DID 101

Diagnosis and assessment

Why the record gets crowded

By the time someone reaches a dissociation assessment, they may have years of notes and several diagnoses behind them. Brand and colleagues report that people with DID commonly spend six to twelve years in mental-health care before receiving the diagnosis.1 Reinders and Veltman describe an average of four earlier diagnoses.2

Some of those earlier diagnoses may explain something real. Even so, the missing conversations, detachment, or sudden losses of control may still be left hanging. An assessor goes back through the record to see which experiences kept returning.2

Start with one moment you can describe

A clinician may ask you to choose one incident. Perhaps part of a conversation is missing. A familiar place suddenly felt unfamiliar, or somebody used a name for you that you did not expect.3 One specific example can be more helpful than trying to find the "right" label.

The clinician can then look at the incident from several directions. What happened just before it? What did somebody else notice? Did any of the memory come back later? The same incident may come up at another appointment as the clinician compares it with other episodes in your life.4

One score isn't a diagnosis

A high score on a screening questionnaire gives the clinician something to follow up on. From there, they'll compare it with the interview, your history, and what you describe in later appointments.5

The original DES paper introduced 28 self-report questions and tested them in several small clinical and nonclinical groups. The scale was built to measure dissociative experiences. A score gives the assessor a trail to follow; it does not work through the diagnosis by itself.65 What can the DES tell you? looks at that first study in more detail.

The SCID-D is a guided interview covering amnesia, depersonalization, derealization, identity confusion, and identity alteration.7 The MID works differently. It has 218 self-report items and can be completed at home or through telehealth.89 A clinician can ask what you had in mind when you chose an answer and whether the same experience shows up in daily life.

DID can involve much quieter experiences than a visible switch. Paul Dell thought dramatic changes in state had received too much attention, so his proposed framework looked for thoughts, emotions, or actions that felt disowned, unexpected changes in skill, and recurrent amnesia.10

These were proposed criteria. Dell wrote that researchers still had to determine how many symptoms, and which combinations, should count.10

What earlier clinical studies kept finding

Putnam and colleagues collected clinician questionnaires on 100 people diagnosed under the older multiple-personality label. Depression and dissociative symptoms repeatedly appeared in those reports, though the research team did not interview the patients independently.11

Boon and Draijer took a different route in the Netherlands. They interviewed 71 patients with the SCID-D and reported an average of 8.2 years in mental-health care before the correct diagnosis. The group had arrived with many symptoms and often several earlier psychiatric or neurological diagnoses.12 Eight years before the right diagnosis goes through what that study can and cannot tell us.

Differential diagnosis

There's a lot of overlap between mental health conditions. A voice, a flashback, or a sharp change in self-image can lead an assessment in more than one direction. Complex PTSD can involve flashbacks, detachment, and a sense of being pulled back into another time. Borderline personality disorder can bring rapid changes in mood, identity, and relationships. Schizophrenia-spectrum conditions can involve voices or unusual beliefs.13

This is where the details matter. With voices, the clinician asks where they seem to come from and what happens to reality testing. With a sudden shift in mood or identity, they ask about memory, control, and what was happening around it.13

The assessor may also need to rule out seizures, other neurological conditions, sleep-wake disorders, medication effects, substance use, and other dissociative disorders.14 The timing matters with substances: symptoms that occur only during intoxication, withdrawal, or another direct substance or medical effect fall outside DID criteria.15

Clinicians can also mistake something else for DID. In a 2021 study, six people out of 85 who came for a detailed assessment strongly identified with DID but did not meet the research team's diagnostic criteria. Some had been told they might have DID before a full assessment. Others spoke fluently in diagnostic language or described memory gaps only around shameful events.15

Pietkiewicz and colleagues recommended asking for concrete examples and comparing self-report scores with a clinical interview. That brings the work back to the incident itself: what happened, and what could the person remember afterward?15

Footnotes15

Footnotes

  1. Brand, B. L., Sar, V., Stavropoulos, P., Kruger, C., Korzekwa, M., Martinez-Taboas, A., & Middleton, W. (2016). Separating fact from fiction: An empirical examination of six myths about dissociative identity disorder. Harvard Review of Psychiatry, 24(4), 257-270. Underdiagnosis discussion; diagnostic delay. Review of evidence concerning prevalence, validity, causes, and treatment. ↩

  2. Reinders, A. A. T. S., & Veltman, D. J. (2021). Dissociative identity disorder: Out of the shadows at last? British Journal of Psychiatry, 219(2), 413-414. (Mis)diagnosing DID. Editorial review describing under-recognition, symptom overlap, an average of four prior diagnoses, and lengthy contact with mental-health services before accurate DID diagnosis. ↩ ↩2

  3. Nooney, G. (2024, September 19). An introductory guide to assessing dissociative identity disorder (DID). PESI. Assessment questions and training guidance. Experience-based assessment prompts and advice to seek specialized training and supervision. ↩

  4. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 123-125. Dissociation-focused clinical interviewing and corroborating history. ↩

  5. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 126-128. Structured interviews and screening measures used in assessment. ↩ ↩2

  6. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174(12), 727-735. Abstract; scale development and initial samples. The original 28-item DES study, including its initial reliability and validity testing in small clinical and nonclinical groups. ↩

  7. Steinberg, M. (2023). The SCID-D interview: Dissociation assessment in therapy, forensics, and research. American Psychiatric Association Publishing. Description and contents; Five Component Model. Purpose, symptom domains, structure, classification mapping, and administration requirements for the SCID-D. ↩

  8. Dell, P. F. (2006). The Multidimensional Inventory of Dissociation (MID): A comprehensive measure of pathological dissociation. Journal of Trauma & Dissociation, 7(2), 77-106. Abstract; development and validation. Development and validation of the 218-item self-report MID, including reliability, stability, and convergent, discriminant, and construct validity findings. ↩

  9. The Multidimensional Inventory of Dissociation. (n.d.). MID administration and materials. MID overview; adult form and telehealth directions. Official information on clinician administration, client self-report completion, home and telehealth directions, and interpretation materials. ↩

  10. Dell, P. F. (2006). A new model of dissociative identity disorder. Psychiatric Clinics of North America, 29(1), 1-26. Box 1; pp. 9-10; proposed subjective/phenomenological model. Dell's proposed three-part framework: general dissociative symptoms, partially dissociated intrusions, and fully dissociated intrusions marked by amnesia; the paper distinguishes this proposal from current diagnostic criteria. ↩ ↩2

  11. Putnam, F. W., Guroff, J. J., Silberman, E. K., Barban, L., & Post, R. M. (1986). The clinical phenomenology of multiple personality disorder: Review of 100 recent cases. Journal of Clinical Psychiatry, 47(6), 285-293. Abstract; clinician questionnaire study. A historical clinician questionnaire describing depressive and dissociative symptoms among 100 reported cases; the study did not independently interview the patients. ↩

  12. Boon, S., & Draijer, N. (1993). Multiple personality disorder in the Netherlands: A clinical investigation of 71 patients. American Journal of Psychiatry, 150(3), 489-494. Abstract; methods and results. SCID-D study of 71 Dutch patients reporting varied symptoms, frequent prior diagnoses, and an average 8.2 years in mental-health care before diagnosis. ↩

  13. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187. pp. 128-130. Differential diagnosis and common sources of diagnostic confusion. ↩ ↩2

  14. Waseem, M. (2023, October 5). Dissociative identity disorder: Differential diagnoses. Medscape. Differential Diagnoses. Psychiatric, neurological, and other conditions considered when assessing possible DID. ↩

  15. Pietkiewicz, I. J., Banbura-Nowak, A., Tomalski, R., & Boon, S. (2021). Revisiting false-positive and imitated dissociative identity disorder. Frontiers in Psychology, 12, 637929. Table 1, Table 4, and clinical implications. Clinical review of differential assessment, including medical and substance exclusions and suggestive features of false-positive or imitated DID that require careful follow-up rather than assumptions. ↩ ↩2 ↩3

Related reading

The first appointment

What can reasonably happen at the start of assessment or therapy.

Myth: DID is schizophrenia

Two different diagnoses that can share some experiences.

Talking with clinicians

How to describe dissociation clearly when you expect skepticism or confusion.

Study review: What can the DES tell you?

The Dissociative Experiences Scale can flag experiences worth discussing. A score by itself cannot tell you which diagnosis fits.

Study review: Eight years before the right diagnosis

A Dutch study of 71 patients recorded crowded histories, varied symptoms, and years spent in care before DID was identified.

Up next

Treatment overview

DID treatment often begins with the week that is falling apart now. Methods come later and change with the person's response.

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