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Dissociative Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition

Dissociative identity disorder (DID) is a mental health condition that has caught the imaginations of many due to movies and television shows exploiting it to make money. Most people are completely ignorant of the realities of DID, and even those who have been diagnosed with it can get lost in the molasses of disinformation.

There is one instrument; however, that outlines and legitimizes dissociative identity disorder, the Diagnostic and Statistical Manual of Mental Disorders, the fifth edition (DSM-5).

This article shall focus on the DSM-5 criteria for dissociative identity disorder and what each category means.

A Brief History of the DID in the Diagnostic and Statistical Manual of Mental Disorders

 In 1994, the name of multiple personality disorder was changed to dissociative identity disorder. To understand a name-change, and how DID has evolved as a diagnosis, one must first look at the history of its listing in the DSM published by the American Psychiatric Association.

The DSM-1. Mental health professionals in the United States found themselves in a quandary. There were too many different diagnostic systems available, and the resulting chaos caused confusion and sometimes harm.

It became obvious that a standardized categorization needs developing that mental health professionals could agree in the diagnosing and treatment of mental illness. In response, the American Psychiatric Association decided to create such a system, and in 1952 published the first Diagnostic and Statistical Manual of Mental Disorders.

The DSM-I offered 102 very broad diagnostic categories based on Freudian (psychodynamic) principles. Each category was then divided into two major groups.

The first group was straight forward and included disorders assumed as caused by brain dysfunction

The second group of conditions was assumed to result from environmental stress that results in an inability to adapt. This second group of conditions subdivided into two parts.

The first subdivision listed psychoses, which are severe conditions such as schizophrenia and bipolar disorder. The second subdivision listed psychoneuroses, which included personality disorders, anxiety, and depressive disorders.

Although the DSM-I was a step forward, the book had little influence on the preferred diagnostic processes used by individual clinicians or clinics. This lack of cooperation led to the development of the next edition of the DSM.

Unfortunately, multiple personality disorder (as it was then called) did not appear in the earlier versions of the DSM.

The DSM-II. In 1968, the American Psychiatric Association released a new rendition of their diagnostic guide, the DSM-II.  Although still influenced by Freudian principals that were falling out of favor with mental health professionals, the DSM-II added some very important categories and definitions not seen in the previous rendition.

Basically, there were two major modifications with an expansion of the definition of mental illnesses seen outside a hospital setting. However, in attempting to describe and differentiate between the illnesses seen in the general population from those of hospitalized individuals, much confusion resulted.

Also included in the new rendition of the Diagnostic and Statistical Manual of Mental Disorders were several newly added diagnoses, which then was subdivided even farther.

However, it was in this edition where that the term Hysterical Neurosis, Dissociative Type first appeared to describe occurrences of changes in a client’s state of awareness or identity. This category broke down further and included amnesia, somnambulism, fugue, and multiple personalities.

The DSM-III-R. To rename and reorganize categories and make changes in the diagnostic criterium, the American Psychiatric Association released the DSM-III-R. This new edition contained 292 diagnostic categories and removed several controversial diagnoses, such as homosexuality. There was a continued attempt to list each diagnosis under a descriptive category using similar symptoms to help clinicians make a reliable diagnosis.

The DSM-III-R, therefore, was a clarification of categorizations found in the DSM-III.

The DSM-IV. In 1994, the APA published the DSM-IV listing 297 different disorders and consisted of over 886 pages.

Beginning in the DSM-III-R, the descriptive, diagnostic term “clinical significance” had occurred to the criterion of each disorder to indicate the symptoms that must be displayed to give that diagnosis. Clinical significance signifies areas of functioning, such as in social or occupational impairment.

This tradition was included in the DSM-IV, and some minor disorders and symptoms were removed for clarity.

Dissociative identity disorder was remained listed under dissociative hysterical neurosis, hysterical type.

The DSM-IV-TR. In 2000, the APA announced it was publishing a new rendition of the DSM-V called DSM-IV-TR. This edition remained like its predecessor but added some new aspects to diagnostic criteria titled Axes.

The manual used a new five-part axial system incorporating several magnitudes to the diagnoses.

They included:

It was in the DSM-IV that dissociative identity disorder was given its own criteria as a true diagnosis.

The DSM-5. The latest rendition of the DSM, the APA published the DSM-5 in 2013 and contained several major changes.

One change was the removal of Asperger’s syndrome as separated from other types of autism was removed and given an overall diagnosis of Autism Spectrum Disorder.

One very controversial move, the removal of the axial diagnostic system from the DSM-IV-TR, causing a number of organizations to declare they were going to develop and publish their own diagnostic tool for the diagnosis and treatment of mental illnesses.

There are many researchers and clinicians who claim the diagnosing criteria for dissociative identity disorder in the previous version of the DSM to be too vague and inconclusive. So, they offered their time and energy to give their insights on what the criteria should look like.

Dissociative identity disorder, by now very controversial, had it not received detailed criteria, until the DSM-V. However, there are problems with the list of symptoms given for this enigmatic disorder.

A letter was written by a group of researchers in the field of dissociative identity disorder in the DSM-5, including Paul Dell and Richard Lowenstein, presented recommendations for new diagnostic criteria for their specialty. They felt DID has a larger range of symptoms than proposed. These researchers felt the inclusion in the new DSM of symptoms such as switching, which occurs in less than 15% of people living with the diagnosis of dissociative identity disorder, had not explained adequately.

Indeed, there are many subtypes or atypical presentations of DID reaching to a possible 40% of all cases. Making too broad criteria meant many people who do indeed have dissociative identity disorder will gain a misdiagnosis and put them in jeopardy of not receiving adequate treatment.

Another problem the researchers had was with the inclusion of mandatory criteria of switching. This left many diagnoses of dissociative disorder not otherwise specified subtype

Included in the new criteria, problems in the DSM-V with wording drastically changed, affecting an overhaul of the criteria for dissociative identity disorder.

 Dissociative Identity Disorder Diagnostic Listing and Criteria in the DSM-5

As one can see, dissociative identity disorder is now a recognized mental health condition by the American Psychiatric Association included in the DSM. It was in the DSM-5 that DID became easier to diagnose because there are laid out defining diagnostic criteria.

The DSM-5 gives the following diagnostic criteria for Dissociative Identity Disorder:

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption of marked discontinuity in the sense of self and sense of agency, accompanied by related alterations in effect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other key areas of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Explaining the Criteria for Dissociative Identity Disorder

Dissociative Identity Disorder has a wide variety of symptoms, the primary symptoms that occur in all people with DID are described in the DSM psychiatric manual. The key characteristic of Dissociative Identity Disorder is the presence of at least two distinct personality states.

The presence of reoccurring periods of amnesia is the next most important characteristic, sometimes referred to as recurrent lapses in memory, which go beyond ordinary forgetting.

The remaining diagnostic criteria require symptoms to cause distress and/or impaired functioning in at least one area of life, and state that DID can only be diagnosed if no other condition provides a better explanation for symptoms.

Criteria A: Distinct Personality States.

Criteria A: A person diagnosed with Dissociative Identity Disorder has “distinct personality states.”

Criteria A is describing the phenomenon of the presence of alternate ego states often called simply alters or parts. Alters may consist of fully developed parts and fragments of parts. They may be children and adults of all ages, sexes, sexual orientations, and have different tastes in many things.

Except for a small number of people, alters do not readily show themselves to strangers or even to their therapists. Trust must be engendered before any of a system will be overt or “out” and be recognizable as not the person normally in control of the body.

Thankfully, a change placed in the DSM-5 makes it easier to diagnose DID without the clinician having to directly observe a switch between alters.

Instead, DID can be confidently diagnosed with self-reports of the presence and effects of alternate ego states, or of another person’s description of seeing a switch between alters.

Two clusters of symptoms indicate the presence of alters if they are not observed.

These are described in the DSM-5’s extended description of Dissociative Identity Disorder: Sudden alterations or discontinuities in the sense of self and sense of agency (Criteria A), and recurrent dissociative amnesias (Criteria B).

Sense of Self

The term “sense of self” is used in the DSM’s Dissociative Identity Disorder Criterion A, and describes the presence of distinct personality states, better known as alter personalities. A discontinuity in a person’s sense of self can drastically affect any part of the person’s functioning.

There are many differences felt among the varying alter ego states.

Attitudes, outlooks, and personal preferences like preferred foods or clothes may change and can be radically different. This is especially true because many of the alters are of different ages and sexes. These alter ego states are often not aware of each other’s existence or are aware of only a few others. For them, the body is theirs and no one else.

Sense of Agency

Alters can also strongly influence the behavior of the waking self, even when not triggered. Their emotions and thoughts are constantly intruding into the consciousness of the waking self, presenting as voices or even images in the mirror.

When that alter is no longer active, everything changes back until the next time the same alter is triggered. At first, the waking self may feel disoriented to time and place and experience confusion. After gaining their bearings, the person may find they are wearing or have in their closet clothes they would not normally buy or wear.

They may find their credit or debit card has been used, but they do not know by whom. The person may feel like they do not have control of their lives, feelings, thoughts, or feelings. Often, it is this symptom that drives these people to therapy because they believe they are going insane.

People who live with dissociative identity describe their dissociative symptoms in the following terms:

“I have no control, I watch what happens, but can’t stop it.”

“I find myself ‘coming to’ in strange places, but I don’t know how I got there.”

“I have found myself crying uncontrollably and sucking my thumb, but I can’t explain why.”

“Sometimes, I’ve had people call me by a different name in the grocery store, but I don’t know who they are.”

Switching

Switching from one alter state to another can happen very unexpectedly and with or without anyone else noticing. Only in DID can a person switch so drastically from one alter ego state to another, where the alter takes over their bodies.

Outside of treatment, many people experience switching but do not know it is abnormal to do so. They assume that since they have been experiencing lost time and not remembering things they have said and done, it is something everyone does. It is their baseline, their normal.

It is a great surprise to find out that what they have been experiencing is considered abnormal.

The waking self may report to their doctor or therapist feelings of watching themselves from the outside or above while “someone else” controls their body. They will hear themselves saying things that are abnormal for them to say and have not the ability to stop it. This is depersonalization taken to the extreme.

Some who live with dissociative identity disorder might think they have been possessed because of experiencing their body and will be “kidnapped” from them.

A person with dissociative identity disorder may experience themselves as feeling they are growing taller, shorter, younger, older, or any range of demographic changes.

Recurrent Amnesia: Criterion B

People who live with DID may or not remember the actions of their alters. It is possible for a person to be knowledgeable of their actions while in a dissociated state.

Total amnesia for the things done while dissociated is more the norm, however.

This discontinuity of behavior and lack of knowing what happened leads friends, relatives, and acquaintances baffled, and when they tell the person of their behaviors and actions, they claim not to know what the reporters are talking about.

Although they are speaking the truth, they can be incorrectly believed to be lying.

There are several ways this amnesia can present.

Gaps in memory of personal life events

The person may know that someone has died, but they have no memory of the event, or the subsequent visitation, burial, or funeral.

This can mean the amnesiac has lost four to six days of life to a traumatic event. There is at least one case, and there are probably more of a woman waking up married. This sounds like a joke from a B movie, but it is not funny to the woman or her new husband.

Gaps of memory of other life events that are meaningful can be lost to amnesia as well, including their childhoods, adolescence, or the birth of their children.

Amnesia for events does not need to be only attached to traumatic events as lapses in dependable memory of what happened during the day today or remembering how to do well-known skills such as driving, or reading can inexplicably disappear.

The above symptom applies to the entire person. For example, they may have a child alter who does not know how to drive, or a teen alter who does not understand that a debit card is not bottomless.

Dissociative Fugues

This means a person in an altered state, will travel to another place, are common experiences of people living with dissociative identity disorder. They will ‘come to’ and find themselves in places they do not remember going to, such as a restaurant, on a date with a stranger, or even in another state. Sometimes, because these fugue states can last for days or even months, people experiencing a fugue state are reported missing by their families.

If all the gaps in memory for the past or present do not occur, but all the other criteria are met, then the person can be sometimes diagnosed with a sister disorder to DID, Other Dissociative Identity Disorder Presentation.

Clinically Significant Distress or Impairment: Criteria C

The entire criteria of C include:

The symptoms cause clinically significant distress or impairment in social, occupational, or other key areas of functioning.

What the term “that excludes normal reactions to psychosocial stress” means it that the person is having severe problems in their lives with the social, work, and in other ways without the average day to day stressors all people face.

As one can imagine, it is exceedingly difficult to manage life in any way, not knowing from day to day who you will become and what you will do. The chaos, as described in a later chapter, that one experiences are almost too hard to describe.

Money comes up missing, bills do not get paid, and unexplained absenteeism from work all make life unbearable.

Criteria D: The Disturbance is Not a part of a normal cultural or religious practice

Criteria D includes trances, or other religious practices such as speaking in tongues, which are part of some religious practices. It also includes the fantasies of children, such as imaginary friends or fantasy play.

Criteria E: Symptoms are not attributable to substance abuse or other medical condition

There are symptoms of substance abuse, such as alcohol or psychogenic drugs, that are not a symptom of DID. However, many people who live with DID do have co-occurring and ongoing problems with the abuse of substances, and this can make it difficult to recognize and treat their disorder.

There are a few medical conditions that are seen that can be misunderstood and lead to a false diagnosis. Those include complex and partial seizures.

Complex seizures can last up to two minutes and include, among other things, becoming unaware of one’s surroundings and wandering behavior.

Partial Seizures can cause the person to suddenly look blank, also commonly observed with DID.

Pulling It All Together

It is unfortunate that many clinicians in the United States do not recognize the legitimacy of dissociative identity disorder. Clearly, the American Psychiatric Association does, and so does the World Health Organization, which has it listed in their ICD-10 Classification of Mental and Behavioral Disorders.

However, reading the criteria of dissociative identity disorder in the DSM-5 should grant an heir of acceptance among those who live with this life-altering disorder.

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