental Psychotherapy and Psychopathology, University of Groningen, Groningen, the Netherlands

Marleen M. Rijkeboer

b Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands

Arnoud Arntz

c Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands

Background : A category of disorders frequently associated with a history of trauma are the dissociative disorders, of which Dissociative Identity Disorder (DID) is the most severe and chronic form. DID is associated with high levels of impairment, treatment utilization, and treatment costs, yet systematic research into treatment effects is scarce. Practice-based clinical guidelines advise a phase-based approach which is lengthy and has rather high reported dropout rates. Therefore, in the current proposal the efficacy of an alternative treatment for DID (i.e. schema therapy) is tested.

Objective : The aim of this study is to critically test the effectiveness of schema therapy for DID patients, for whom at present no evidence-based treatment is available.

Method : In light of the low prevalence of DID, and the proposed treatment length of three years, a case series experimental approach is used (non-concurrent multiple baseline design). Ten outpatients are included, who are diagnosed with DID by an independent rater using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), which is double-checked by another independent expert. Primary outcomes are a (bi)weekly assessed state measure of dissociative symptoms, a pre-, post- and follow-up measure of the presence of the DID diagnosis, and drop-out rate. Secondary outcomes include various measures of trait dissociative symptoms, comorbid symptomatology, and global symptomatic distress.

Trial registration : Netherlands Trial Register (NTR): NTR4496

• At present, no evidence-based treatment is available for DID patients.• Practice-based clinical guidelines advise a phase-based approach.• Drawback of this phase-based approach is its substantial average length and dropout rates.• In the current study, the efficacy of an alternative approach to treatment for DID (i.e. schema therapy) is tested using a case series design.

Antecedentes: Una categoría de trastornos frecuentemente asociados con un historial de trauma son los trastornos disociativos, de los cuales el trastorno de identidad disociativo (DID, por sus siglas en inglés) es la forma más grave y crónica. El DID se asocia con altos niveles de deterioro, utilización y costos de tratamiento, aunque la investigación sistemática sobre los efectos de tratamiento es escasa. Las guías clínicas basadas en la práctica aconsejan un enfoque basado en fases que es largo y tiene tasas reportadas de deserción más bien altas. Por lo tanto, en la propuesta actual, se prueba la eficacia de un tratamiento alternativo para DID (es decir, terapia de esquema).

Objetivo: El objetivo de este estudio es probar críticamente la efectividad de la terapia de esquema para pacientes con DID, para quienes en la actualidad no hay disponible un tratamiento basado en la evidencia.

Método: En vista de la baja prevalencia de DID y la duración del tratamiento de tres años propuesto, se utiliza un enfoque experimental de series de casos (diseño de línea base múltiple no concurrente). Se incluyen diez pacientes ambulatorios, que son diagnosticados con DID por un evaluador independiente usando el SCID-D-R, que es verificado por otro experto independiente. Los resultados primarios son una medida (bi)semanal de estado de síntomas disociativos, una medida previa, posterior y de seguimiento de la presencia del diagnóstico de DID, y tasa de deserción. Los resultados secundarios incluyen diversas medidas de los síntomas de rasgos disociativos, sintomatología comórbida y malestar sintomático global.

背景: 解离障碍是一类常常与创伤史相关的疾病,其中解离性身份障碍(DID)是最严重和最长期的形式。 DID与高水平的损伤,治疗使用和治疗成本相关,但对治疗效果的系统研究很少。基于实践的临床指南建议采用一种分阶段的疗法,但该疗法耗时且脱落率相当高。因此,在本方案中考察了DID的一种替代治疗(即,图式治疗)的功效。

目的: 目前尚无基于证据的DID治疗方法,本研究的目的是严格考查图式治疗的有效性。

方法: 鉴于DID患病率低,建议治疗时间为3年,我们采用病例系列实验方法(非并发多基线设计)。研究包括10名门诊患者,由独立评估者使用SCID-DR诊断为DID,由另一位独立专家进行二次检查。主要结果是每(两)周评估的解离症状状态测量,治疗前、后和追踪期的DID诊断,以及脱落率。二级结果包括各种特质性状解离症状,共病症状和整体症状压力。

1. Introduction

Clinical and epidemiological research has indicated a significant association between trauma exposure and a variety of psychological disorders (e.g. Fierman et al., 1993 ; Leskin & Sheikh, 2002 ). One category of disorders frequently associated with a history of trauma are the dissociative disorders, of which Dissociative Identity Disorder (DID) is the most severe and chronic form (Dalenberg et al., 2012 ; see Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008 , for a critical evaluation of the association between trauma and DID). Although dissociative symptoms can be found in many mental disorders, highest levels of dissociative experiences were found in DID (Lyssenko et al., 2018 ). The main diagnostic criterion for DID is a disruption of identity characterized by two or more distinct personality states. The disruption in identity involves marked discontinuity in sense of self and sense of agency, and is accompanied by alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. In addition, the patient experiences recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events (DSM-5; American Psychiatric Association, 2013 ). The DSM-5 estimates the 12-month prevalence of DID as 1.5% of the population of American adults (American Psychiatric Association, 2013 ). The prevalence in psychiatric settings has been estimated to be around 5% (range 0.4–14%; Şar, 2011 ). However, these estimations are generally not based on strict assessment procedures and therefore are probably overestimating the real prevalence. Patients suffering from DID show high levels of impairment, high treatment utilization, and high treatment costs (Ross & Dua, 1993 ). Of all dissociative disorders, DID patients have the highest mean impairment scores on measures of psychosocial, occupational, and interpersonal functioning (Johnson, Cohen, Kasen, & Brook, 2006 ). These impairment scores are over 50% higher than those of patients with other syndromal or personality related psychiatric disorders, and results remained significant after controlling for age, gender, and comorbid disorders (Johnson et al., 2006 ; Mueller-Pfeiffer et al., 2012 ). Dissociative disorder pathology is also strongly related to self-harm and multiple suicide attempts (Foote, Smolin, Neft, & Lipschitz, 2008 ). DID patients specifically are at high risk for early mortality, and are among the most expensive patients in the mental health care system (Galbraith & Neubauer, 2000 ).

1.1. Treatment for Dissociative Identity Disorder and evidence regarding its effectiveness

No formal, evidence-based treatment guidelines are available for DID (e.g. National Institute for health and Care Excellence [NICE] guidelines). The most commonly provided treatment approach for DID is individual psychodynamic psychotherapy (Brand, Classen, McNary, & Zaveri, 2009 ; Putnam & Loewenstein, 1993 ). According to practice-based guidelines initiated by the International Society for the Study of Trauma and Dissociation (ISSTD, 2011 ), DID treatment preferably is delivered in sequenced stages or phases. Generally, this treatment encompasses three phases. In the first phase safety and symptom stabilization is established, in the second phase traumatic memories are confronted and processed, and in the third phase identity integration and rehabilitation is addressed (International Society for the Study of Trauma and Dissociation, 2011 ). Following a basic tenet of compartmentalized identities, the main aim of this treatment is to bring about an increased degree of co-consciousness, communication, and integrated functioning among the different parts, facilitating the processing of compartmentalized traumatic memories, and the integration of separate identities in the second and third stage of therapy (International Society for the Study of Trauma and Dissociation, 2011 ). It is thought that a lack of concentration on stabilization, and/or a premature focus on detailed exposure to and processing of traumatic memories, will result in overwhelming emotions, exacerbation of symptoms, and decompensation of the patient, accompanied by increased deterioration in day-to-day functioning (Brand, Loewenstein, & Spiegel, 2014 ). The second, trauma-focused, phase of therapy is considered too destabilizing for chronically low-functioning patients, including those with severe attachment problems, minimal ego strength and coping capacity, ongoing enmeshment with perpetrators, severe personality pathology, significant medical problems, and ongoing substance abuse and dependency (International Society for the Study of Trauma and Dissociation, 2011 ). Hence, phase two is only started when there are relatively few life stressors, and there is enough ego strength, commitment to treatment, social support, economic resources, and other factors that help patients to undertake a demanding, change-oriented treatment. Consequently, patients may stay in phase one for long periods of time, sometimes even for the entire course of treatment, which may last 10 years or longer.

Research on the effectiveness and efficacy of DID treatments is still in its infancy, partly because patients with these disorders are usually excluded from treatment studies (e.g. due to their complexity, poly-symptomatology, and the long treatment length they are supposed to need), even when these studies involve treatment of patients who faced chronic childhood abuse (e.g. Van der Kolk & Courtois, 2005 ). In a review of eight treatment outcome studies of dissociative disorders (most included patients had DID or dissociative disorder not otherwise specified; DDNOS), all nonrandomized, Brand, Classen, McNary, & Zaveri ( 2009 ) concluded that treatment was associated with a reduction of dissociative symptoms from pre- to post-treatment (mean effect size Hedges g  = .70), and a range of associated symptoms (including symptoms of anxiety, borderline personality disorder (BPD), depression, substance use, and general distress; mean overall outcome effect size g  = .72 at discharge, and .66 at follow-up ranging from three months to two years). In addition, Brand and colleagues (Brand, Classen, Lanius, et al., 2009 , 2013 ; Myrick, Webermann, Loewenstein, Lanius, Putnam, & Brand, 2017 ) performed an observational prospective naturalistic survey study following DID and DDNOS outpatients and their therapists. Each participating therapist self-selected a patient from his or her caseload, who was followed for a period of 30 months. Patients had been in treatment with the current therapist for an average of five years, and had been formally diagnosed with DID or DDNOS for an average of seven years. Positive treatment results were reported: in addition to a decrease on a range of symptoms (e.g. dissociative symptoms, posttraumatic stress disorder symptoms, general distress), both patients and therapists reported an improvement in social functioning for patients, and a decrease in, among others, drug use, self-injurious behaviour, and number of hospitalizations. It was also suggested that treatment was associated with reduced inpatient and outpatient costs over time (Myrick, Webermann, Langeland, Putnam, & Brand, 2017 ).

Jepsen, Langeland, Sexton, and Heird ( 2014 ) investigated symptomatic change in patients suffering from a history of childhood sexual abuse with versus without a complex dissociative disorder (CDD, with complex referring to DID and DDNOS-1, see Dell, 2009 ) attending a three-months inpatient phase-one treatment (i.e. stabilization). Results indicated that, whereas patients with CDD had higher symptom levels pre-treatment, both patient groups showed parallel improvement on dimensional symptom measures for posttraumatic stress symptoms, general psychiatric symptoms, interpersonal problems, depressive symptomatology, and dissociative symptoms from admission to 12-months follow-up (mean effect size Cohen’s d = 0.43 for the CDD group and 0.68 for the non-CDD group).

These studies provide preliminary evidence of treatment effectiveness on a range of symptoms associated with DID. Yet, the number of studies has been very small. Moreover, previous studies suffer from major methodological shortcomings, limiting both internal and external validity (i.e. generalizability). Most of the studies did not report whether changes following treatment constituted clinically meaningful changes. Details on treatment programmes were missing, as all studies included non-manualized interventions, rendering replication difficult, if not impossible. Furthermore, most of the studies relied on a single therapist and a single treatment site. Yet, most important, studies lacked an adequately randomized controlled design. There were no comparison groups (i.e. a patient group without treatment or with an alternative treatment) or comparison conditions , (e.g. the inclusion of a baseline measurement phase; as an exception of the latter see the case study by Kellett, 2005 ). As a consequence, it cannot be determined if, and if so, how much patients would have improved without treatment. Hence, it is impossible to know whether change occurred due to treatment or some other variable (e.g. the passage of time, regression to the mean, or placebo effects). It is even possible that no treatment would result in better results than the treatment provided. Another limitation is that, for most studies, diagnostic status was not based on structured interviews, leaving it undetermined whether true cases of DID were included. Also, several studies suffered from problematic high drop-out rates (i.e. 60% in a study by Ellason & Ross, 1997 ; 68% in Gantt & Tinnin, 2007 ), whilst in other studies drop-out was not reported (Ross & Ellason, 2001 ), rendering the external generalization of results hazardous. Based on the results of these uncontrolled studies, changes following treatment cannot be causally attributed to the treatment, as it is also possible that improvement would have occurred without treatment (Brand, 2012 ).

Besides the lack of controlled studies to test the effectiveness and efficacy of the phase-based approach for DID, there is room for improvement in the treatment of DID. As mentioned before, drop-out is relatively high and the treatment is intensive and lengthy. The minimum frequency of sessions for most DID patients is once a week, with many experts advising two or three sessions a week. Statistics on the mean length of treatment are scarce. Groenendijk and van der Hart ( 1995 ) mentioned a mean length of six years of treatment, based on therapist reports, in a combined sample of DID and DDNOS patients. In the aforementioned study by Brand and colleagues, patients in the last phase of treatment were seen by the current therapist for over eight years (Brand, Classen, Lanius, et al., 2009 ). Notably, during these years many patients stay in phase-one (i.e. with a continuous focus on stabilization, crisis management, and symptom reduction) and, hence, will not reach the second phase of therapy. Only a minority of DID patients reach phase three (22% in Ellason & Ross, 1997 ; 7% in Brand, Classen, Lanius, et al., 2009 ).

Although we consider stabilization techniques (i.e. throughout treatment) important for these patients, we consider delaying or restricting access to effective (phase two) trauma-focused treatments may be potentially harmful to patients (for a comparable argumentation in the context of PTSD see Neuner, 2008 ).

Whereas treatment outcome for DID or DDNOS seem to be associated with improvement across a wide range of outcomes, this is not always the case. In some studies, no pre- to post-treatment change in dissociation scores were found (e.g. Jepsen et al., 2014 ; Ross & Ellason, 2001 ) and amnesia scores even worsened (Choe & Kluft, 1995 ). In the studies that report positive effects, most patients do not completely recover from their chronic struggles with severe dissociation, PTSD, depression, and general distress. For example, in the study by Gantt and Tinnin ( 2007 ), 68% of the patients diagnosed with DID or DDNOS did not ’recover’. Thus, whereas treatment is associated with a decrease of a wide range of symptoms, patients typically do not recover.

To summarize, the phase-based approach of DID seems related to reduced levels of dissociative and comorbid symptomatology. However, the level of evidence for these findings is low, as previous studies suffer from serious methodological weaknesses. We do not know how these improvements compare to what is observed during the passage of time.

1.2. Rational for an alternative treatment: schema therapy

Whereas DID patients may subjectively perceive their different identities as compartmentalized, empirical evidence from the experimental psychopathology field contradicts the view of identities with separate memory store divided by amnesic barriers. A series of studies in different labs assessed the transfer of information between identities in DID. Both tests of implicit and explicit memory were included, and neutral, emotional, and autobiographical information. The data across studies were consistent in that, subjectively, DID patients reported amnesia among identities, but objectively, no evidence was found for inter-identity amnesia (for an overview, see Dorahy & Huntjens, 2007 ; Huntjens, Verschuere, & McNally, 2012 ). In sum, these studies do not support the view of compartmentalized personalities but show intact memory pathways. Whereas the DID patient may – on a metacognitive level – not acknowledge all memories as ‘personal’ memory in each identity state, this is not to say that memory functioning in DID is compartmentalized or impaired in other ways (Huntjens, Postma, Peters, Woertman, & van der Hart, 2003 ). Moreover, it is important to note that shifts among feelings, emotions, and behaviours, as often seen in DID, also appear in other disorders related to severe, early, and prolonged childhood abuse, including BPD, other personality disorders, and PTSD (Arntz, Klokman, & Sieswerda, 2005 ; Johnston, Dorahy, Courtney, Bayles, & O’Kane, 2009 ). Note that DID and BPD are highly comorbid conditions (Gleaves, May, & Cardeña, 2001 ).

An evidence-based treatment for patients with personality disorders is schema therapy (for reviews see Jacob & Arntz, 2013 ; Masley, Gillanders, Simpson, & Taylor, 2012 ; Sempértegui, Karreman, Arntz, & Bekker, 2013 ). Schema therapy is an integrative therapy lasting 1–3 years, blending traditional cognitive behavioural treatment with experiential and interpersonal elements (Young, 1990 ; Young & Gluhoski, 1996 ; Young, Klosko, & Weishaar, 2003 ), and using the therapeutic relationship as an important vehicle to bring about corrective emotional experiences (see Nordahl & Nysæter, 2005 ; Young et al., 2003 ). Schema therapy seems a viable option for the treatment of DID given its emphasis on the consequences of early childhood neglect and abuse, and the explanation within the therapeutic model of the patient’s experience of drastic shifts between states. Unlike the ISSTD guidelines, that tend to reify the idea of severely dissociated identities with amnestic barriers, in the e model these states are not considered as ‘compartmentalized’ identity states. Schema therapy aims to normalize for the patient the different ‘identities’ by reframing them as modes (or as parts of modes), which are common in all humans, though different in their degree of intensity, and amnestic barriers are not assumed. The various identities of a patient with DID are regarded as extreme expressions of dysfunctional modes, differing from the modes of patients with PDs in how the patient experiences the mode, thus in degree of experienced dissociation from the other modes (Johnston et al., 2009 ; Lobbestael, van Vreeswijk, & Arntz, 2007 ; Young et al., 2003 ).

Treatment effect studies into schema therapy yielded robust results. In comparison to other treatment conditions, in schema therapy relatively low drop-out rates were found for BPD (less than 10% in the first year of treatment) (Farrell, Shaw, & Webber, 2009 ; Giesen-Bloo et al., 2006 ; Nadort et al., 2009 ) and for other personality disorders (Bamelis, Evers, Spinhoven, & Arntz, 2014 ). An explanation might be that patients in the schema therapy condition highly valued the therapeutic relationship (see for empirical evidence: Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, 2007 ). Next, symptoms were found to reduce significantly. After 2–3 years of treatment with schema therapy, 45–90% of the patients recovered, i.e. did not meet criteria of a formal diagnosis anymore (Bamelis et al., 2014 ; Farrell et al., 2009 ; Giesen-Bloo et al., 2006 ). Giesen-Bloo and colleagues ( 2006 ) also looked into the effectiveness of schema therapy on dissociative symptoms, using the subscale ‘Paranoid and Dissociative Ideation’ of the Borderline Personality Disorder Severity Index (Arntz et al., 2003 ). Schema therapy resulted in significant lower scores on the scale, with the effects already apparent after one year of treatment. However, as this subscale is a combination score, it was unclear whether this effect is evident in dissociative symptoms, paranoid ideation symptoms, or both. Moreover, DID patients were excluded from this study, so it remains unknown whether schema therapy (ST) is effective in this specific group of patients as well.

1.3. The present study

Farrell and Shaw adapted their ST treatment, originally developed and tested in BPD (Farrell & Shaw, 2012 ; Farrell et al., 2009 ; Reiss, Lieb, Arntz, Shaw, & Farrell, 2014 ), to meet the needs of DID patients. They piloted this adaptation in six inpatients suffering from DID. The positive clinical observations of this effort led to the development of a detailed standardized protocol of schema therapy for DID (Shaw, Rijkeboer, Huntjens, Arntz, & Farrell, 2014 ). Central in this treatment is the acknowledgment and validation of both the patient’s subjective experience of alternating senses of self, sense of agency, and of differential identity functioning, and the subjective experience of (inter-identity) amnesia, whilst at the same time compartmentalization of identities is not assumed. Early in treatment patients are educated on the various modes, the function of shown behaviours when in certain modes, and the basic emotional needs that drive these modes. Gradually identities are grouped by their function, constantly focusing on the underlying needs. The adaptations to the original schema therapy protocol in order to treat DID patients include the following. First, there is a much slower pace overall. Patients have to adjust to this model that is sometimes very different from what they have learned about their pathology so far. Also, patients are intensely vulnerable, with frequent dissociative reactions and extreme avoidant behaviour. In order to keep the patient in control, the therapist constantly needs to slow down the process, much more than in the treatment of BPD. Next, several techniques are added to help patients stay focused in the present reality. Also, metaphors and stories are provided to help patients understand and validate their needs, feelings, thoughts, and behaviours, thus normalizing these. Moreover, aggressive, critical modes are dealt with more patiently than in BPD treatment. Close attention is paid to their function and their needs are validated, followed by education on how messages of abusive family members or acquaintances get internalized. Whereas the actual aggressive actions are stopped during the session, patients in this mode are gradually invited to use their strength to get rid of this ongoing victimization. Furthermore, the technique imagery rescripting is cut into small steps, in order to be able to start with the processing of traumatic experiences relatively early in therapy. Also patients are helped to gradually overcome cognitive avoidance, a central characteristic of DID (see Huntjens, Wessel, Hermans, & van Minnen, 2014 ), by the consistent use of experiential techniques, which form an important ingredient of schema therapy. Therapists need to be aware not to give in to the inclination to rescue the patient; next to a warm and empathic attitude they need to set limits and be firm in helping the patient to step-by-step break through the avoidance. Finally, there is a strong emphasis on relaxing activities and other positive experiences, and the progress (successes) in therapy is regularly evaluated with the patient, much more so than in the treatment of BPD.

The aim of the present study is to critically test this treatment protocol in DID patients. Whereas RCTs are generally considered the ‘gold standard’ for testing therapy effectiveness, there are limitations with respect to feasibility, costs, and external validity (e.g. Hawkins, Sanson-Fisher, Shakeshaft, D’Este, & Green, 2007 ). Therefore, and given the lengthy treatment of these patients, as a powerful alternative we use a multiple baseline case series design (Onghena, 2005 ). Multiple baseline case series fit with daily practice more closely than RCTs (Kazdin, 2011 ). There is also an ethical advantage: in comparison to RCTs, less patients have to be included. More specifically, we utilize a multicentre, non-concurrent multiple baseline design. Different baseline lengths are determined before the start of the study. When a patient is included, he/she is randomly assigned to one of the predetermined baseline lengths. The baseline condition consists of a waitlist control period. Patients complete weekly assessments in this period, but do not receive any psychotherapy. Advantages of this approach are (a) patients serve as their own controls and (b) variation in baseline lengths offers the possibility to differentiate between time effects and experimental effects of the treatment. We also included an education condition. By adding this condition (i.e. developing an idiosyncratic case-conceptualization and explaining the therapy model), it is possible to control for the effect of attention, thus increasing the power of the design (see Arntz, Sofi, & van Breukelen, 2013 ). No treatment effects are expected in this phase. Baseline observations are carried out and, after an education phase, the treatment is implemented. Observations are continued throughout the intervention phase. Every two weeks, dissociative and posttraumatic symptoms are measured. Additionally, various pre-, post-, six-, and 12-month follow-up measures are included, encompassing an assessment of the presence of DID, trait dissociative symptoms, comorbid symptomatology, and global symptomatic distress.

2.1. Participants

Ten DID outpatients are recruited in several community mental health institutes in the Netherlands. The inclusion criteria are (1) a main diagnosis of DID, (2) age between 18 and 60 years, and (3) Dutch literacy. Exclusion criteria are (1) mental retardation (IQ < 80), (2) a current drug/alcohol dependency, (3) acute suicide risk, (4) present florid psychotic episodes, (5) previous schema therapy, and (6) completed trauma-focused treatment. Other comorbid syndrome or personality disorders are allowed, as is medication use (this is monitored throughout the treatment) and ongoing sexual/physical abuse.

2.2. Intervention

Treatment consists of two individual sessions a week for 160 sessions, followed by 40 individual sessions once a week, with each session lasting 50 minutes. After treatment, patients receive six monthly booster sessions. The treatment is theoretically consistent with the model described in Young et al. ( 2003 ), and adapted for the specific treatment needs of DID patients. For this purpose, a treatment protocol was developed that identifies the goals of treatment, describes the various techniques, and contains a workbook of patient materials (Shaw et al., 2014 ). Patients are not allowed to receive concurrent additional psychological treatment.

2.3. Treatment integrity check

All participating therapists are well trained and licensed cognitive behavioural therapy (CBT) and ST therapists. To optimize treatment integrity, therapists received a two-day training in which the treatment protocol for DID was critically discussed and practiced. Furthermore, during the study the therapists are supervised monthly by the third author in subgroups of maximal five therapists via video conferencing. Also, peer supervision sessions are held every month via video conferencing in the same subgroups. Finally, all therapy sessions are recorded on audiotape. At random, tapes will be selected and rated for treatment integrity by independent raters using a treatment adherence scale.

2.4. Study design and procedure

Patients are recruited from community mental health care centres and receive written study information. After informed consent, diagnosis is independently verified by a trained clinician by taking the SCID-D-R. Hereafter, a second independent expert on DID diagnostic assessment provides a second opinion in each case, based on the interview recordings of the SCID-D-R, and a written report of Structured Clinical Interviews for DSM-IV Axis I and Axis II disorders (SCID-I and SCID-II). If both agree on a formal diagnosis of DID, the patient is included, baseline assessment is completed, and the patient is assigned to a participating therapist.

Ten possible baseline lengths are selected beforehand (i.e. 11 weeks, up to 20 weeks) and divided in two pools, one consisting of the five shortest baseline lengths and the second of the five longest baselines. When a patient agrees to participate, a baseline length is randomly selected (without replacement) from a randomly selected pool. When a second patient is included at the same site, a baseline length is randomly selected from the pool that was not used before at the site. At the end of the baseline phase, an education phase starts with a fixed length of eight weeks for every patient, encompassing 16 sessions in which an idiosyncratic case-conceptualization is made, and the patient is educated on the schema mode model. After this, the intervention phase starts. Next, there are 160 sessions twice a week, after which the frequency is reduced to one session a week for 40 sessions. After treatment patients receive six monthly booster sessions. All patients complete outcome measures on state dissociative symptoms and PTSD symptoms once a week in the baseline and education phase, and once every two weeks in the intervention phase. In addition, they complete several other outcome measures (i.e. presence DID, trait dissociative symptoms, comorbid symptomatology, and global symptomatic distress) at the start of the baseline phase, start of the education phase, start of the intervention phase, and after that every six months until the end of treatment. After treatment, there is a first follow-up measurement right after the booster sessions (i.e. six months after treatment), and a second follow-up measurement one year after treatment (see Table 1 for detailed overview of assessments). No additional treatment is delivered during the follow-up period, unless this is deemed clinically necessary (i.e. in case of acute crisis the emergency procedure of each clinical site is followed). To avoid therapist effects, each participating therapist only treats one patient. Participants receive a financial compensation of 150 euros for participation in the assessments.

Assessment per measurement moment.

Int = interview, SR = self-report, T0 = baseline, T1 = baseline-start, T2 = baseline-end = education-start, T3 = education-end = intervention-start, T4–T6 = every 40 sessions during intervention, T7 = intervention-end, T8 = follow-up after six months of booster sessions, T9 = follow-up one year after end of treatment, six months after end of the booster sessions.

2.5. Measures

2.5.1. diagnostic assessments, 2.5.1.1. scid-d-r, scid-i, and scid-ii.

The diagnosis DID is verified with the SCID-D-R (Steinberg, 1994 , 2004 ; also see Boon & Draijer, 1993 ). The SCID-D-R assesses five symptom clusters (depersonalization, derealization, identity confusion, identity fragmentation, amnesia) and is considered the gold standard instrument for the diagnosis of dissociative disorders. Boon and Draijer ( 1993 ) assessed the Dutch version and reported an excellent interrater reliability for presence versus absence of a dissociative disorder and for type of dissociative disorder. The interview is repeated at the end of treatment, and at every follow-up.

The Structured Clinical Interviews for DSM-IV Axis I and Axis II disorders (SCID-I and SCID-II; First, Gibbon, Spitzer, & Williams, 1997 ; First, Spitzer, Gibbon, & Williams, 1996 ; Lobbestael, Leurgans, & Arntz, 2011 ; Van Groenestijn, Akkerhuis, Kupka, Schneider, & Nolen, 1999 ; Weertman, Arntz, & Kerkhofs, 2000 ) with excellent psychometric properties were used to assess DSM-IV syndrome disorders and personality pathology.

2.5.2. Baseline assessments

At baseline, patients complete an assessment of severity of childhood trauma and neglect, and provide background information (e.g. nationality, marital status, level of education, terms of employment, religion).

Severity of childhood trauma and neglect is assessed with a 28-item brief Childhood Trauma Questionnaire (CTQ-SF; Bernstein et al., 2003 ). Subscales determine emotional abuse, emotional neglect, sexual abuse, physical abuse, and physical neglect, each scale consisting of five items plus an additional three-item minimization/denial scale. Items are scored on a 5-point Likert scale, reflecting the frequency of maltreatment experiences (range: never true to very often true). The internal consistency, convergent, and discriminant validity of the instrument were well supported (Bernstein et al., 2003 ; Thombs, Bernstein, Lobbestael, & Arntz, 2009 ).

2.5.3. Outcome assessments

The primary outcome is the Dissociation Tension Scale (DTS; Stiglmayr et al., 2010 ), assessing psychoform and somatoform dissociative symptoms in the past week. The DTS is a 21-item self-report measure of dissociative symptoms experienced in the past week. Participants are asked to rate the intensity using a Likert scale ranging from 0 to 9. The Dutch version was generated using standard translation and back-translation procedures. Discrepancies in the translations were then resolved in dialogue with the author of the original instrument.

Additional primary outcome measures are the assessment of diagnosis of DID using the SCID-D-R (Steinberg, 1994 , 2004 ; also see Boon & Draijer, 1993 ) and assessment of patient dropout.

2.5.4. Secondary outcomes

2.5.4.1. ptsd symptom scale self-report (pss-sr).

Comorbid PTSD symptoms are assessed with the PSS-SR (Foa, Riggs, Dancu, & Rothbaum, 1993 ; also see Engelhard, Arntz, & van Den Hout, 2007 ), a 17-item self-report instrument. Because this measure is taken every two weeks, the instruction was adapted to refer to symptoms experienced in the past week. Respondents rate the frequency of each symptom on a 4-point Likert scale ranging from 0 (not at all) to 3 (five or more times per week/almost always). The English (Foa et al., 1993 ) and Dutch versions (Engelhard et al., 2007 ) have good psychometric properties.

2.5.4.2. Multidimensional Inventory of Dissociation (MID)

Pathological dissociation is assessed with the MID (Dell, 2006a , 2006b ; Dell & Lawson, 2009 ). The MID is a comprehensive 218-item self-report instrument (168 dissociation items, 50 validity items). The items are rated on a 11-point Likert scale that ranges from 0 (never) to 10 (always). The scale provides a summary score between 0 and 100. The MID has demonstrated adequate reliability and validity (Dell, 2006a ; Mueller-Pfeiffer et al., 2013 ).

2.5.4.3. World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

To capture functioning and disability in daily life, the WHODAS 2.0 (36-item version; World Health Organization, 2000 ) is used. This measure has been recommended for determination of functional decline secondary to psychiatric illness by the DSM-5. The WHODAS examines activity limitations and restrictions for six different tasks: (1) understanding and communication; (2) self-care; (3) mobility (getting around); (4) interpersonal relationships (getting along with others); (5) work and household roles (life activities); and (6) community and civic roles (participation). Items are rated for the extent of difficulty doing the activity in the past 30 days on a 5-point scale (none, mild, moderate, severe, extreme/cannot do). The WHODAS 2.0 has been examined in several different populations and showed good psychometric properties (Üstün et al., 2010 ).

2.5.4.4. Schema Mode Inventory (SMI)

Schema modes are assessed using the SMI (Lobbestael, van Vreeswijk, Spinhoven, Schouten, & Arntz, 2010 ). The SMI consists of 118 items and 14 schema mode scales (e.g. vulnerable child mode, angry child mode, detached protector). Items are rated according to frequency on a 6-point scale from (almost) never to always. The psychometric results indicate that the short SMI is a valuable measure that can be of use for mode assessment in schema focused therapy (Lobbestael et al., 2010 ).

2.5.4.5. Dissociative Beliefs about Memory Questionnaire (DBMQ)

Beliefs about memory functioning are indexed using the newly developed 16-item Dissociative Beliefs about Memory Questionnaire; Huntjens, & Dorahy, 2018). As recent studies of inter-identity amnesia in DID suggest that reported memory problems in DID are not the result of impaired coding and/or retrieval functioning, but rather may result from metacognition, this instrument assesses meta-memory beliefs related to dissociative experiences with 16 items and four subscales (Fragmentation, Fear of Retrieval of Negative Events, Amnesia, and Lack of Self-Reference) using a 1 (not at all/not applicable) to 5 (very much) scale. Preliminary analyses have indicated good psychometric properties (Huntjens & Dorahy, in preparation).

2.5.4.6. Progress in Treatment Questionnaire (PITQ)

Finally, progress in treatment is determined using the Progress in Treatment Questionnaire, consisting of a part to be completed by the therapist (PITQ-t) and a part to be completed by the patient (PITQ-p) (Schielke, Brand, & Marsic, 2017 ). This questionnaire was specifically developed for treatment research in dissociative disorders and assesses (therapist ratings of) the patients’ ability to safely and effectively manage their emotions, symptoms, and relationships. Each item offers 11 response options ranging from 0% (never) to 100% (always) in 10% intervals. In the current study, both the PITQ-t is used and a selection of six items from the PITQ-p specifically referring to the integration of dissociative identities. The Dutch version was generated using standard translation and back-translation procedures. Discrepancies in the translations were then resolved by dialogue with the author of the original instrument. Both the PITQ-p and the PITQ-t demonstrated good internal consistency and evidence of moderate convergent validity in relation to relevant established measures (Schielke et al., 2017 ).

2.6. Statistical analysis

To assess the difference between the baseline and intervention phase, a mixed regression approach will be used, applied successfully in previous comparable case series studies (Arntz et al., 2013 ; Brewin et al., 2009 ; Van Den Noortgate & Onghena, 2003 ; Videler et al., 2017 ). To determine pre- to post-treatment individual change, a Reliable Change Index (Jacobson & Truax, 1991 ) will be calculated for instruments for which appropriate normative data are available.

3. Discussion

DID is a highly debated disorder with disagreement on the aetiology (including the relation to childhood trauma), the diagnosis, and the treatment of the disorder. Whereas consensus-based treatment guidelines are lacking, the practice-based expert DID guidelines forwarded by the ISSTD ( 2011 ) advocate a phase-based approach to treatment. However, empirical evidence supporting this approach is scarce and of low quality. Hence, the field is in need of methodologically stronger effectiveness studies. Moreover, there is ample room for improvement in the treatment of these patients, given the long mean treatment length, the dropout rates, and relatively large percentage of patients not moving beyond the phase of establishing safety and symptom stabilization.

The goal of the current study is to provide a first test of the effectiveness of a manualized alternative treatment approach for DID (i.e. schema therapy) with the use of a methodologically sophisticated design in the form of a non-concurrent experimental multiple baseline design. To this end, a treatment protocol was designed, describing the use of schema therapy in DID. The primary outcome are dissociative symptoms, presence of DID diagnosis, and patient dropout. Secondary outcome measures include measures of posttraumatic symptoms, trait dissociative symptoms, comorbid symptomatology, daily functioning, progress in treatment, meta-memory beliefs, and mode functioning. Strengths of the treatment approach forwarded include: (1) it is based on an evidence-based therapy for patients with a background of severe childhood trauma in childhood, the latter being considered by many as the main etiological cause of DID, (2) there is a broad focus covering a wide array of consequences following childhood trauma, including posttraumatic complaints and personality pathology, (3) a shorter treatment length, compared to current ISSTD guidelines, and earlier active trauma focused treatment ingredients (i.e. compared to a relatively long phase aimed purely at establishing safety and symptom stabilization), (4) an emphasis on overcoming cognitive avoidance, a hallmark characteristic of DID (see Huntjens et al., 2014 ), and finally, (5) the approach is in agreement with recent findings from experimental memory research on inter-identity amnesia. Acknowledging the subjective experience of patients, the treatment approach forwarded in this study considers the personality states in DID as different emotional, behavioural, and cognitive states of one underlying unified identity.

Despite the controlled experimental design, the relatively small number of patients included limits the generalizability of the study results. This study therefore serves as a natural first investigation of the effectiveness of schema therapy for DID. It should be replicated in larger samples and other settings. Furthermore, one might argue that a possible limitation of this study treatment protocol is that DID is taken as a disorder of self-understanding instead of involving discrete compartmentalized parts with relative autonomous functioning. Some clinical experts consider DID to involve discrete, personified behavioural states or ‘biopsychosocial action systems’ that take ‘executive control of the person’s body and behaviour’ (Van der Hart, Nijenhuis, & Steele, 2006 ). In the current approach, whereas the patient’s experience of fragmentation is acknowledged and validated, we start from the premise of a single person with subjectively divided self-aspects. This agrees with the guidelines of the ISSTD ( 2011 ) where clinicians are discouraged from using terms that would reinforce a belief that alternate identities in DID are separate persons. Also, experts acknowledge: ‘We do not disagree that DID is in part a disorder of self-understanding. Clearly those with DID have the inaccurate idea that they are more than one person’ (Dalenberg et al., 2012 , p. 568). We thus take a more trans-diagnostic model as a starting point, emphasizing common pathways comprised of partly overlapping clinical syndromes such as complex PTSD, dissociative disorders, and borderline phenomena (see Şar, 2017 ).

Finally, and most importantly, the results of this study might help to ameliorate treatment for DID patients, a group of patients for which, at present, no evidence-based treatment is available and very much in need of effective and feasible clinical help. Evidence-based treatment is a necessary prerequisite for the formulation and acceptance of evidence-based consensus treatment guidelines for this controversial disorder.

Disclosure statement

No potential conflict of interest was reported by the authors.

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6 minute read

Dissociative Identity Disorder

Two famous cases.

Also referred to as multiple personality disorder, a condition in which a person's identity dissociates, or fragments, creating additional, distinct identities that exist independently of each other within the same person.

Persons suffering from dissociative identity disorder (DID) adopt one or more distinct identities which co-exist within one individual. Each personality is distinct from the other in specific ways. For instance, tone of voice and mannerisms will be distinct, as well as posture, vocabulary, and everything else we normally think of as marking a personality. There are cases in which a person will have as many as 100 or more identities, while some people only exhibit the presence of one or two. In either case, the criteria for diagnosis are the same. This disorder was, until the publication of DSMIV, referred to as multiple personality disorder. This name was abandoned for a variety of reasons, one having to do with psychiatric explicitness (it was thought that the name should reflect the dissociative aspect of the disorder).

The DSM-IV lists four criteria for diagnosing someone with dissociative identity disorder. The first being the presence of two or more distinct "identities or personality states." At least two personalities must take control of the person's identity regularly. The person must exhibit aspects of amnesia—that is, he or she forgets routine personal information. And, finally, the condition must not have been caused by "direct physiological effects," such as drug abuse or head trauma.

Persons suffering from DID usually have a main personality that psychiatrists refer to as the "host." This is generally not the person's original personality, but is rather developed along the way. It is usually this personality that seeks psychiatric help. Psychiatrists refer to the other personalities as "alters" and the phase of transition between alters as the "switch." The number of alters in any given case can vary widely and can even vary across gender. That is, men can have female alters and women can have male alters. The physical changes that occur in a switch between alters is one of the most baffling aspects of dissociative identity disorder. People assume whole new physical postures and voices and vocabularies. One study conducted in 1986 found that in 37 percent of patients, alters even demonstrated different handedness from the host.

Statistically, sufferers of DID have an average of 15 identities. The disorder is far more common among females than males (as high as 9-to-1), and the usual age of onset is in early childhood , generally by the age of four. Once established, the disorder will last a lifetime if not treated. New identities can accumulate over time as the person faces new types of situations. For instance, as a sufferer confronts sexuality in adolescence , an identity may emerge that deals exclusively with this aspect of life. There are no reliable figures as to the prevalence of this disorder, although it has begun to be reported with increased frequency over the last several years. People with DID tend to have other severe disorders as well, such as depression , substance abuse, borderline personality disorder and eating disorders , among others.

In nearly every case of DID, horrific instances of physical or sexual child abuse—even torture—was present (one study of 100 DID patients found that 97 had suffered child abuse ). It is believed that young children, faced with a routine of torture and neglect, create a fantasy world in order to escape the brutality. In this way, DID is similar to post-traumatic stress disorder , and recent thinking in psychiatry has suggested that the two disorders may be linked; some are even beginning to view DID as a severe subtype of post-traumatic stress disorder.

Treatment of dissociative identity disorder is a long and difficult process, and success (the complete integration of identity) is rare. A 1990 study found that of 20 patients studied, only five were successfully treated. Current treatment method involves having DID patients recall the memories of their childhoods. Because these childhood memories are often subconscious, treatment often includes hypnosis to help the patient remember. There is a danger here, however, as sometimes the recovered memories are so traumatic for the patient that they cause more harm.

The stories of two women with multiple personality disorders have been told both in books and films. A woman with 22 personalities was recounted in 1957 in a major motion picture staring Joanne Woodward and in a book by Corbett Thigpen, both titled the Three Faces of Eve. Twenty years later, in 1977, Caroline Sizemore, the 22nd personality to emerge in "Eve," described her experiences in a book titled I'm Eve. Although the woman known as "Eve" developed a total of 22 personalities, only three could exist at any one time—for a new one to emerge, an existing personality would "die."

The story of Sybil (a pseudonym) was published in 1973 by Flora Rheta Schreiber, who worked closely for a decade with Sybil and her New York psychiatrist Dr. Cornelia B. Wilbur. Sybil's sixteen distinct personalities emerged over a period of 40 years.

Both stories reveal fascinating insights—and raise thought-provoking questions—about the unconscious mind, the interrelationship between remembering and forgetting, and the meaning of personality development. The separate and distinct personalities manifested in these two cases feature unique physical traits and vocational interests. In the study of this disorder, scientists have been able to monitor unique patterns of brainwave activity for the unique multiple personalities.

There is considerable controversy about the nature, and even the existence, of dissociative identity disorder. One cause for the skepticism is the alarming increase in reports of the disorder over the last several decades. Eugene Levitt, a psychologist at the Indiana University School of Medicine, noted in an article published in Insight on the News (1993) that "In 1952 there was no listing for [DID] in the DSM, and there were only a handful of cases in the country. In 1980, the disorder [then known as multiple personality disorder] got its official listing in the DSM, and suddenly thousands of cases are springing up everywhere." Another area of contention is in the whole notion of suppressed memories, a crucial component in DID. Many experts dealing with memory say that it is nearly impossible for anyone to remember things that happened before the age three, the age when much of the abuse supposedly occurred to DID sufferers.

Regardless of the controversy, people diagnosed with this disorder are clearly suffering from some profound disorder. As Helen Friedman, a clinical psychologist in St. Louis told Insight on the News, "When you see it, it's just not fake."

Further Reading

Arbetter, Sandra. "Multiple Personality Disorder: Someone Else Lives Inside of Me." Current Health (2 November 1992): 17.

Mesic, Penelope. "Presence of Minds." Chicago (September 1992): 100.

Sileo, Chi Chi. "Multiple Personalities: The Experts Are Split." Insight on the News (25 October 1993): 18. Sizemore, Chris Costner. I'm Eve . Garden City, NY: Doubleday, 1977.

Sybil [video recording].

Thigpen, Corbett H. The Three Faces of Eve. New York: Popular Library, 1957.

The Three Faces of Eve [videorecording]. Beverly Hills, CA: Fox Video, 1993. Produced and directed from his screenplay by Nunnally Johnson. Originally released as motion picture in 1957.

"When the Body Remembers." Psychology Today (April 1994): 9.

Additional topics

  • Divergent Thinking
  • Other Free Encyclopedias

Psychology Encyclopedia Psychological Dictionary: Kenneth John William Craik Biography to Jami (Mulla Nuruddin ʼAbdurrahman ibn-Ahmad Biography

  • Acronyms and Glossary
  • Myths and Misconceptions
  • DSM-5 and ICD 10
  • Presentation
  • Alter Functions
  • Non-Human Alters
  • Systems and Subsystems
  • Internal Worlds
  • Switching and Passive Influence
  • Time Loss, Black Outs, and Co-con
  • DID in the Media
  • I Am Not Sybil
  • Abuse of Males
  • Reactions to Disclosure
  • Traumatic Bonding
  • Primary Structural Dissociation
  • Secondary Structural Dissociation
  • Tertiary Structural Dissociation
  • Structural Dissociation and Cores
  • Problems with the Theory
  • Synthesis of Models
  • Reactive Attachment Disorder
  • Posttraumatic Stress Disorder
  • Complex-Posttraumatic Stress Disorder
  • Dissociative Amnesia
  • Depersonalization / Derealization
  • OSDD-1 Compared to DID
  • Psychogenic Non-Epileptic Seizures
  • Factitious Disorder
  • Borderline Personality Disorder
  • Antisocial Personality Disorder
  • Narcissistic Personality Disorder
  • Depressive and Bipolar Disorders
  • Anxiety Disorders
  • Feeding and Eating Disorders
  • Developmental Disorders
  • Integration
  • Grounding Techniques
  • DID in Children
  • DID Around the World
  • Iatrogenic and Sociocognitive Models
  • DID Validity
  • False Memories
  • Repressed Memory Validity
  • Assessing Repressed Memories
  • Factitious and Malingered DID
  • Hotlines and Crisis Resources
  • Reporting Child Abuse
  • About the Author
  • Privacy Policy
  • Acknowledgements
  • Participate in Research!

“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”

― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook

case studies for did

Image: " child abuse " by Peter Bulthuis

CC BY-NC-SA 2.0

Dissociative identity disorder is the result of repeated or long-term childhood trauma . It cannot form after 6 to 9 years of age. Therefore, there must be children who can be diagnosed with DID. Because children are diagnosed with DID more rarely than adults are, some assume that DID is not valid or that it does not truly form as a response to childhood trauma . What this position fails to take into account is that that although DID must form while an individual is still a child, it can fully manifest or become apparent at any age. Even many adults with DID are often not immediately diagnosable to such, and clinicians who have no training regarding dissociation might never realize if one or more of their patients have DID. DID in adults is often at first mistaken for a variety of other conditions , and DID is even harder to recognize in children.

In children, the presentation of DID is often more covert and less complete than it is in adults. Dissociation may be visible primarily through problems with memory, concentration, attachment, and play with traumatic themes. Full switches between alters are rare when compared to passive interference that presents as overlap or disruption between mental states and discontinuities in experience. When switches do occur, they're easily mistaken for normal signs of adolescence or for other, better known disorders such as major depressive disorder, bipolar disorder , or attention deficit disorder (APA, 2013). 1   Because dissociative states develop more the more that they are used and exposed to new situations, dissociative states in children are often not as fully developed or obvious as can be alters in adults. Additionally, children might be less likely to realize that having such distinct parts is unusual, and when they do have this knowledge, they might be unwilling or frightened to admit to having parts or to talk about their parts. Finally, even if the dissociative child attempts to seek help, the adults around and in charge of the child might deny that the child could have been hurt enough for them to have a dissociative disorder, especially a severe dissociative disorder like DID (ISST-D, n.d.). 2

Despite all of this, DID is sometimes diagnosed in children, even young children, who show especially noticeable symptoms of the disorder or who blatantly switch. Occasionally, children with documented trauma histories will show extreme variations in behavior and temperament that are associated with identifying themselves by a different name. Episodes of fear, anger, or aggression may not be recalled by the child after they occur. These children might frequently zone out, daydream, or enter trance-like states. They might have unprovoked and extreme changes in mood or consistently switch through different sets of preferences, opinions, and skills (Muller, 2013) . 3 A dditional indicators of dissociation in children include the child repeatedly regressing to a younger state, referring to themself by a different name or as "we," repeatedly cycling through gaining and losing the same sets of skills, seeming unable to feel emotions or being unaware of their emotional state, showing confusion over what situations are or are not safe, being unable to recall important but non-traumatic events and situations, admitting to hearing voices in their head, reporting having people inside who boss them around, displaying signs and symptoms of posttraumatic stress disorder , being unable to feel pain or not reacting to pain, or having frequent but unexplained health problems (ISST-D, n.d.). 2

There are specific diagnostic measures that can indicate that a child might be struggling with a dissociative disorder. These include the Children’s Dissociative Experiences Scale and Posttraumatic Symptom Inventory [CDES/PTSI], Adolescent Dissociative Experiences Scale, version 2 [A-DES, II], Adolescent Multi-Dimensional Inventory of Dissociation [A-MID], and Child Dissociative Checklist [CDC-III]. It is important that dissociative children be recognized as such so that they can get proper treatment before their disorder can worsen and to prevent further suffering (ISST-D, n.d.). 2  

When a child has unrecognized problems with dissociation, they are likely to be subjected to many difficult struggles. Often, they cannot hide their dissociation well, and they might be accused of being careless, inattentive, or liars. Particularly if the child does not understand the reason behind their lapses in attention or memory, they can become confused, self critical, and depressed. Harsh or judgmental reactions from others in response to the children's seemingly inconsistent interests, preferences, and abilities can also confuse and upset dissociative children. Some children seem to be genetically predisposed to dissociate, but maladaptive dissociation is generally associated with maltreatment or other stressful experiences. When children repeatedly rely on dissociation in order to avoid being overwhelmed by difficult situations, they can become sensitized to it and inappropriately dissociate in educational or social settings, which can interfere with their learning and development. This can lead to additional criticism and maltreatment from adults and peers, further upsetting the child and reinforcing their reliance on dissociation. Problems such as social withdrawal or aggressive acting out are also possible (Hauggard, 2004). 4

In contrast, when dissociation is recognized and diagnosed in children, the prognosis is very positive. In one study, four out of five children with DID were successfully fully integrated , and when two of the children were followed up with 22 and 69 months later respectively, the integration was still stable for both. In the latter case, integration of all five alters was achieved within only twelve therapy sessions. Prior to integration, most of the children's alters had expressed a desire to be "normal." They did not strongly express or differentiate themselves, and most were trauma-oriented (Kluft, 1985). 5 In general, important aspects of successfully treating dissociative children include ensuring that the child's environment is safe, empathizing with the child about their desire to dissociate in frightening situations, expressing concern about the child's use of dissociation in situations in which they need to be mentally present, learning to recognize signs that the child is dissociating and helping them learn to ground themselves, and educating the child's caregivers and helping them to support the child (Hauggard, 2004). 4

Both the International Society for the Study of Trauma and Dissociation (ISST-D) and the Sidran Institute have guidelines for caregivers of dissociative children or for professionals who work with dissociative children and adolescents. For parents, advice is given such as how to avoid triggering or upsetting children who are victims of abuse as well as how to handle children's alters. The Sidran guidelines discuss acting out and destructive behaviors, amnesia between alters and how this relates to system responsibility and accountability, and how to allow the child to express their emotions in safe and healthy ways (Waters, 1996). 6 In contrast, the ISSTD's guidelines for professionals addresses a wide variety of dissociative symptoms that can arise in disordered and traumatized children. It discusses who is qualified to treat dissociation in children, how dissociation can present in children, how to assess trauma and dissociation in children, the length and course of treatment, the role of the therapist in treatment, the goals of treatment, and possible adjunctive treatments. Care is taken to inform clinicians how to recognize switches between alters during diagnostic interviews and how to react by encouraging internal cohesion and awareness as opposed to switching or dissociative behaviors. Instructions are given as to how the clinician can encourage the child's family to react in similar ways by acknowledging the child as a whole and not placing emphasis on the child's internal separation (ISSD, 2004). 7

Not only is DID possible in children, it is something that is not created or encouraged by clinicians. In contrast, clinicians stress that childhood DID must not be worsened by treating alters as separate individuals instead of dissociative parts that should be helped to integrate into one whole. Several books address how to promote integration in children. Books related to recognizing and treating dissociation in children include The Dissociative Child: Diagnosis, Treatment and Management edited by Joyanna Silberg (a chapter of which can be found online here ), Dissociative Children: Bridging the Inner and Outer Worlds by Lynda Shirar, The Child Survivor: Healing Developmental Trauma and Dissociation by Joyanna Silberg, and Dissociation in Traumatized Children and Adolescents: Theory and Clinical Interventions edited by Sandra Wieland (which can be found online here ).

Finally, there was an article about how psychiatric nurses can recognize and treat dissociation and dissociative disorders in children. It has since been redacted due to references that could not be verified, but it itself is still referenced in many other similar case studies and articles and can confirm the way in which clinicians were meant to react to dissociation and alters in children and adolescents. It can be found here (Weber, 2009). 8

1 American Psychiatric Association. (2013). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm08

2 ISST-D. (n.d.). Child/adolescent FAQ's. Retrieved from

https://www.isst-d.org/resources/child-adolescent-faqs/

3 Muller, R. T. (2013, December 27). Understanding dissociative identity disorder in children. Retrieved from https://www.psychologytoday.com/blog/talking-about-trauma/201312/understanding-dissociative-identity-disorder-in-children

4 Haugaard, J. J. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolesce who have been severely maltreated: Dissociative disorders. Child Maltreatment, 9 (46), 146-153.

5 Kluft, R. P. (1985). Hypnotherapy of Childhood Multiple Personality Disorder. American Journal of Clinical

Hypnosis, 27 (4).

6 Waters, F. S. (1996). Parents as partners. Retrieved from http://www.sidran.org/resources/for-survivors-and-loved-ones/parents-as-partners/

7 ISSD Task Force on Child and Adolescents. (2004). Guidelines for the evaluation and treatment of dissociative symptoms in children and adolescents. Journal of Trauma & Dissociation, 5 (3), 119-150. doi:10.1300/J229v05n03_09

8 Weber, S. (2009). THIS ARTICLE HAS BEEN RETRACTED Treatment of trauma- and abuse-related dissociative symptom disorders in children and adolescents. Journal of Child and Adolescent Psychiatric Nursing, 22 (1), 2-6. doi:10.1111/j.1744-6171.2008.00163.x

Additional Resources

Additional research exists on the existence and presentation of dissociative identity disorder in children. Much of it is behind paywalls, but abstracts for some relevant studies can be found here , here , and here . If one can read Turkish, 36 case studies are presented here .

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All content on this website is provided for the purpose of general information only. It is not intended to be used as a substitute for professional diagnosis and treatment. Please consult a licensed professional before making any healthcare decisions or for guidance about potential mental health conditions.

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Methodology

  • What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

  • Provide new or unexpected insights into the subject
  • Challenge or complicate existing assumptions and theories
  • Propose practical courses of action to resolve a problem
  • Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Normal distribution
  • Degrees of freedom
  • Null hypothesis
  • Discourse analysis
  • Control groups
  • Mixed methods research
  • Non-probability sampling
  • Quantitative research
  • Ecological validity

Research bias

  • Rosenthal effect
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  • Status quo bias

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McCombes, S. (2023, November 20). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved February 14, 2024, from https://www.scribbr.com/methodology/case-study/

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Anti-abortion group’s studies retracted before supreme court mifepristone case, a large number of other, non-retracted studies find mifepristone to be very safe..

Beth Mole - Feb 7, 2024 12:07 am UTC

Mifepristone (Mifeprex) and misoprostol, the two drugs used in a medication abortion, are seen at the Women's Reproductive Clinic, which provides legal medication abortion services, in Santa Teresa, New Mexico, on June 17, 2022.

Scientific journal publisher Sage has retracted key abortion studies cited by anti-abortion groups in a legal case aiming to revoke regulatory approval of the abortion and miscarriage medication, mifepristone—a case that has reached the US Supreme Court , with a hearing scheduled for March 26.

On Monday, Sage announced the retraction of three studies, all published in the journal Health Services Research and Managerial Epidemiology. All three were led by James Studnicki, who works for The Charlotte Lozier Institute, a research arm of Susan B. Anthony Pro-Life America. The publisher said the retractions were based on various problems related to the studies' methods, analyses, and presentation, as well as undisclosed conflicts of interest.

Two of the studies were cited by anti-abortion groups in their lawsuit against the Food and Drug Administration ( Alliance for Hippocratic Medicine v. FDA ), which claimed the regulator's approval and regulation of mifepristone was unlawful. The two studies were also cited by District Judge Matthew Kacsmaryk in Texas, who issued a preliminary injunction last April to revoke the FDA's 2000 approval of mifepristone. A conservative panel of judges for the 5th Circuit Court of Appeals in New Orleans partially reversed that ruling months later , but the Supreme Court froze the lower court's order until the appeals process had concluded.

Mifepristone, considered safe and effective by the FDA and medical experts, is used in over half of abortions in the US.

Amid the legal dispute, the now-retracted studies drew immediate criticism from experts, who pointed out flaws. Of the three, the most influential and heavily criticized is the 2021 study titled " A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999–2015 " (PDF). The study suggested that up to 35 percent of women on Medicaid who had a medication abortion between 2001 and 2015 visited an emergency department within 30 days afterward. Its main claim was that medication abortions led to a higher rate of emergency department visits than surgical abortions.

Critics noted a number of problems: The study looked at all emergency department visits, not only visits related to abortion. This could capture medical care beyond abortion-related conditions, because people on Medicaid often lack primary care and resort to going to emergency departments for routine care. When the researchers tried to narrow down the visits to just those related to abortion, they included medical codes that were not related to abortion, such as codes for ectopic pregnancy, and they didn't capture the seriousness of the condition that prompted the visit. Medication abortions can cause bleeding, and women can go to the emergency department if they don't know what amount of bleeding is normal. The study also counted multiple visits from the same individual patient as multiple visits, likely inflating the numbers. Last, the study did not put the data in context of emergency department use by Medicaid beneficiaries in general over the time period.

In contrast to Studnicki's study, the American College of Obstetricians and Gynecologists notes that studies looking at tens of thousands of medication abortions have concluded that "serious side effects occur in less than 1 percent of patients, and major adverse events—significant infection, blood loss, or hospitalization—occur in less than 0.3 percent of patients. The risk of death is almost non-existent."

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Fake and Explicit Images of Taylor Swift Started on 4chan, Study Says

The people on 4chan who created the images of Ms. Swift thought of it as a sort of game, the researchers said.

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Taylor Swift, wearing a white knit cap and a red jacket with the number 87 in white.

By Tiffany Hsu

Images of Taylor Swift that had been generated by artificial intelligence and had spread widely across social media in late January probably originated as part of a recurring challenge on one of the internet’s most notorious message boards , according to a new report.

Listen to This Article

Open this article in the New York Times Audio app on iOS.

Graphika, a research firm that studies disinformation, traced the images back to one community on 4chan, a message board known for sharing hate speech, conspiracy theories and, increasingly, racist and offensive content created using A.I.

The people on 4chan who created the images of the singer did so in a sort of game, the researchers said — a test to see whether they could create lewd (and sometimes violent) images of famous female figures.

The synthetic Swift images spilled out onto other platforms and were viewed millions of times . Fans rallied to Ms. Swift’s defense, and lawmakers demanded stronger protections against A.I.-created images.

Graphika found a thread of messages on 4chan that encouraged people to try to evade safeguards set up by image generator tools, including OpenAI’s DALL-E, Microsoft Designer and Bing Image Creator. Users were instructed to share “tips and tricks to find new ways to bypass filters” and were told, “Good luck, be creative.”

Sharing unsavory content via games allows people to feel connected to a wider community, and they are motivated by the cachet they receive for participating, experts said. Ahead of the midterm elections in 2022, groups on platforms like Telegram, WhatsApp and Truth Social engaged in a hunt for election fraud, winning points or honorary titles for producing supposed evidence of voter malfeasance. (True proof of ballot fraud is exceptionally rare .)

In the 4chan thread that led to the fake images of Ms. Swift, several users received compliments — “beautiful gen anon,” one wrote — and were asked to share the prompt language used to create the images. One user lamented that a prompt produced an image of a celebrity who was clad in a swimsuit rather than nude.

Rules posted by 4chan that apply sitewide do not specifically prohibit sexually explicit A.I.-generated images of real adults.

“These images originated from a community of people motivated by the ‘challenge’ of circumventing the safeguards of generative A.I. products, and new restrictions are seen as just another obstacle to ‘defeat,’” Cristina López G., a senior analyst at Graphika, said in a statement. “It’s important to understand the gamified nature of this malicious activity in order to prevent further abuse at the source.”

Ms. Swift is “far from the only victim,” Ms. López G. said. In the 4chan community that manipulated her likeness, many actresses, singers and politicians were featured more frequently than Ms. Swift.

OpenAI said in a statement that the explicit images of Ms. Swift were not generated using its tools, noting that it filters out the most explicit content when training its DALL-E model. The company also said it uses other safety guardrails, such as denying requests that ask for a public figure by name or seek explicit content.

Microsoft said that it was “continuing to investigate these images” and added that it had “strengthened our existing safety systems to further prevent our services from being misused to help generate images like them.” The company prohibits users from using its tools to create adult or intimate content without consent and warns repeat offenders that they may be blocked.

Fake pornography generated with software has been a blight since at least 2017, affecting unwilling celebrities , government figures , Twitch streamers , students and others. Patchy regulation leaves few victims with legal recourse; even fewer have a devoted fan base to drown out fake images with coordinated “Protect Taylor Swift” posts.

After the fake images of Ms. Swift went viral, Karine Jean-Pierre, the White House press secretary, called the situation “alarming” and said lax enforcement by social media companies of their own rules disproportionately affected women and girls. She said the Justice Department had recently funded the first national helpline for people targeted by image-based sexual abuse, which the department described as meeting a “rising need for services” related to the distribution of intimate images without consent. SAG-AFTRA , the union representing tens of thousands of actors, called the fake images of Ms. Swift and others a “theft of their privacy and right to autonomy.”

Artificially generated versions of Ms. Swift have also been used to promote scams involving Le Creuset cookware . A.I. was used to impersonate President Biden’s voice in robocalls dissuading voters from participating in the New Hampshire primary election. Tech experts say that as A.I. tools become more accessible and easier to use, audio spoofs and videos with realistic avatars could be created in mere minutes.

Researchers said the first sexually explicit A.I. image of Ms. Swift on the 4chan thread appeared on Jan. 6, 11 days before they were said to have appeared on Telegram and 12 days before they emerged on X. 404 Media reported on Jan. 25 that the viral Swift images had jumped into mainstream social media platforms from 4chan and a Telegram group dedicated to abusive images of women. The British news organization Daily Mail reported that week that a website known for sharing sexualized images of celebrities posted the Swift images on Jan. 15.

For several days, X blocked searches for Taylor Swift “with an abundance of caution so we can make sure that we were cleaning up and removing all imagery,” said Joe Benarroch, the company’s head of business operations.

Audio produced by Tally Abecassis .

Tiffany Hsu reports on misinformation and disinformation and its origins, movement and consequences. She has been a journalist for more than two decades. More about Tiffany Hsu

Explore Our Coverage of Artificial Intelligence

News  and Analysis

OpenAI announced that it was releasing a new version of ChatGPT that would remember all prior conversations with users  so it could use that information in future chats.

The F.T.C. outlawed unwanted robocalls generated by A.I. , amid growing concerns over election disinformation and consumer fraud facilitated by the technology.

Google has released Gemini, a smartphone app that behaves like a talking digital assistant as well as a conversational chatbot .

The Age of A.I.

Amid an intractable real estate crisis, fake luxury houses offer a delusion of one’s own. Here’s how A.I. is remodeling the fantasy home .

New technology has made it easier to insert digital, realistic-looking versions of soda cans and shampoo on videos on social media. A growing group of creators and advertisers is jumping at the chance for an additional revenue stream .

A start-up called Perplexity shows what’s possible for a search engine built from scratch with A.I. Are the days of turning to Google for answers numbered ?

Chafing at their dependence on the chipmaker Nvidia, Amazon, Google, Meta and Microsoft are racing to build A.I. chips of their own .

A.I. image generators are trained on other people’s artwork. Are the tools violating copyright in the process? A series of tests run with the technology suggests as much .

Biden responds angrily to special counsel report questioning his memory

President declares his memory is ‘fine’ and blasts counsel for suggesting he does not know when his son died.

President Biden on Thursday night gave an emotional and at times angry response to a special counsel’s report questioning his memory, addressing the nation hours after the release of the report that painted a devastating picture of his mental agility even as it said he would not be charged for mishandling classified documents.

“I’m well-meaning, and I’m an elderly man — and I know what the hell I’m doing,” he declared from the Diplomatic Reception Room at the White House, as he shouted at times, jousted with reporters and gave responses that verged on sarcasm.

Biden was responding to a comment in the report that he can come off as a “well-meaning, elderly man with a poor memory.”

The president, who is 81, grew particularly emotional recounting a line from special counsel Robert K. Hur’s report that suggested he did not recall the year in which his son Beau had passed away. Beau Biden died of cancer in 2015, when his father was vice president.

“There’s even [a] reference that I don’t remember when my son died,” Biden said. “How in the hell dare he raise that?”

The president said he remembers his son’s death every day. “Frankly, when I was asked the question, I thought to myself it wasn’t any of their damn business,” he said. “I don’t need anyone to remind me of when he passed away.”

Capping a tumultuous afternoon, the White House scrambled to put together the address on short notice, notifying reporters just 20 minutes before it was to take place. Biden’s aides seemed taken aback by the furor caused by the report’s stark comments about his memory, saying it was “significantly limited” and that he had “limited precision and recall.”

Privately, Biden was also furious about the report’s comments on his memory. During a private meeting with House Democrats at their policy retreat in Virginia earlier Thursday, Biden grew especially animated when asked how he was doing.

“How the f--- could I forget the day my son died? Of course I remember everything,” he said, according to two people with knowledge of his remarks who spoke on the condition of anonymity to describe a closed-door conversation.

At his White House remarks, Biden began by stressing that the report concluded that charges were not merited, even citing specific page numbers to bolster his case.

“I was pleased to see he reached the firm conclusion that no charges should be brought against me in this case,” the president said. “This was an exhaustive investigation.”

He also highlighted a separate investigation into former president Donald Trump’s own handling of classified documents, and the differences between them — notably that Trump allegedly sought to keep the documents even when authorities asked for them back and that he, unlike Biden, now faces criminal charges.

“I was especially pleased to see special counsel make clear the stark distinction and difference between this case and Mr. Trump’s case,” Biden said.

Later, when asked if he took responsibility for being careless with classified material, he largely pointed to his staff.

“I take responsibility for not having seen exactly what my staff was doing,” Biden said. “Things that appeared in my garage, things that came out of my home, things that were moved — were moved not by me but by my staff. By my staff.”

Later he added, “I didn’t know how half the boxes got in my garage, until I found out staff gathered them up, put them together and took them to the garage in my home.”

His home, he noted, is a private residence, unlike Trump’s Mar-a-Lago, which doubles as a club for members. “It was in my house,” he said. “It wasn’t like, in Mar-a-Lago, in a public place.”

The comments punctuated a remarkable moment in the Biden presidency. The nation’s oldest president has been fighting off voters’ concerns about his age as he prepares to seek reelection against his predecessor — who at 77 is also elderly — only to see a prosecutor’s document unexpectedly and, his aides say, gratuitously renew those concerns in a stark way.

During his address, Biden spoke without a teleprompter. He took questions from an animated press corps, even coming back to the lectern to answer additional queries being fired at him. He repeatedly downplayed concerns that voters have about his age and rebutted any notion that he has lost a mental step.

“Look, my memory has not gotten — my memory is fine,” he said. “Take a look at what I’ve done since I’ve become president. None of you thought I could pass any of the things I got passed. How’d that happen? You know, I guess I just forgot what was going on.”

At a time when some Democrats have expressed concern about the risks of keeping him as the nominee, he was asked why it had to be him.

“I’m the most qualified person in this country to be president of the United States and finish the job I started,” Biden shot back.

When he returned to answer a final question, however, criticizing Israeli Prime Minister Benjamin Netanyahu in perhaps his harshest terms yet, he appeared to again have a verbal stumble. While speaking about aid to Palestinians facing an Israeli bombardment in Gaza, he referred to President Abdel Fatah El-Sisi of Egypt but misstated the country he represents.

“As you know, the president of Mexico, Sisi, did not want to open the gate to allow humanitarian material to get in,” Biden said. “I talked to him. I convinced him to open the gate.”

Cleve R. Wootson Jr. and Marianna Sotomayor contributed to this report.

case studies for did

Information Technology Services

Office of Internal Audit relies on ITS Managed Desktop Services

By Louise Flinn

Dean Weber chief audit officer in the office of internal audit

The Office of Internal Audit (OIA) at UNC-Chapel Hill is a service unit that assists University management in providing the highest quality education and services to students and the people of North Carolina. Dean Weber, Chief Audit Officer, said that OIA’s underlying premise is that “the University must function at the highest level possible.” The OIA supports this objective by providing independent and proactive analyses of operations, financial activities and systems of internal control. Weber said these analyses evaluate whether resources are used in keeping with State requirements and the University’s mission, goals and objectives.

The Office of Internal Audit has been an ITS Managed Desktop Support (MDS) customer since June 2019. MDS provides IT support to faculty, staff and administrators at UNC-Chapel Hill. The group supplies “fixers” for technical support as well as consultative services, with a focus on security and reliability. It supports 15 different campus departments.

In this customer case study, Weber answered a few questions about the “terrific” partnership between OIA and MDS.

Tell us a little about the Office of Internal Audit.

The University established an internal audit function in 1961 with an internal auditor position in the Division of Business and Finance. Fast forward to 2024, the Office of Internal Audit (OIA) operates as an independent department with the chief audit officer administratively reporting to the University’s chancellor and functionally to the Board of Trustees, Audit, Compliance and Risk Management Committee.

Why did you enlist ITS Managed Desktop Services?

We turned to MDS to aid in supporting the technology administration of our department. As a smaller unit of eight FTE administratively housed under the Chancellor’s Office, we realized our department lacked the professional expertise necessary to maintain our administrative technology needs. Specifically, we needed to ensure our technology was properly managed, administered, secured and understood by our department’s users. MDS was the solution to meet our needs in providing professional, efficient, knowledgeable and user-friendly staffing to support our desktop computing needs.

What services does MDS provide to your department?

MDS provides support and direction guiding desktop computing needs for our department. This encompasses addressing departmental staff’s immediate technology questions, as well as our technology hardware and software application planning needs. MDS quickly and efficiently responds to our requests to prepare laptops for our team members, comprising wiping and refreshing equipment when changes in staffing occur. They readily respond to user inquiries regarding technology access, software application questions and technology procurement needs.

How does partnering with MDS benefit OIA?

Partnering with MDS as the provider for our department’s administrative desktop hardware and software computing needs has been terrific! As a department focused on cost-effectiveness, the OIA recognizes substantial value in this partnership, both from a financial standpoint and in terms of the knowledge-based expertise offered in technology administration. The utilization of this shared University resource adds significant value to our unit, given that the costs incurred are minimal compared to the alternative of hiring an in-house professional to support our computing needs. This strategic approach allows us to benefit from specialized support while maintaining a prudent fiscal approach.

What about MDS’ support or service has exceeded your expectations?

I am consistently impressed by the professionalism and expertise demonstrated by every member of the Managed Desktop Services Team with whom I interact. Their responsiveness in addressing our inquiries, fulfilling requests and addressing concerns is prompt and delivered in a friendly manner. Our designated representative is readily accessible through various communication channels, including text, email, phone and Teams, making the process of reaching out to MDS remarkably convenient.

The utilization of Teams chat and remote screen sharing between MDS and our staff has proven to be an invaluable resource. This collaborative approach facilitates swift and effective solutions, enabling the resolution of technology concerns or problems in real time. This efficient process allows us to promptly return to our work, supporting our audit activities with minimal disruption.

What would you tell other schools or departments that are considering hiring MDS?

I would tell them that based on my experience, this is certainly a value-added opportunity to successfully meet the desktop computing needs of their team. MDS personnel are extremely professional, knowledgeable, responsive and customer focused. They are a valuable resource possessing the expertise necessary to support and solve your team’s desktop computing issues.

Anything else you would like to say?

In the decentralized University operating environment, leveraging Managed Desktop Services (MDS) offers a steadfast and dependable solution for meeting desktop computing requirements. MDS services stand out as an efficient and cost-effective option, equipped with the expertise to offer guidance and direction in addressing user technology needs. This includes providing swift and effective solutions, along with expert advice on the optimal methods for addressing software and hardware requirements.

MDS and the OIA IT Systems Auditor are collaborating to explore IT audit services that will provide MDS management insight. The audit tool Nessus Professional will be used to assist MDS with evaluating settings in the baseline images for computers they configure. The OIA will provide recommendations from the Center for Internet Security (CIS) benchmarks. This collaboration supports our common goals to strengthen controls and add value to the University of North Carolina at Chapel Hill.

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    case studies for did

  2. 49 Free Case Study Templates ( + Case Study Format Examples + )

    case studies for did

  3. 49 Free Case Study Templates ( + Case Study Format Examples + )

    case studies for did

  4. 49 Free Case Study Templates ( + Case Study Format Examples + )

    case studies for did

  5. 49 Free Case Study Templates ( + Case Study Format Examples + )

    case studies for did

  6. Example Of A Case Study Format: 8 Writing Tips For Reference

    case studies for did

VIDEO

  1. What is case study and how to conduct case study research

  2. What Is A Case Study?

  3. How to Write a Case Study? A Step-By-Step Guide to Writing a Case Study

  4. Types of Case Study [Explanation with Examples]

  5. Learn How to Write a Case Study Assignment the Easiest Way

  6. Types of Case Study. Part 1 of 3 on Case Studies

COMMENTS

  1. A Strange Case of Dissociative Identity Disorder: Are There Any

    In this case study, we present an interesting case of DID with triggers. The association of triggers with DID is not well-studied and understood. We hope that this case study will help unearth the possible association of DID with triggers like stress and substance use disorder. Go to: Case presentation

  2. Dissociative Identity Disorder Cases: Famous and Amazing

    There are many famous dissociative identity disorder (DID) cases, probably because people are so fascinated by the disorder. While DID is rare, detailed reports of DID have existed since the 18th century. Famous cases of dissociative identity disorder have been featured on the Oprah Winfrey show, in books and have been seen in criminal trials.

  3. Dissociative Identity Disorder with Five Alters: A Case Report

    Dissociative Identity Disorder (DID) is a complex disorder that stems from repeated trauma during childhood. Although not particularly rare, DID is surrounded by myths and stigma that prevent...

  4. A systematic review of the neuroanatomy of dissociative identity

    1. Introduction. Although DID has been recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) since the 1980s, the disorder has remained controversial (APA, 2013).The validity of the diagnosis is often called into question because of the lack of reliable diagnostic measures (Reinders et al., 2012, van Ijzendoorn and Schuengel, 1996, Weniger et al., 2008).

  5. Schema therapy for Dissociative Identity Disorder: a case report

    Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment.

  6. Dissociative Identity Disorder: Overview and Current Research

    Introduction to Dissociative Identity Disorder (DID) Dissociative Identity Disorder (DID) is a fascinating disorder that is probably the least extensively studied and most debated psychiatric disorder in the history of diagnostic classification.

  7. Frontiers

    This study explores meaning which patients with false-positive or imitated DID attributed to their diagnosis. 85 people who reported elevated levels of dissociative symptoms in SDQ-20 participated in clinical assessment using the Trauma and Dissociation Symptoms Interview, followed by a psychiatric interview.

  8. 10 Famous Cases Of Dissociative Identity Disorder

    10 Famous Cases Of Dissociative Identity Disorder - Listverse Health | March 16, 2015 10 Famous Cases Of Dissociative Identity Disorder by Robert Grimminck fact checked by Jamie Frater Dissociative identity disorder (DID), often called multiple personality disorder (MPD), has fascinated people for over a century.

  9. Dissociative identity disorder

    Dissociative identity disorder ( DID ), also known as multiple personality disorder, split personality disorder or dissociative personality disorder, is a member of the family of dissociative disorders classified by the DSM-5, DSM-5-TR, ICD-10, ICD-11, and Merck Manual for diagnosis. It remains a controversial diagnosis. [21] [22] [23] [24] [25]

  10. Dissociative Identity Disorder (DID): Myths vs. Facts

    Similarly, in a study of 628 community women in Turkey, 1.1% had DID. In addition, studies looking at populations with exceptionally high exposure to trauma or cultural oppression show the highest ...

  11. Three Cases of Dissociative Identity Disorder and Co-Occurring

    Limitations of the present case series include the observational nature of the study, exclusive reliance on clinical diagnoses, and restriction of the study sample to clients with co-occurring BPD. It is unclear whether DDP would be effective for DID clients who are free from this severe personality pathology.

  12. 12 Famous Cases of Dissociative Identity Disorder

    Louis Vivet was one of the most extensively studied cases of DID in the early days of psychiatry. Vivet lived in the latter part of the 19th century. His youth was marked by abuse and neglect, and at eight years old, he was sent to a house of correction. By the age of 17, Vivet was a functioning and intelligent man.

  13. History of Dissociative Identity Disorder

    Jeanne Fery was actually called "the most perfect case" of "dédoublement de la personnalité," the most perfect case of DID, by Bourneville, the man who reissued a book about her life in 1886 (van der Hart, Lierens, Goodwin, 1996).1

  14. Gender Dysphoria and Dissociative Identity Disorder: A Case Report and

    In the present article, we have decided to use a patient's assigned gender at birth when discussing case reports about patients with DID and without GD. Methods Case Report. The assessment and follow-up of a patient suffering for DID but asking for treatment for GD was described. The patient provided written informed consent. Literature Review

  15. Schema therapy for Dissociative Identity Disorder (DID): rationale and

    Practice-based clinical guidelines advise a phase-based approach.•. Drawback of this phase-based approach is its substantial average length and dropout rates.•. In the current study, the efficacy of an alternative approach to treatment for DID (i.e. schema therapy) is tested using a case series design. 1. Introduction.

  16. Dissociative Identity Disorder

    People with DID tend to have other severe disorders as well, such as depression, substance abuse, borderline personality disorder and eating disorders, among others. In nearly every case of DID, horrific instances of physical or sexual child abuse—even torture—was present (one study of 100 DID patients found that 97 had suffered child abuse).

  17. Dissociative Identity Disorder in Children

    In one study, four out of five children with DID were successfully fully integrated, and when two of the children were followed up with 22 and 69 months later respectively, the integration was still stable for both. In the latter case, integration of all five alters was achieved within only twelve therapy sessions.

  18. What Is a Case Study?

    Step 1: Select a case Step 2: Build a theoretical framework Step 3: Collect your data Step 4: Describe and analyze the case Other interesting articles When to do a case study A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject.

  19. Case Study: Dissociative Identity Disorder (DID)

    Case Study: Dissociative Identity Disorder (DID) Improved Essays 1360 Words 5 Pages Open Document Essay Sample Check Writing Quality Show More Introduction: The case study Dissociative Identity Disorder: Multiple Personality is a case study about a 38-year-old woman named Paula, who had a Dissociative Identity Disorder (DID).

  20. Case Study Methodology of Qualitative Research: Key Attributes and

    All subjects Allied Health Cardiology & Cardiovascular Medicine Dentistry Emergency Medicine & Critical Care Endocrinology & Metabolism Environmental Science General Medicine Geriatrics Infectious Diseases Medico-legal Neurology Nursing Nutrition Obstetrics & Gynecology Oncology Orthopaedics & Sports Medicine Otolaryngology Palliative Medicine &...

  21. Anti-abortion group's studies retracted before Supreme Court

    0. Scientific journal publisher Sage has retracted key abortion studies cited by anti-abortion groups in a legal case aiming to revoke regulatory approval of the abortion and miscarriage ...

  22. Rare Human Case of Bubonic Plague in Oregon Confirmed by Authorities

    The state of Oregon just confirmed its first case in eight years, and officials say it probably came from a domestic cat, which also showed symptoms. Oregon health officer Richard Fawcett told Aria Bendix at NBC News that the patient who contracted the plague from their pet became "very sick". Usually, an infection of this kind starts with flu ...

  23. Fake and Explicit Images of Taylor Swift Started on 4chan, Study Says

    Researchers said the first sexually explicit A.I. image of Ms. Swift on the 4chan thread appeared on Jan. 6, 11 days before they were said to have appeared on Telegram and 12 days before they ...

  24. Biden responds angrily to special counsel report questioning his memory

    5 min. President Biden on Thursday night gave an emotional and at times angry response to a special counsel's report questioning his memory, addressing the nation hours after the release of the ...

  25. Office of Internal Audit relies on ITS Managed Desktop Services

    In this customer case study, Weber answered a few questions about the "terrific" partnership between OIA and MDS. Tell us a little about the Office of Internal Audit. The University established an internal audit function in 1961 with an internal auditor position in the Division of Business and Finance. Fast forward to 2024, the Office of ...

  26. Best Online Paralegal Degrees Of 2024

    South University. Online. NON-PROFIT PRIVATE. Earn an Online Associate or Bachelor's degree in the field of Legal Studies. Programs include: Associate of Science (AS) in Paralegal Studies and ...