What is DID?

What clinicians want to find out

When considering the possibility of DID, a clinician shouldn't immediately push you to recount detailed trauma memories. If they do that before discussing safety, that's a red flag.¹² They'll likely ask how long the gaps have been occurring, if other people have noticed, and possibly what accommodations have had to be made to keep daily life going. The clinician will also consider substances, medication effects, seizures, sleep disorders, and other mental health conditions.³⁴⁵

As professionals define it, DID involves a recurring disruption in identity and agency alongside memory gaps that go beyond ordinary forgetting. On top of that, the DSM-5-TR and ICD-11 both require the symptoms to interfere with daily life and that a substance or another condition doesn't better explain them.⁴⁵ Interestingly enough, the manuals word a few requirements differently. ICD-11 says at least two states repeatedly take executive control, and amnesia doesn't have to occur with every change. DSM-5-TR allows the identity disruption to be reported by the person or observed by somebody else.⁵⁴

ICD-11: 6B64

ICD-11 describes these requirements:⁵

• Two or more distinct identity states, with marked breaks in the person's sense of self and agency. At least two states repeatedly take control of consciousness and daily functioning, either in ordinary life or in particular situations.
• A change in state comes with related changes in sensation, perception, emotion, thought, memory, movement, or behaviour.
• Episodes of amnesia go beyond ordinary forgetting. They do not have to occur with every change in state, though substantial episodes are usually present at some point.
• The symptoms interfere with personal, family, social, educational, or working life. Someone who keeps those areas going through significant extra effort can still meet this requirement.
• The symptoms are not better explained by another mental disorder, a substance or medication, neurological disease, or a sleep-wake disorder.

ICD-11 also draws a line around culturally accepted practices. Multiple states that are welcomed within such a practice and do not interfere with daily life are outside the diagnosis.⁵

DSM-5-TR

DSM-5-TR organizes the diagnosis into five criteria:⁴

• Identity is disrupted by two or more distinct personality states, sometimes described in a culture as possession. The change involves a break in the person's sense of self and agency, together with changes in emotion, behaviour, awareness, memory, perception, thinking, or movement. The person may report it themselves, or somebody else may observe it.
• Memory gaps recur around everyday events, important personal information, or traumatic events, and they go beyond ordinary forgetting.
• The symptoms cause significant distress or interfere with social life, work, or another important area.
• The experience falls outside an ordinary part of a broadly accepted cultural or religious practice. For a child, it cannot be better explained by imaginary playmates or fantasy play.
• A substance or medical condition, such as certain kinds of seizure, does not account for the symptoms.

Why the name changed

Clinicians described dissociation and identity-related issues long before anyone drafted a formal name for them.⁶ The diagnosis became official in DSM-III as multiple personality disorder. DSM-IV later updated it to dissociative identity disorder. At least in part, this was because “multiple personality” suggests that several personalities or people inhabit the same body.⁷

The DSM-5 work group later recommended putting more emphasis on disruptive changes in identity, amnesia for everyday events as well as trauma, and possession-form experiences.⁸ For the longer story, read How our understanding of trauma and dissociation changed.

Parts and identity states

There's a number of different words for the self-states involved in DID, such as parts, alters, and identity states.⁹ What matters most, in the end, is whatever helps the person describe and understand their experience.

Having different versions of you is normal: you may be easygoing with an old friend and guarded at work, yet both ways of being still feel like you. Therapists may call these ego states. With ego states, the person generally has continuity in their memories and personal history between them.¹⁰

In DID, this gets disrupted further. You may find messages that feel like someone else wrote them, for example. One state may reach a memory that another cannot, or an action may begin without feeling you consciously chose it.¹⁰

To some people with DID, alters can feel like separate people - this isn't the case for everyone. Clinical treatment guidelines urge the clinician to treat each identity state as part of one whole person. Despite this, a therapist can still respect how separate the states feel and keep treatment focused on the whole person.⁹

Similarly, child-identified states can feel very young. Shusta-Hochberg warned that treating one as a literal child may stall therapy and pull attention away from the adult person's present-day needs.¹¹ Even so, they should be treated with patience and respect. The person is also living in an adult body with relationships and responsibilities outside of the session.⁹

In IFS, “parts” language is also used, which stems from the idea that every mind contains subpersonalities.¹² An IFS part and a dissociative identity state require different approaches. IFS and dissociative parts goes into what a therapist may need to change when amnesia and loss of control are involved.¹⁰

What improvement can look like

Improvement can begin while identity states are still present.¹³ Some people opt for final fusion, others do not. A good clinician should not force any specific treatment outcome. You may notice improvements such as fewer dangerous gaps, more consistent days, more shared awareness, or less time spent in crisis. Maybe a week that used to disappear into crisis becomes a week you can account for. It's up to you and your clinician to decide on longer-term goals as the work unfolds.

In a six-year follow-up, therapists reported higher overall functioning, fewer stressors, and fewer hospitalizations among the patients they continued to follow.¹⁴ Better is not the same as finished takes a closer look at what changed over those six years.

Footnotes14

Footnotes

1. 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. 135-136. Consensus model for sequenced treatment. ↩

2. 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. 136-141. Safety assessment, stabilization, symptom management, and pacing. ↩

3. 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. 117-118. Core diagnostic features, including identity disruption and amnesia. ↩

4. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). pp. 330-331, Dissociative identity disorder. DSM-5-TR diagnostic criteria for dissociative identity disorder, including identity disruption, recurrent memory gaps, impairment, and exclusions. ↩ ↩² ↩³ ↩⁴

5. World Health Organization. (2024). Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. pp. 382-383, Essential (required) features and Additional clinical features. ICD-11 DID requirements, including recurrent executive control by at least two identity states, amnesia, impairment, exclusions, and the normality threshold. ↩ ↩² ↩³ ↩⁴ ↩⁵

6. van der Hart, O., & Horst, R. (1989). The dissociation theory of Pierre Janet. Journal of Traumatic Stress, 2(4), 397-412. Abstract. Historical account of Janet's theory of dissociation as a response to overwhelming experience and of his concepts of memory, emotion, and psychological integration. ↩

7. Young, M., Almaskati, M., Vrabtchev, S., & Kuruvilla, T. (2024). Dissociative identity disorder: A review of the diagnosis that divides. Progress in Neurology and Psychiatry, 28(2), 23-27. Diagnostic history and current DSM/ICD descriptions. Clinical review of DID's diagnostic history, classifications, controversies, and current clinical implications. ↩

8. Spiegel, D., Loewenstein, R. J., Lewis-Fernandez, R., Sar, V., Simeon, D., Vermetten, E., Cardena, E., & Dell, P. F. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28(9), 824-852. Abstract and recommendations. The DSM-5 work group's review and its recommendations to emphasize disruptive dissociation, everyday amnesia, and possession-form presentations. ↩

9. 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. 120-121. Clinical language for identity states and the person as a whole. ↩ ↩² ↩³

10. Mosquera, D. (2023, July 1). What are dissociative parts and how or when to introduce 'parts' language? European Society for Trauma and Dissociation. Sections: What are dissociative parts?; How to distinguish dissociative parts from ego states?. Clinical distinctions between ego states and dissociative parts, including boundaries, autobiography, autonomy, and first-person perspective. ↩ ↩² ↩³

11. Shusta-Hochberg, S. R. (2004). Therapeutic hazards of treating child alters as real children in dissociative identity disorder. Journal of Trauma & Dissociation, 5(1), 13-27. pp. 13-27; abstract and clinical discussion. Clinical discussion of the risks of treating child-identified states as literal children. ↩

12. IFS Institute. (n.d.). The Internal Family Systems model outline. Sections I and III: Basic assumptions; Parts. The IFS model treats parts as subpersonalities within a naturally multiple mind and describes how they may be experienced. ↩

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. 132-134. Treatment goals, coordinated functioning, and integration. ↩

14. Myrick, A. C., Webermann, A. R., Loewenstein, R. J., Lanius, R., Putnam, F. W., & Brand, B. L. (2017). Six-year follow-up of the treatment of patients with dissociative disorders study. European Journal of Psychotraumatology, 8(1), 1344080. Results, limitations, and conclusions. Naturalistic symptom and functioning outcomes over six years. ↩