Dissociative identity disorder, formerly known as multiple personality disorder, is a mental disorder characterized by the presence of at least two distinct and relatively permanent personalities, often accompanied by difficulties in remembering events that cannot be explained by the normal process of forgetting. These states appear alternately in a person's behavior, and vary from person to person. Dissociative identity disorder is often associated with borderline personality disorder, post-traumatic stress disorder, depression, substance abuse disorder, self-harm, and stress. Childhood trauma is thought to be the cause of dissociative identity disorder. In about 90% of cases, there was a history of childhood abuse, while other cases are linked to experiences of war or health problems during childhood. Genetic factors are also thought to play a role. An alternative hypothesis is that dissociative identity disorder is a by-product of techniques used by some therapists, particularly those who use hypnosis. Before making a diagnosis, it is important to make sure that the condition is not due to drug use, seizures, childhood fantasy play, or religious practices. Treatment includes Generally supportive care and psychological counseling. The condition often persists without treatment. It is thought to affect about 2% of the general population and 3% of those admitted to hospitals for mental health problems in Europe and North America. DID is diagnosed six times more often in females than in males. The number of cases has risen dramatically in the second half of the 20th century, along with the number of identities claimed by patients. DID is controversial in both psychiatry and the legal system. It has been used in some cases as a rarely successful model for the insanity defense. A large proportion of patients diagnosed with DID are clustered around a small number of clinicians who support the hypothesis that DID can be induced by treatment. Typical symptoms of the disorder may vary by location and according to how the disorder is portrayed by the media. Dissociation, the term under which dissociative disorders, including DID, fall, lacks a generally agreed-upon, precise, empirical definition. A wide range of diverse experiences have been described as dissociative, ranging from the ordinary failure to Attention is ultimately impaired by the breakdown of memory processes that characterize dissociative disorders. It is therefore not known whether there is a common origin for all that fall under dissociative experience, or whether the range of moderate to severe symptoms is a product of different etiologies and biological structures. Other terms used in the literature, including personality, personality state, identity, ego state, and amnesia, have also not been agreed upon. There are several competing models that incorporate some non-dissociative symptoms while excluding dissociative symptoms. The most widely used model of dissociation depicts DID as severe dissociation that is persistent at one end and flux at the other, although this model is still being tested. Some terminology has been proposed in relation to dissociation, and psychiatrist Paulette Gillig has drawn a distinction between the terms “ego state” and “alter egos,” which are commonly used in discussions of DID. Elert Nijenhuis and colleagues have proposed a distinction between personalities responsible for daily functioning and those that emerge from survival states. Van der Hart and colleagues have used the term “structural dissociation.” "Personality" to distinguish dissociations attributed to traumatic and pathological causes, which in turn are divided into primary, secondary, and tertiary. According to this hypothesis, primary dissociation involves "a normal personality part" and "an emotional personality part", secondary dissociation involves "a normal personality part" and at least two "emotional personality parts", and tertiary dissociation, unique to dissociative identity disorder, is described as having at least two "normal personality parts" and "two emotional personality parts". Others have suggested that dissociation can be separated into two distinct forms, affective detachment and fragmentation, arguing that fragmentation, in which there is a failure to control normally controllable actions and processes, is most prominent in dissociative identity disorder. Efforts have been made to distinguish normal from pathological dissociation through psychometrics, but they have not been generally accepted. DID, according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, involves "the presence of two or more distinct personalities", The DSM symptoms include loss of identity in relation to multiple personalities or states, loss of sense of time, self, and level of consciousness. The clinical presentation of the disorder varies in each individual, and the level of functioning can vary from severely impaired to adequate. Symptoms of dissociative amnesia are included under the diagnosis of DID, but they can also be diagnosed separately. Individuals with DID may experience distress from both the symptoms of DID and the consequences of associated symptoms. The majority of patients with DID report sexual and/or physical abuse, although the accuracy of these reports is debated. The multiple personalities or identities may be unaware of each other, and the fragmentation of knowledge and memories results in a chaotic personal life. Individuals with DID may be reluctant to discuss symptoms because of their association with abuse, shame, and fear. Patients with DID may frequently and strongly experience time disturbances. The number of changes varies widely, with Most patients identify with fewer than ten, although over 4,500 have been reported. The average number of alterations has increased recently over the past few decades, from two or three to now an average of about 16. However, it is unclear whether this is due to a true increase in alterations, or simply that the psychiatric community has become more accepting of a high number of alterations. The primary identity, usually the patient's given name, tends to be "passive, dependent, guilty, and depressed" with other personalities or alterations that are more active, aggressive, or hostile, and usually contain more complete memories. Most identities are of ordinary people, although fantastical, mythical, famous, and animal alterations have been reported. Most cases of dissociative identity disorder have comorbid mental disorders, with an average of 8 DSM-I diagnoses and 4.5 DSM-II diagnoses. The psychiatric history frequently contains multiple previous diagnoses of various disorders and failed treatments. The most common presenting complaint of dissociative identity disorder is depression, with headaches being a neurological symptom. Common. Comorbid disorders can include substance abuse, eating disorders, anxiety, post-traumatic stress disorder, and personality disorders. A significant percentage of those diagnosed with dissociative identity disorder meet DSM axis II criteria for personality disorders such as borderline personality disorder; A significant minority met criteria for avoidant personality disorder and other personality disorders, with about half meeting criteria for borderline personality disorder specifically. On the other hand, the data support a high level of psychotic symptoms in DID, and that both individuals diagnosed with schizophrenia and those diagnosed with DID have a history of trauma. Individuals diagnosed with DID also appear to be more susceptible to hypnosis than clinical patients. The large number of symptoms displayed by individuals diagnosed with DID has led some clinicians to suggest that, rather than being a separate disorder, the diagnosis of DID is actually an indication of the severity of other disorders the patient is diagnosed with. The DSM-IV showed that self-mutilation, impulsivity, and rapid changes in interpersonal relationships "could justify a consensus diagnosis of borderline personality disorder." Stephen Leinen and colleagues have suggested that the significant overlap between BPD and DID may be a contributing factor to the development of drug-induced DID. These are suggestions of subtle changes by therapists who suggest a diagnosis of DID that provide an explanation for the behavioral instability, self-mutilation, mood swings, and unpredictable behaviors that patients experience. In 1993, a group of researchers reviewed both DID and BPD, concluding that DID was an additional manifestation of BPD, with no tests or clinical descriptions able to distinguish between the two. Their conclusions about the empirical evidence for DID were reiterated by a second group, who still believe that the diagnosis exists, but while the knowledge to date has not justified DID as a separate diagnosis, it has also not disproved its existence. Reviews of medical records and psychological tests have shown that the majority of DID patients could be diagnosed with BPD instead, although a third could not, suggesting that DID does exist but could be overdiagnosed. Between 50 and 66% of patients also meet criteria for BPD, Approximately 75% of patients with borderline personality disorder also meet criteria for dissociative identity disorder, with significant overlap between the two conditions in terms of personality traits, cognitive and daily functioning, and assessments by clinicians. Both groups also report higher rates of physical and sexual abuse than the general population. Patients with borderline personality disorder also score high on measures of schizophrenia. Even using very strict criteria, it can be difficult to distinguish between dissociative disorders and borderline personality disorder, although the presence of comorbid anxiety disorders can help. The cause of DID is unknown and widely debated, with debate occurring among proponents of different hypotheses: that DID is a reaction to trauma; that DID is caused by inappropriate psychotherapeutic techniques that cause the patient to assume the role of a patient with DID; More recent hypotheses include memory processes that allow for the possibility that trauma-induced dissociation can occur after childhood in DID, as it does in PTSD. It has been suggested that all trauma-induced and stress-related disorders could be placed into a single category that would include both DID and PTSD. Disturbed or altered sleep has also been suggested to play a role in dissociative disorders in general and DID in particular. Changes in environments also significantly affect the patient with DID. Research is needed to determine the prevalence of the disorder in those who have never been in treatment, and prevalence rates across cultures. These central issues related to the epidemiology of DID remain largely unaddressed despite decades of research. Debates about the causes of DID also extend to disagreements about how to assess and treat the disorder. People diagnosed with DID often report having been subjected to physical and sexual abuse, particularly during early or middle childhood. Others reported an early loss, serious medical illness, or other traumatic event. They also reported more historical psychological trauma than those diagnosed with any other mental illness. Severe sexual, physical, or psychological abuse in childhood has been suggested as an explanation for the development of the illness; Awareness, memories, and emotions of traumatic events and actions are erased from consciousness, and alternate personalities or subpersonalities are formed with different memories, emotions, and behavior. Dissociative identity disorder is characterized by extreme distress or attachment disorders. It can be interpreted as post-traumatic stress disorder in adults and can become dissociative identity disorder when it occurs in children, perhaps because of their greater use of fantasy as a coping mechanism. Perhaps because of developmental changes and a greater sense of coherence about their past before the age of six, experiencing trauma at its most intense can result in personality disorders and dissociative symptoms that are diverse, yet complex. A particular relationship between childhood abuse, disturbed attachments, and lack of social support is thought to be essential components of dissociative identity disorder. Others have proposed explanations that include incomplete childhood upbringing and the innate ability of children in general to dissociate memories and experiences from consciousness. The separation of early trauma from the etiology of dissociation has been explicitly rejected by those who support the early trauma model. However, a 2012 review of an article supports the hypotheses that Recent or current trauma can influence individuals' appraisals more than more recent trauma, altering past experience and resulting in dissociative states. Giesbrecht et al. have suggested that there is no real empirical evidence linking early trauma with schizophrenia, and instead suggest that problems are neuropsychological processes, such as increased fragmentation in responses to certain emotions and contexts, that explain dissociative characteristics. A middle-ground postulates that trauma, in some cases, alters neural mechanisms associated with memory. Evidence is growing that dissociative disorders are associated with a history of trauma and "specific neural mechanisms." It has also been suggested that there may be a real but more modest link between trauma and DID, with early trauma causing increased fantasy tendencies, which in turn may make individuals more sensitive to the social cognitive influences surrounding the development of DID. The suggestion that DID results from childhood trauma has increased demand for the diagnosis among health care providers, patients, and the public because it lends credence to the idea that child abuse has serious, lasting effects. There is very little empirical evidence to support the schizophrenia-related hypothesis. With trauma, there is no research showing that schizophrenia is consistently associated with long-term memory disturbances. The model of schizophrenia and dissociative disorders following widespread stress is controversial. It has been hypothesized that symptoms of DID can be created by a therapist using memory therapy techniques on suggested individuals. Referred to as the social cognitive model, it proposes that DID is caused by a person's conscious or unconscious behavior in specific ways reinforced by culturally constructed stereotypes, and the therapist inadvertently provides cues through inappropriate therapeutic techniques. This behavior is reinforced by media depictions of DID. Proponents of the social cognitive model note that bizarre dissociative symptoms are rarely present prior to intensive treatment by DID professionals who, through elicitation, talk to, and identify changes, shape, or perhaps create a diagnosis. While proponents note that DID is accompanied by real distress and grief symptoms, and can be reliably diagnosed using DSM criteria, they are skeptical of the trauma causality proposed by proponents. Characteristics of people diagnosed with DID Contributing These concerns and those regarding the validity of recovered memories of trauma. Skeptics note that a subset of clinicians are responsible for diagnosing the majority of individuals with DID. Psychologist Nicholas Spanos and others have suggested that in addition to treatment-induced conditions, DID may be the result of alternative identities, although others have disagreed, citing lack of motivation to create or maintain separate identities and alleged history of abuse. Other evidence that treatment can cause DID includes the lack of children diagnosed with DID, the dramatic rise in diagnosis rates after 1980, the absence of evidence of increased rates of child abuse, the disorder most likely to occur in individuals undergoing psychotherapy, particularly involving hypnosis, the presence of bizarre alternative identities, and an increase in the number of alternative identities over time. These diverse therapeutic and cultural causes occur in the context of pre-existing mental illness, particularly borderline personality disorder, which is a common comorbidity with DID. In addition, the manifestations of the illness can vary across cultures, Like Indian patients who switch personalities after a period of sleep, which is common in how DID is presented by the media in that country. Treatment-induced cases of DID are argued to be closely related to false memory syndrome, a concept and term coined by members of the False Memory Syndrome organization in response to memories of alleged abuse that have been exposed by a range of controversial treatments of unproven efficacy. Such memories can be used to make false claims of child sexual abuse. There is little agreement between those who see treatment as a cause and trauma as a cause. Proponents of treatment as a cause of DID suggest that the small number of physician diagnoses and a disproportionate number of cases provide evidence for their position, although it has been argued that diagnoses at higher rates in a particular country, such as the United States, may be due to greater awareness of DID. Lower rates in other countries may be due to less diagnostic recognition. However, false memory syndrome itself is not considered a valid diagnosis by mental health professionals. It has been described as a "non-psychiatric term created by A private organization whose stated goal is to support accused parents, critics argue that the concept has no empirical support, and further describe the False Memory Syndrome organization as an advocacy group that has distorted and misrepresented the research on memory. DID is rarely diagnosed in children, although the average age of onset is three years. This fact is cited as a reason to doubt the validity of DID. Proponents of both pathogenesis models believe that the discovery of DID in a child who has never undergone treatment would critically undermine the social cognitive model (SCM). Conversely, if children were found to develop DID only after undergoing treatment, it would challenge the trauma-mediated model. In 2011, approximately 250 cases of DID in children were identified, although the data do not provide clear evidence for either theory. While the children were diagnosed with DID prior to treatment, many were presented to clinicians by parents who themselves had been diagnosed with DID; Others were influenced by the appearance of DID in popular culture or by being diagnosed with mania due to hearing voices, a symptom found in DID. No studies have looked at children with DID who were not previously in treatment, but by examining the children of those previously in treatment for DID. An analysis of children's diagnoses reported in scientific publications found that 44 single-patient case studies were regularly distributed, but in articles referring to a group of patients, four studies accounted for the majority of the reports. The initial theoretical description of DID was that dissociative symptoms were ways of coping with acute stress, but this belief has been challenged by data from multiple research studies. Proponents of the trauma-origin hypothesis have stated that the high correlation of reported childhood physical and sexual abuse by adults with DID supports the association between trauma and DID. However, the association of poor treatment and DID has been questioned for several reasons. Studies reporting an association usually rely on self-report rather than Independent corroboration, and these results can be distorted by selection or conversion errors. Most studies of trauma and schizophrenia are cross-sectional rather than longitudinal, which means that researchers cannot attribute cause, and studies that avoid recall error have failed to support such a causal association. In addition, studies rarely control for the many comorbid disorders associated with DID, or family disharmony. The common association of DID with childhood abuse is relatively recent, occurring only after the publication of Sybil in 1973. The most recent example of a "multiple" is Chris Costner Sizemore, whose life was depicted in the book and film The Three Faces of Eve, which revealed no history of child abuse. DID can be diagnosed in the fourth revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders using the diagnostic criteria found in the section on dissociative disorders. DID is difficult to diagnose primarily because there is no universally accepted definition. The criteria require that two or more separate identities or personality states repeatedly control an adult, accompanied by loss of recollection of important information, and that no cause is alcohol, drugs, medications, or other medical conditions such as partial seizures. The diagnostic criteria for the disorder in children also specify that the symptoms should not be confused with imaginative play. Diagnosis is usually made by a clinically trained mental health professional, such as a psychiatrist. The psychologist, through clinical assessment and interviews with the patient's family and friends, and taking into account other supportive tools. Some personal assessments and interviews designed specifically for differentiation can also be used in the assessment. Since most symptoms are self-reported, and since they are intangible and unobservable, there is a degree of subjectivity in the diagnosis. Sufferers are often reluctant to seek treatment, especially since their symptoms may not be taken seriously; Dissociative disorders have thus come to be referred to as "disappearance diseases." The diagnosis has been criticized by proponents of the treatment-as-causal or social cognitive hypothesis as being culture-bound and often triggered by health care. Social cues involved in the diagnosis can play a significant role in shaping the patient's behavior and characteristics, such that symptoms in one context may be associated with DID, while in another setting or time the diagnosis may be something other than DID. Other researchers disagree, arguing that the condition's existence and inclusion in the DSM are supported by multiple lines of reliable evidence, with diagnostic criteria that allow it to be distinguished from conditions that are mistaken for such. A large proportion of cases are therefore diagnosed by specific health care providers, and those symptoms that are generated in non-clinical research subjects and given appropriate indications have been suggested as evidence that a small number of clinicians specializing in DID are responsible for the development of alters through treatment. Perhaps because of its scarcity of understanding, dissociative disorders were not initially included in the Structured Clinical Interview in the DSM. The Structured Clinical Interview for DSM-IV, designed to make psychiatric diagnoses more rigorous and reliable. Instead, soon after the publication of the Structured Clinical Interview (SCID), a free system for dissociative disorders was published. This interview takes about 30 to 90 minutes, depending on the subject's experiences. An alternative diagnostic tool, the Dissociative Disorders Interview Schedule, also exists, but the SCID-D is generally considered better. The DDIS is a highly structured interview that distinguishes between the different DSM-IV diagnoses. The DDIS can usually be completed in 30 to 45 minutes. Other questionnaires include the Dissociative Experiences Scale (DES), the Perceptual Changes Scale, the Dissociative Experiences Questionnaire, the Dissociative Experiences Questionnaire, and the Mini-SCIDD. All are related except the Mini-SCIDD, and all include comprehension, a normal part of personality that involves narrowing or widening of attention. The DES provides a quick way to screen people, so the more time-consuming structured interview can be used in groups who have achieved High scores on the DES. Depending on where the cutoffs are placed, people who would later be diagnosed may be mistakenly avoided. An early recommended cutoff was 15–20. The reliability of the DES in nonclinical samples has been questioned. People with DID are diagnosed with five to seven comorbid disorders at a rate much higher than other mental illnesses. Because of the overlapping symptoms, differential diagnoses include schizophrenia, bipolar disorder, epilepsy, borderline personality disorder, and Asperger syndrome. Delusions or auditory hallucinations can be mistaken for formal speech by other personalities. Persistence and stability of identities and behavior, amnesia, or dissociative or hypnotic measurements and reports from family members or other caregivers detailing a history of such changes can help distinguish DID from other conditions. A diagnosis of DID takes precedence over any of the other dissociative disorders. Other. Distinguishing DID from malingering is of interest when there is financial or legal gain, and factitious disorder may be considered if there is a history of seeking help and attention. Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with dissociative disorder not otherwise specified rather than DID because of the lack of identity or personality states. Most people who present to the emergency department and are unaware of their names are generally in a psychotic state. Auditory hallucinations are also common in DID, and complex visual hallucinations can also occur. Those with DID generally have adequate reality testing; They may have the positive Schneiderian symptoms of schizophrenia but lack the negative symptoms. They can perceive any voice they hear as coming from inside their head. In addition, individuals with psychosis are much less susceptible to hypnosis than those with DID. The difficulties in differential diagnosis are greater in children. DID must be distinguished, or identified if it is comorbid, from a variety of disorders including mood disorders, psychosis, anxiety disorders, post-traumatic stress disorder, personality disorders, perceptual disorders, neurological disorders, epilepsy, somatoform disorder, factitious disorder, malingering, other dissociative disorders, and trance states. An additional aspect of the controversy over diagnosis is that there are many forms of schizophrenia and amnesia, which can be common in both stress and nonstress states and can be attributed to less controversial diagnoses. Individuals who fake or imitate DID due to factitious disorder will typically exaggerate symptoms, lie, and blame bad behavior on the symptoms and often exhibit mild distress about their apparent diagnosis. In contrast, a true DID patient is characterized by confusion, distress, and shame about their symptoms and history. The condition can be underdiagnosed due to skepticism and lack of awareness among mental health professionals, made difficult by the lack of specific and precise criteria for diagnosing DID as well as by the lack of prevalence rates due to the failure to systematically test a representative, selective population. A specific relationship between DID and BPD has been postulated many times, with different clinicians noting significant overlap between symptoms and patient behaviors and suggesting that some cases of DID may arise "from a substrate of borderline features." Reviews of DID patients and their medical records have concluded that the majority of those diagnosed with DID may also meet criteria for either BPD or more generally for borderline personality. The DSM-5 elaborates on cultural background as an influence on some clinical presentations of DID. Many characteristics of DID can be influenced by cultural background. Individuals with this disorder may present with unexplained neurological symptoms, such as non-epileptic seizures, paralysis, or sensory loss, in cultural settings where such symptoms were common. Similarly, in settings where standardized ownership is common, divided identities may take the form of possessive spirits, gods, demons, animals, or mythical figures. Cultural exchange or prolonged contact between cultures may shape the characteristics of other identities. The possessive form of DID can be distinguished from culturally acceptable possessions in that the possessive form of DID is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and the family, social, or work environment; It appears in times and places that break the norm of culture or religion. The DSM-II used the term hysterical neurosis, dissociative type. It described the potential for changes in the patient's conscious state or identity, and included symptoms of "amnesia, sleepwalking, fugues, and multiple personalities." The DSM-III combined the diagnosis with the four major dissociative disorders using the term "multiple personality disorder." The DSM-IV made more changes to DID than any other dissociative disorder, and renamed it dissociative identity disorder. The name was changed for two reasons. First, the change emphasized that the primary problem was not multiple personalities, but rather the lack of a single, unified identity and emphasized "identities as information-processing centers." Second, the term "personality" was used to refer to "distinct patterns of beliefs, feelings, moods, and behaviors of the entire individual," whereas for a patient with DID, the shifts between identities and behavior patterns are the personality. For this reason, the revised DSM-IV referred to "Distinct identities or personal states" rather than personalities. The diagnostic criteria were also changed to indicate that while the patient could name and personally make the alters, they lacked an independent objective existence. The changes also included increased amnesia as a symptom, which was not included in the DSM-III because, despite being a core symptom of the condition, patients could experience "amnesia about amnesia" and fail to report it. Amnesia was replaced when it became clear that the risk of a false negative diagnosis was low because the amnesia was core to DID. The ICD-10 placed the diagnosis in the category of "dissociative disorders", in the subcategory of "other dissociative disorders", but went on to record the condition as multiple personality disorder. The revised DSM-IV criteria for DID have been criticized for failing to capture the clinical complexity of DID, reducing the usefulness of diagnosing individuals with DID and resulting in a high rate of false negatives and a large number of diagnoses of dissociative disorder not otherwise specified (DDNOS). To exclude possession, and to include only two of the core symptoms of DID while failing to address the symptoms of hallucinations, trance-like states, somatoform, depersonalization and derealization. Arguments have been made to allow diagnosis by the presence of some, but not all, of the features of DID rather than the current focus. The two exclusive features are the two less common and observable ones. The DSM-IV-TR criteria have also been criticized for being tautological, for using undefined and imprecise language, and for using tools that give a false sense of validity and empirical certainty to the diagnosis. The DSM-5 redefined DID in 2013, summarizing changes such as: Several changes to the criteria for DID were made in the DSM-5. First, Criterion A was expanded to include the phenomenon of possession-form specifically and functional neurological symptoms to account for more diverse presentations of the disorder. Second, Criterion A now specifically states that the identity shift can be observed by others or self-reported. Third, according to Criterion B, individuals with DID may have recurrent gaps in recall of everyday events, not just traumatic experiences. Other textual changes clarify the nature and course of the identity dissociation. DID is among the most controversial of the dissociative disorders, and among the most controversial of the disorders in the DSM-IV-TR DSM-IV-TR. The initial conflict was between those who believed that DID was caused by traumatic stressors that forced the mind to split into multiple identities, each with a separate set of memories, and those who believed that DID symptoms were artificially produced by specific psychotherapeutic practices or by having patients play a role they believed was app