Dorahy Dissociative 2014

DID: An empirical overview
Dissociative Identity Disorder: An empirical overview
Martin J Dorahy1, Bethany L Brand2, Vedat Şar3, Christa Krüger4, Pam Stavropoulos5,
Alfonso Martínez-Taboas6, Roberto Lewis-Fernández7 and Warwick Middleton8
RUNNING HEAD: DID: An empirical overview

1
Department of Psychology, University of Canterbury, New Zealand
2
Department of Psychology, Towson University, USA
3
Department of Psychiatry, Istanbul University, Turkey
4
Department of Psychiatry, University of Pretoria, South Africa
5
Adults Surviving Child Abuse, Australia
6
Department of Psychology, Carlos Albizu University, Puerto Rico
7
Department of Psychiatry, Columbia University, USA
8
Department of Psychiatry, University of Queensland, Australia
Corresponding author: Martin J Dorahy, Department of Psychology, University of Canterbury, Private Bag
4800, Christchurch, 8140, New Zealand
Email: martin.dorahy@canterbury.ac.nz
Abstract
Objective: Despite its long and auspicious place in the history of psychiatry, dissociative
identity disorder (DID) has been associated with controversy. This paper aims to examine
the empirical data related to DID and outline the contextual challenges to its scientific
investigation. Method: The overview is limited to DID-specific research in which one or
more of the following conditions are met: 1) a sample of participants with DID was
systematically investigated, 2) psychometrically-sound measures were utilised, 3)
comparisons were made with other samples, 4) DID was differentiated from other
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disorders, including other Dissociative Disorders, 5) extraneous variables were controlled
or 6) DID diagnosis was confirmed. Following an examination of challenges to research,
data is organised around the validity and phenomenology of DID, its aetiology and
epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its
treatment. Results: DID was found to be a complex yet valid disorder across a range of
markers. It can be accurately discriminated from other disorders, especially when
structured diagnostic interviews assess identity alterations and amnesia. DID is
aetiologically associated with a complex combination of developmental and cultural
factors, including severe childhood relational trauma. The prevalence of DID appears
highest in emergency psychiatric settings and affects approximately 1% of the general
population. Psychobiological studies are beginning to identify clear correlates of DID
associated with diverse brain areas and cognitive functions. They are also providing an
understanding of the potential metacognitive origins of amnesia. Phase-oriented
empirically-guided treatments are emerging for DID. Conclusions: The empirical
literature on DID is accumulating, although some areas remain under-investigated.
Existing data show DID as a complex, valid, and not uncommon disorder, associated with
developmental and cultural variables, that is amenable to psychotherapeutic intervention.
Keywords
Dissociative identity disorder, validity, phenomenology, aetiology, psychobiology,
treatment
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Dissociative identity disorder (DID) has an auspicious place in the archives of
psychiatry. It captured the attention of many of the great 19th and early-20th century
thinkers, whose ideas form the foundation of modern psychiatric thought (James, 1896
[see Taylor, 1983], Janet, 1907; Prince, 1905). More recently DID has become the subject
of considerable debate (e.g., Dalenberg et al., 2012; Gleaves, 1996; McHugh and Putnam,
1995; Merskey, 1992), especially around its validity, aetiology and prevalence. Often
overlooked is the empirical understanding of DID accrued over 30 years, and which
commenced in earnest with the adoption of DID (then referred to as Multiple Personality
Disorder) as a discrete diagnostic entity in the third edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association,
1980). The accumulation of empirical knowledge paints a clear and consistent picture of
DID.
This overview is designed to provide a current „broad-brush‟ outline of the
scientific foundation of DID by focusing on DID-specific research. Thus the overview
excludes opinion pieces and papers without DID data and is confined to studies identified
in searches of major psychological (e.g., Psycinfo) and psychiatric databases (e.g.,
Medline) which investigated individuals with DID where one or more of the following
conditions were met: 1) a sample of participants with DID was systematically
investigated, 2) psychometrically-sound measures were utilised, 3) comparisons were
made with other samples, 4) DID was differentiated from other disorders, including other
Dissociative Disorders1, 5) extraneous variables were controlled or 6) DID diagnosis was
1 Some studies on DID and dissociative disorder not otherwise specified (DDNOS)–
type 1, a condition closely resembling DID, were included.
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confirmed (e.g., with structured interview). Sociological and contextual issues, especially
with reference to the scientific study of DID, are explored.
We have chosen to limit the current overview to empirical research on DID,
thereby bypassing a wide literature on dissociation and dissociative disorders. This
literature provides abundant, consistent evidence that dissociative experiences, symptoms
and disorders exist throughout the world (Spiegel et al., 2013). Stein et al. (2013) found
dissociative symptoms among 14.4% of individuals with PTSD from a sample of 25,018
respondents from 16 different countries. In a review of the cross-cultural assessment of
dissociation, Lewis-Fernández et al. (2007) provide extensive evidence that reliably
assessed dissociative symptoms and disorders are found in many different countries.
Limiting the overview to DID data precludes important discussions about the
commonalities among the dissociative disorders and the conceptual nature of dissociation
(e.g., whether it is best conceived as a continuum, as a set of discrete categories or as a
combination of these). Recent reviews examine these and other relevant issues (e.g.,
Dalenberg et al., 2012; Spiegel et al., 2013). Our aim is to provide an up-to-date overview
of scientific evidence about DID by reviewing the most compelling research in a variety
of areas, including DID‟s construct validity, aetiology, prevalence, psychobiological and
cognitive foundations, and treatment. Challenges in the empirical investigation of DID
will first be considered, to provide the contextual landscape for the work that follows.
Each section might fruitfully be reviewed in depth following this broad overview.
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‘Contextual Challenges in Empirical Investigation of DID
Research on DID is constrained by obstacles atypical for those of other
psychiatric disorders. The impediments cover five areas: diagnostic concerns, cultural
issues, post-traumatic avoidance, cost-benefit issues, and conceptual challenges.
Diagnostic concerns
DID is only weakly represented in the 10th edition of the International
Classification of Diseases (ICD-10; among “other” dissociative disorders). In the DSM-5
it is more fully elaborated. The discrepancy of definition hampers international research
efforts. DID patients usually present a plethora of diverse symptoms in addition to core
diagnostic features (Şar and Ross, 2006; see „construct validity‟, below). This
polysymptomatic profile may obscure DID unless dissociative symptoms are
systematically assessed. Since major general psychiatric diagnostic instruments used in
epidemiological and clinical research (e.g., the Structured Clinical Interview for DSM-IV
[SCID] and the Composite International Diagnostic Interview [CIDI]) lack a Dissociative
Disorders (DD) section (Şar and Ross, 2009), DID is repeatedly under-researched.
However, many researchers outside the field of dissociation are now including questions
about dissociation, which may lead to increased assessment for DD, including DID, more
widely. Adding DID symptoms to existing diagnostic and screening tools, and
developing shorter diagnostic instruments specific for DID is crucial.
Cultural issues
Cultural variation in the clinical manifestation of DID remains under-researched
(see „Aetiological Pathways and Influences in the Development of DID‟, below).
Challenges that have contributed to the paucity of cross-cultural research include lack of
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uniformity between international diagnostic classifications (ICD and DSM), and the
difficulty of assessing for diverse modes of dissociative self-representation (e.g., different
idioms in different regions can preclude meaningful comparative research).
A further contextual challenge to DID research pertains to the varying nature of
identity across cultures, that „identity‟ per se may not be unified, and that „self‟ is
constructed as more relational in some contexts and cultures than in others (Castillo,
1997). Whereas the „Western‟ conception of self emphasises autonomy, DID challenges
the notion of identity as fixed, unitary and autonomous. Thus it is not surprising that
identity-related cultural differences complicate comparative DID research.
Post-traumatic avoidance
DID is consistently linked to childhood relational trauma (see „Aetiological
Pathways and Influences in the Development of DID‟, below) and post-traumatic
avoidance operates at several levels, both individually and socially. Many DID patients
are conditioned „not to tell‟ of their trauma, which pertains to intra-psychic factors (self-
denial, shame), threats from perpetrators, and/or experiences of being disbelieved. This
reticence may hinder their participation in research studies.
A major challenge in researching DID relates to the reaction of the human mind
when confronted with terrible, unspeakable events directed at children - that is, defensive
denial of their occurrence or minimisation of their severity. Such denial, to which
researchers, clinicians and policy makers are also subject (Herman, 1992), sabotages
understanding and effective treatment of the impact of such events on victims.
The abuse of adult power over children (which violates the central societal norm
of protection of the young) calls into question such mainstream social institutions as the
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family and other organisations which ostensibly operate in the provision of care. Since
the aetiology of DID is associated with childhood relational trauma, the discomfort
caused by studying DID may serve as a potent disincentive to its investigation. Thus
avoiding study of DID protects mainstream social institutions – at the expense of the
children who are violated by them – as well as enabling researchers, clinicians, and the
public to retain a comforting denial of both the occurrence of abuse and its disabling
psychiatric legacy. Hence avoidance of the central issues associated with DID operates
not only in the patient, but in society at large.
Cost-Benefit Issues
Further challenges to DID research include the expensive treatment for these
complicated, heterogeneous patients, and lack of funding for both long-term treatment
and the long-term research needed to study treatment outcome. The cost of DID to health
systems and its amenability to treatment remain largely outside the awareness of
researchers, clinicians and policy makers. Thus DID is not targeted as a research priority
in mental health.
As neurobiological studies on DID accrue, they show that DID is as suitable for
biological investigation as any other psychiatric disorder (see „Unique neurophysiological
profile of DID‟). But as DID shows only limited responsiveness to existing medication, it
falls outside the purview of many researchers who focus on disorders that respond better
to pharmacotherapy and short-term treatments, and that are diagnosed by current
standardised interviews.
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Conceptual challenges
Other contextual challenges relate to the concept of self as an autonomous and
integrated entity (which is challenged by the psychic fragmentation of DID), and the
limits of objectivity and neutrality when addressing the enormity of psychological trauma
associated with DID. Conceptual and methodological challenges include the risk of
abstraction of symptomatology from its social context, the discounting of lived
experience as a form of evidence (and corresponding need for phenomenological
approaches) and the reductionism of standard classificatory nomenclature as accurate
representation of complex dimensions of subjectivity: “At issue here are core questions
about what constitutes the appropriate data upon which to base our understandings of
mental life” (Hornstein, 2013:31).
Validity and phenomenology of DID
The validity of psychiatric disorders is established by demonstrating content
validity (i.e., a consistent, detailed clinical presentation found by independent
researchers), criterion validity (i.e., data from laboratory, psychological and
neurobiological tests must be consistent with the clinical presentation), and construct
validity (the disorder can be distinguished from other disorders and from simulation;
Robins and Guze, 1970). Data support all three types of validity for DID (Gleaves et al.,
2001).
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Content Validity: Repeated, detailed, independently-observed clinical presentation.
The dissociative symptoms of identity confusion, identity alteration and amnesia2
form the core symptoms differentiating DID from other disorders in the DSM-5, with
only the latter two required in ICD-10 (APA, 2013; World Health Organization [WHO],
1993). While common among individuals with DID, derealisation and depersonalisation3
are not required for the diagnosis (APA, 2013; Steinberg et al., 1994a). Researchers from
Asia, North and South America, Europe, and Australia have found these five dissociative
symptoms are typically present in DID, often at severe levels (e.g., Boon and Draijer,
1993a; Gingrich, 2009; Martínez-Taboas, 1991; Middleton and Butler, 1998; see
„construct validity‟ section for further discussion). The consistent clinical picture across
cultures and research laboratories supports the content validity of DID.
Criterion Validity: Consistency across multiple methods of assessment
The structured clinical interviews for diagnosing DID show inter-rater reliability
rates that are as high, and generally higher, than those for other psychiatric disorders
(e.g., .80 or higher for the Structured Clinical Interview for DSM-IV Dissociative
Disorders [SCID-D; Steinberg, Rounsaville and Cicchetti, 1990; See Gleaves et al.,
2001]). The SCID-D/SCID-D-Revised (Steinberg, 1994a; 1994b; Steinberg et al., 1990)
assesses five categories of dissociative symptoms (identity confusion, identity alteration,
amnesia, depersonalisation, derealisation) and allows diagnosis of DID. For example,
2 Identity confusion is the subjective sense of conflict or uncertainty about one’s

identity due to non-integrated or fragmented self-states; identity alteration refers to
the objective behaviours that are observable manifestations of different identities;
amnesia is an inability to recall autobiographical information. (Steinberg, 1994a).
3 The DSM-5 defines depersonalisation as “experiences of unreality or detachment
from one’s self” and derealisation as “experiences of unreality or detachment from

one’s surroundings” (p. 291).
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Dutch researchers using the SCID-D found excellent inter-rater reliability for symptom
severity scores as well as the presence of a DD, including DID (weighted kappas ranging
from .85-.98; Friedl and Draijer, 2000). Scientists in numerous countries have found the
SCID-D effective in detecting DID (e.g., Gingrich, 2009; Mueller-Pfeiffer et al., 2013;
Ross et al., 2002).
Another structured interview, the Dissociative Disorders Interview Schedule
(DDIS; Ross et al., 1989b) assesses the symptoms of the five DSM-IV dissociative
disorders, and has good reliability and validity. For example, in detecting DID and
dissociative disorder not otherwise specified (DDNOS), the DDIS shows good inter-rater
reliability with a clinical interview (kappa=.71), the self-report Dissociative Experiences
Scale (DES; Bernstein and Putnam, 1986) taxon (i.e., an empirically derived subscale that
distinguishes individuals with a high probability of having a DD from those with other
disorders and controls; kappa=.81; [Waller et al., 1996]), and the SCID-D (kappa=.74;
Ross et al., 2002).
The DES is an effective screening tool for DID and DDNOS-I (a presentation
with dissociative identities but without amnesia), although there appear to be cultural
differences in the most effective cut-off scores for adequate sensitivity and specificity
(Mueller-Pfeiffer et al., 2013). This may be due to differences in reporting and
experiencing dissociation in different countries, and differences in translated versions of
the DES and research methodology (Mueller-Pfeiffer et al., 2013). Such findings
highlight the importance of determining dissociation scale norms within specific cultural
settings.
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Construct Validity - Discriminant type: Distinctiveness from other disorders
DID can be distinguished accurately from other psychiatric disorders and non-
patients using structured interviews and self-report measures of dissociation. Two core
symptoms (identity alteration, amnesia) differentiate DID from other disorders
(Steinberg, 1994a). So, too, does the combined frequency of other dissociative symptoms,
including identity confusion, depersonalisation/derealisation, and somatoform
dissociation (Dell, 2006; Nijenhuis et al., 1999).
The dissociative symptoms in DID and DDNOS appear to be qualitatively
different (e.g., identity alteration, amnesia) from other kinds of dissociation (Putnam et
al., 1996; Rodewald et al., 2011a). This suggests that assessing a range of dissociative
symptoms facilitates differential diagnosis. The core symptoms of DID (identity
alteration, amnesia) contribute considerably to detriments in global functioning beyond
other dissociative symptoms (e.g., depersonalisation) and Axis I symptoms (Mueller-
Pfeiffer et al., 2012).
The severity and breadth of multiple dissociative symptoms, particularly the
pathognomonic symptoms of identity alteration and amnesia, are characteristic of DID.
Despite these classic indicators of DID, multiple covert dissociative (e.g., flashbacks,
auditory hallucinations) and non-dissociative (e.g., affective instability) symptoms may
obscure from clinical view the true nature of the pathology, thereby delaying accurate
diagnosis of DID (Rodewald et al., 2011b; Ross and Ness, 2010; Ross et al., 1990a).
Research shows, however, that careful assessment of the range of dissociative symptoms
can accurately distinguish DID.

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Psychotic and dissociative disorders show symptoms that resemble each other,
including most of the Schneiderian symptoms (Kluft, 1987; Ross et al., 1990a; Welburn
et al., 2003). For example, studies show that individuals with DID have auditory
hallucinations emanating from both inside and outside the head, not unlike in
schizophrenia (Dorahy et al., 2009; Honig et al., 1998). Yet patients with DID are more
likely to hear more than two voices, including those of children and adults, beginning
before 18 years of age (Dorahy et al., 2009).
DID patients do not have true delusions (e.g., they tend not to endorse delusional
perception; Kluft, 1987). Patients with DID or allied forms of DDNOS have better
cognitive insight than patients with schizophrenia, and similar levels compared to those
with obsessive-compulsive disorder or depression (Şar et al., 2012). Dissociative patients
also have self-reflective capacities indicating cognitive insight in the non-psychotic range
(Brand et al., 2009c; Şar et al., 2012).
Patients with DID may decompensate to a dissociative psychosis as a transient
crisis state which may be confused with schizophrenia (Tutkun, Yargic, and Şar, 1995).
Patients with such a dissociative (formerly called hysterical) psychosis (Van der Hart et
al., 1993) may appear functionally “psychotic” due to temporarily poor reality-testing and
disorganised behaviour. The aetiology of the process is post-traumatic and dissociative
(e.g., post-traumatic content may manifest in hallucinatory symptoms; Şar and Öztürk,
2009). On the other hand, some patients with a schizophrenic disorder may present with
symptoms associated with DID,, thereby fitting the proposed dissociative subtype of
schizophrenia (Ross, 2004). Alternatively, this presentation may be due to comorbidity
between schizophrenia and DID among traumatised individuals (Şar et al., 2010).
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No study to date has found DID without multiple non-dissociative comorbid
psychopathology (e.g., Boon and Draijer, 1993a; Mueller-Pfeiffer et al., 2012; Rodewald
et al., 2011b). Depression and associated symptoms (lability, suicidal ideation) are among
the most frequent (e.g., Ellason et al., 1996; Middleton and Butler, 1998). Posttraumatic
stress disorder (PTSD) is present in the majority of cases (e.g., Boon and Draijer, 1993a;
Middleton and Butler, 1998; Vermetten et al., 2006). Of the anxiety disorders, panic
disorder is the most common and generalised anxiety disorder is the least common
(Rodewald et al., 2011b). Increased comorbid anxiety disorders may differentiate DID
from other conditions, including borderline personality disorder (BPD) and schizophrenia
(Fink and Golinkoff, 1990).
Self-harm and substance abuse are typically found in over 50% of people with
DID (e.g., Boon and Draijer, 1993a; McDowell et al., 1999). Over a third have eating or
somatoform disorders (Ellason et al., 1996). BPD is the most common personality
disorder, and is typically present in between a half to two-thirds of cases (Ellason et al.,
1996; Horevitz and Braun, 1984; Middleton and Butler, 1998), with some studies
reporting higher rates (Lipsanen et al., 2004; Şar et al., 2003). Crisis states prompting
emergency service visits in DID include self-mutilation, flashbacks, non-epileptic
seizures and suicide attempts. They also include acute episodes of mixed dissociative and
psychotic symptoms characterised by a “revolving door” (rapid switching among
identities) or “co-consciousness” (temporary breakdown of internal dissociative barriers)
crises (Tutkun et al., 1995). The interplay between psychotic and dissociative processes
requires further empirical investigation in these crisis episodes.

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This complex clinical picture complicates assessment and diagnosis. The
empirical phenomenological literature (which can be used to assess discriminate validity)
suggests that dissociative symptoms, as measured by instruments such as the SCID-D or
the DDIS, differentiate DID from other disorders (e.g., Ross et al., 1989a; Welburn et al.,
2003). While individuals with DID present a multifaceted symptom profile that goes
beyond the dissociative domain, neither personality measures (e.g., Minnesota
Multiphasic Personality Inventory–2 [MMPI-2]; Millon Clinical Multiaxial Inventory-III)
nor non-dissociative symptom measures reliably differentiate DID from other disorders
(e.g., Kemp et al., 1988; Welburn et al., 2003). One exception in the personality domain,
however, may be projective tests (e.g., Rorschach) which detect some differences,
including those with DID having a greater capacity to develop a working therapeutic
alliance (e.g., Brand et al., 2009c).
Some psychiatric patients consciously or unconsciously imitate DID (Draijer and
Boon, 1999). Thus an important method of establishing construct validity is determining
whether simulators who are knowledgeable about a disorder can imitate it on
psychological and neurobiological tests. A growing evidence base using both types of
tests indicates that genuine DID can be distinguished from feigned (i.e., malingered,
factitious or simulated) DID. The dissociative interviews show the most utility in this
differential diagnosis, although some personality tests are also useful. Most self-report
measures of dissociation are not effective for this purpose because they do not have
validity scales. The SCID-D is effective in distinguishing genuine DID from malingered
and factitious DID (Draijer and Boon, 1999; Friedl and Draijer, 2000). Welburn and
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colleagues (2003) found a 0% false positive rate in distinguishing feigned DID from DID
patients using the SCID-D-R.
Psychological tests often include “fake bad” validity scales that consist of items
typically endorsed by individuals who are exaggerating symptoms of mental illness.
However, research shows that many such validity scales contain items characteristic of
the symptoms experienced by traumatised individuals, including those with DID. Thus,
paradoxically, they may be endorsed by individuals who are not feigning or exaggerating
mental illness. For example, a study compared the MMPI-2 profiles (Butcher et al.,
2001) of 53 DID patients with 67 uncoached and 77 coached DID simulators. Monetary
awards were given to those who best feigned DID following hours of training about DID,
including media and internet information about the disorder (Brand and Chasson, in
press). The DID group‟s scores were more extreme than many psychiatric groups‟ scores
on validity and clinical scales, but they were not more extreme than those found among
PTSD or child sexual abuse groups. Furthermore, the direction of the correlations
between dissociation scores and the MMPI-2 validity and clinical scales were in the
opposite direction for the simulators compared to the DID group for 15 out of 18
correlations conducted.
The researchers concluded that the DID group‟s elevations on the validity scales
stemmed from their endorsement of dissociative and trauma-related items (which are
mistakenly included on these scales). For example, one “fake bad” validity item, in
abbreviated form, asks participants whether they “Sometimes do things and don’t
remember doing them” (i.e., dissociative amnesia typical of DID). Another inquires
about whether individuals “Feel things aren’t real” (i.e., derealisation) (MMPI®-2
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4
Booklet of Abbreviated Items) . Despite these problems with the test‟s items, in a
discriminant function analysis, 83.0% of simulators and 86.0% of the DID cases were
correctly classified on the MMPI-2 (Brand and Chasson, in press). That is, despite media
exposure, training, and incentives, the feigners still could not accurately imitate DID.
Studies using a well-established forensic interview for assessing feigned mental
illness, the Structured Interview of Reported Symptoms (SIRS or SIRS-2; Rogers et al.,
2010) indicate that if a Trauma Index is used, feigners can be distinguished from DID
patients with overall diagnostic power (ODP) as high as 83.3 (Brand et al., 2006; Brand,
Tursich, Tzall & Loewenstein, in press). The Trauma Index is an empirically-derived
index of subscales that accurately classifies severely traumatised individuals, because
unlike some SIRS/SIRS-2 subscales, its subscales do not include dissociative and trauma-
related items. Without the Trauma Index, the overall utility of the SIRS/SIRS-2 is lower
(i.e., ODP=58.7 – 81.0; Brand et al. in press).
Dissociative items are often included on other tests‟ validity and clinical scales,
including the Personality Assessment Inventory‟s (PAI) NIM scale (a so-called “fake
bad” scale; Morey, 1991). Thus it is not surprising that DID individuals show elevated
ratings on validity scales that include dissociative items. Yet DID individuals do not
elevate on the PAI‟s validity subscales that do not include dissociative, trauma-related
items (Brand, Stadnik and Savoca, 2013). Importantly for the validity of the diagnosis,
DID individuals do not typically score above ranges found in other trauma samples,
4MMPI-2 Booklet of Abbreviated Items. Copyright © 2005 by the Regents of the

University of Minnesota. All rights reserved. Used by permission of the University of
Minnesota Press. “MMPI” and “Minnesota Multiphasic Personality Inventory” are
registered trademarks owned by the Regents of the University of Minnesota.
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particularly if the “fake bad” scales do not include trauma and dissociation content
(Brand and Chasson, in press; Brand et al., in press). These data underscore the
importance of assessors being informed about research regarding severely dissociative
clients to avoid misclassification of those with DID as malingering, exaggerating, or as
suffering from a psychotic disorder (i.e., when their pattern of symptoms is in fact
characteristic of DID).
Consistent with the psychological tests, neurobiological studies have shown that
DID can be accurately differentiated from simulated DID. Reinders and colleagues
distinguished DID patients from DID simulators - even simulators high in suggestibility -
on emotional arousal, cerebral brain flow patterns, heart rate, heart rate variability, and
blood pressure (Reinders et al., 2012). Dissociative identities fully aware of trauma
experiences showed different subjective, neural, and psychophysiological patterns when
listening to autobiographical trauma scripts, compared to dissociative identities who were
less aware of trauma experiences. These patterns could not be replicated by simulators,
regardless of whether they were high or low in suggestibility (see Schlumpf et al., 2013
for similar findings using a different methodology).
In summary, DID is a disorder that: 1) has a complex clinical presentation; 2) can
be discriminated reliably from other disorders according to frequency and severity of
multiple dissociative symptoms; and 3) meets accepted standards for content, criterion,
and construct validity. Therefore, data consistently indicate DID is a valid diagnosis.
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Aetiological Pathways and Influences in Development of DID: Cultural and
Relational Context
There is wide consensus that the processes and mechanisms intrinsic to the
experience of psychopathology are sensitive to cultural and societal influences (Eshun
and Gurung, 2009). Culture impacts how individuals display and communicate their
symptoms, how such symptoms are interpreted, and what type of care is sought. For
example, data support the role of culture in patterning the presentation of eating disorders
(Anderson-Fye and Becker, 2004), personality disorders (Mulder, 2012), depressive
disorder (Korman and Molina, 2010), schizophrenia (Stompe and Friedmann, 2007), and
anxiety disorders (Lewis-Fernández et al., 2010).
Both universal and cultural processes influence the development and
phenomenology of DID (Dorahy, 2001a). Dissociation and dissociative disorders (DD)
can be found in all cultural settings (e.g., Spiegel et al., 2013; Stein et al., 2013). DID has
been documented in Turkey, Puerto Rico, Scandinavia, Japan, Canada, Australia, the
United States, Philippines, Ireland, United Kingdom, and Argentina, among many other
cultural and geographical contexts (Rhoades and Şar, 2005).
DID is intrinsically related to experiences of self and personhood. This point is of
particular importance, because Western views of the person emphasise a conception of
self as separate, autonomous, self-contained and independent (Cross and Markus, 1999).
In a recent review of the role of culture in construction/s of self, Markus and Kitayama
(2010) assert that selves actively engage in a dynamic process in which they influence
and are influenced by their sociocultural contexts. Western preoccupation with
individualism leads to experiences of self as separate or independent from those of others.

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In contrast, non-Western societies tend to endorse an interdependent self, which fosters
experiences of self as entwined with the expectations and needs of others.
The cultural construction of self means that DID - essentially a dysfunction of self
- must be understood as a response to overwhelming, usually traumatic, experiences that
are necessarily shaped by cultural norms and behavioural repertoires of the context in
which it occurs. In African, Asian, and other non-Western countries - where social
constructions of self are relatively porous to influences external to the person - DID
usually takes the form of pathological possession experiences which are more congruent
with a conception of self as not separate or individual (Cardeña et al., 2009). Thus
research in India (Chaturvedi et al., 2010), Japan (Umesue et al., 1996), Oman (Chand et
al., 2000), China (Xiao, et al., 2006), and Iran (Alvi and Assad, 2011) has found a high
prevalence of DD (>5%), but few, if any, „non-possession-form‟ DID cases.
This situation may change with inclusion in the DSM-5 (APA, 2013) of
presentations characterised by pathological possession in the diagnostic criteria for DID:
“Disruption of identity characterized by two or more distinct personality states, which
may be described in some cultures as an experience of possession” (p. 292). This
diagnostic broadening will likely increase the validity of DID criteria cross-culturally,
making the description of the disorder more consonant with cultural constructions of self
that are inter-dependent and patterned by religious beliefs about spiritual beings. In such
settings, pathological fragmentation of self is expressed in the idiom of external
malicious forces that disrupt identity and consciousness. There is not, however, a strict
dichotomy between Western and non-Western expressions, as a subgroup of patients with
DID in North America and Turkey attribute the origin of at least some of their identities
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to spirit possession (Ross, 2011; Şar et al., 1996). Nor is pathological possession
exclusively associated with DID. It represents instead a behavioural “final common
pathway” (Carr and Vitaliano, 1985) that is normative in many cultures (though not
“normal” when it causes distress) and can present as part of many disorders, not only
DID (e.g., how depressive symptoms present in disorders beyond mood disorders). DSM-
5 refers to the presentation of pathological possession in individuals with DID, but does
not equate all pathological possession with this disorder.
Alongside cultural factors, data have consistently shown that DID is associated
with traumatic and stressful experiences. Large-scale clinical and epidemiological studies
in the United States, Australia, Turkey, Puerto Rico, and Canada have found that DID is
linked to antecedent severe, chronic abusive and traumatic experiences in childhood,
typically at the hands of an attachment figure (e.g., Martínez-Taboas, 1991; Middleton
and Butler, 1998; Ross et al. 1990b; Şar, 2011). Dalenberg et al. (2012) calculated Ross
and Ness‟ (2010) comparison of DID patients to controls, and found effect sizes of .74-
.78 for physical and sexual abuse. More severe and earlier-onset child abuse appears to
differentiate DID from other disorders (Boon and Draijer, 1993b). By using corroborating
documentation from hospital, police and child protection agencies or witnesses, several
studies confirm histories of severe abuse in DID (Coons, 1994; Martínez-Taboas, 1991;
Lewis et al., 1997). Studies exploring DID as a longitudinal outcome of confirmed child
abuse are needed to examine further the abuse-DID link.
Every study that has systematically examined aetiology has found that antecedent
severe, chronic childhood trauma is present in the histories of almost all individuals with
DID. Yet the interplay between trauma and DID in non-Western countries (Asia, Africa,
21
Arabia) has been understudied. Ugandan villagers with pathological possession had more
psychoform and somatoform dissociation, and had suffered greater traumatic exposure,
than randomly selected mentally healthy inhabitants from the same village (Van Duijl et
al., 2010). However, research in Turkey suggests that milder presentations of DID are
sometimes associated with traumatisation that is covert, such as severely dysfunctional
communication and relationship styles in family members (Öztürk and Şar, 2005).
Understanding the aetiology of DID requires the amalgamation of several
exposure-, coping- and developmental factors. These include traumatic experiences,
family dynamics, child development, attachment (Kluft, 1993; Putnam, 2006; Ross,
1997) and the role culture plays in constructing “alternate” selves (i.e. embodied
representations of the metaphor of “a different person” [or spiritual being]) with separate
attributes and specific memories for trauma). DID develops when a child is exposed to
chaos, coercion, and most commonly, overt severe physical and/or sexual abuse, often
with disorganised attachment to caregivers. The child must also have the biological
capacity to dissociate to an extreme level, leading to multiple states that do not become
integrated over time. Such self-states allow the child to compartmentalise overwhelming
and conflicting feelings of betrayal, terror, love and shame (Putnam, 2006; Van der Hart
et al., 2006). Overwhelmed by intense conflicting needs and emotions, the child is unable
to integrate discrete behavioural and emotional states into a coherent or relatively
integrated self according to the appropriate socio-cultural construction/s of self (Putnam,
2006). In certain (e.g., mainstream Western) cultures, this process is consonant with a
fragmentation of internal identities; in other (e.g., non-Western) cultures it may accord
with external spiritual entities that take control of the individual‟s consciousness and
22
identity. In summary, existing data demonstrate that development of DID is likely due to
a complex combination of traumatic experiences, dissociative processes, psychosocial
mediators and socially constructed understandings of self.
Epidemiology of DID
The absence of DD modules in diagnostic interviews assessing general
psychopathology (e.g., SCID, CIDI; First et al., 1997; World Health Organization, 1997),
may account for the lack of DID data from large-scale community-based
epidemiological studies (Andrews et al., 2001; Bijl et al., 1998). Measures such as the
SCID-D and DDIS have been developed to assess the epidemiology of DID.
Clinical Studies
Findings from consecutive samples of inpatients and outpatients in general
psychiatric clinics in diverse countries vary by clinical setting, and to some extent
geographic region. Two cross-sectional studies from North America found that 4.0-5.4%
of psychiatric inpatients met DSM-IV criteria for DID (Ross et al., 1991; Saxe et al.,
1993). In Turkey, the prevalence rate of DID is 5.4% among general psychiatric
inpatients, 2.8% among substance dependence inpatients, and 2.0-2.5% among general
psychiatric outpatients (Karadag et al., 2005; Şar et al., 2003; Tutkun et al., 1998).
Inpatient rates are 2.0% in the Netherlands (Friedl and Draijer, 2000), 0.9% in Germany
(Gast et al., 2001), and 0.4% in Switzerland (Modestin et al., 1996). The highest
prevalence is seen in psychiatry emergency departments or outpatient units that receive
emergency admissions. For example, cross-sectional rates were 14.0% in a university
emergency department in Istanbul (Şar et al., 2007) and 6.0% in an outpatient psychiatric
unit in New York City that included emergency admissions (Foote et al., 2006).
23
Marked variation in prevalence (0.4%-14.0%) is likely due, at least in part, to
methodological differences across studies and settings (Friedl et al., 2000). Research
using the semistructured SCID-D usually reports lower rates of DID than the fully-
structured DDIS. Since the SCID-D requires clinicians to judge which experiences are
dissociative in nature, use of the SCID-D may lead to exclusion of more false positive
cases than the DDIS. Other explanations for the variation may be cultural factors which
influence both emergence of DID and interpretation of symptoms (Şar et al., 2013). For
example, European studies report substantially lower rates of DID than Turkish or North
American studies. While each European country may be relatively homogenous in socio-
cultural factors influencing identity formation, North America and Turkey may be
characterised by more dramatic cultural diversity.
Overall, cross-sectional prevalence of DID tends to increase with level of
psychiatric severity, ranging from about 2% in outpatient clinics to about 5% in inpatient
units, with even higher rates in emergency settings.
Community Studies
Community-based epidemiological studies describe the full extent and
distribution of the disorder in the population. This is because clinical epidemiology
research is affected by local utilisation patterns for mental health services, as determined
by accessibility factors and variations in the severity and impairment associated with the
disorder (Fleming and Hsieh, 2002). Unfortunately, community-based research on DID is
limited. One representative sample from Manitoba, Canada found a lifetime prevalence
of 3.1% for DID using the DDIS and DSM-III-R criteria (Ross, 1991). A representative
24
sample of women in Sivas City, Turkey (N=648) had a lifetime prevalence of 1.1% using
the DSM-IV version of the DDIS (Şar, Akyuz and Dogan, 2007).
For practical reasons, proxy instruments may be used to estimate diagnostic rates.
A community-based epidemiological study in New York State (N=658) used the DES-
Taxon items for initial screening. Four SCID-D items (2 on dissociative amnesia and 2 on
identity alteration) were then administered to approximate a DID diagnosis (Johnson et
al., 2006). Results yielded a 12-month prevalence for DID of 1.5%. While the findings in
Sivas City and New York State produced similar rates of DID, the prevalence in
Manitoba was higher, due to utilisation of the DSM-III-R criteria which did not list
amnesia among diagnostic criteria of DID.
Epidemiological studies of DID have utilised DSM-III-R or DSM-IV diagnostic
criteria. The DSM-5 introduced specific forms of pathological possession into the DID
criteria. A recent general population study of 628 Turkish women (Sar et al., in press)
found two of the 13 with an experience of possession had DID (seven women in the
sample had DID). The diagnostic heterogeneity of the pathological possession
experiences is consistent with the “final common pathway” concept of possession in
DSM-5. Yet most epidemiological studies do not distinguish possession trance that meet
DID criteria from that which does not. In India, for example, the prevalence of trance and
possession disorders was reported at 5.3% among inpatients and 11.5% among
outpatients in a tertiary referral psychiatric hospital over a 10-year period (Chaturvedi et
al., 2010). However, no diagnosis of DID was made. This is likely to change when DSM-
5 criteria are used in future studies.

25
Psychobiological Findings Related to DID
Unique neurophysiological profile of DID
Although imaging studies have elucidated neurophysiological markers of the
dissociative response in patients with a range of DD and PTSD, studies performed
specifically in DID patients are more circumscribed. Different imaging techniques
support three as yet unintegrated hypotheses. On the whole, single photon emission
computerised tomography (SPECT) studies support an orbitofrontal hypothesis; magnetic
resonance imaging (MRI), functional MRI (fMRI) and positron emission tomography
(PET) studies support a cortico-limbic hypothesis; and EEG and QEEG studies support a
temporal hypothesis for DID.
Forrest (2001) proposed a neurodevelopmental model for DID, underlining
deficient functionality of the orbitofrontal region in the brain. The orbitofrontal lobe has
been hypothesised to be affected by early trauma. Consistent with this orbitofrontal
hypothesis, DID patients exhibited orbitofrontal hypoperfusion in comparison with
normal controls in two SPECT studies (Şar et al., 2001; Şar et al., 2007) conducted in
“host” identities (i.e., identities predominantly engaging with the external world).
Bilaterally increased perfusion in medial and superior frontal regions and occipital areas
accompanied orbito-(inferior) frontal hypoperfusion in one of these studies (Şar et al.,
2007). There was no difference in perfusion of any brain area between different identities
(Şar et al., 2001).
With respect to the cortico-limbic hypothesis as originally formulated in the
context of PTSD studies (Lanius et al., 2006), a structural MRI study established that
DID patients have smaller hippocampi and amygdalae than normal controls (Vermetten
26
et al., 2006). Ehling et al. (2007) also found reduced volumes in the parahippocampal
gyrus of individuals with DID and strong correlations between reduction of
parahippocampal volume and both psychoform and somatoform dissociation.
Moreover, significant functional brain imaging (PET and fMRI) differences have
been found between (1) different identities in DID patients (Reinders et al., 2003, 2006;
Schlumpf et al., 2013) and (2) perfusion before versus perfusion during “switching”
between identities in a DID patient (Tsai et al., 1999). In the PET studies by Reinders et
al. an “emotional” dissociative identity (associated with trauma memories), when
compared to an “apparently normal” dissociative identity (numb and depersonalised from
trauma memories), showed increased cerebral blood flow in the amygdala, insular cortex,
and somatosensory areas in the parietal cortex and the basal ganglia, as well as certain
areas in the occipital and parietal cortex and anterior cingulate and frontal areas (Reinders
et al., 2003, 2006). In a subsequent PET study, healthy controls simulating two identity
states were unable to reproduce the same network patterns as DID patients (Reinders et
al., 2012).
In the fMRI study by Tsai et al. (1999) bilateral hippocampal inhibition, right
parahippocampal and medial temporal inhibition, and inhibition in small regions of the
substantia nigra and globus pallidus were seen during the switch into another identity, as
well as right hippocampal activation when the participant was returning to the original
identity. The fMRI studies by Wolk and coworkers (Savoy et al., 2012; Wolk et al., 2012)
demonstrate activation of the primary sensory and motor cortices, frontal and prefrontal
regions and nucleus accumbens during switching in a DID patient. In summary, the
switching process in DID is typified by activation and inhibition of a varying array of

27
neurological areas and structures. The exact patterning of these may be related to the
psychobiological characteristics of the dissociative identities involved.
Electrophysiological differences between identity states have also been found in a
DID patient, who after 15 years of diagnosed cortical blindness, gradually regained sight
during psychotherapeutic treatment. Waldvogel et al. (2007) demonstrated absent visual
evoked potentials (VEP) in the blind identity versus normal VEP in the seeing identity.
As a neural basis of such psychogenic blindness, the authors assumed a top-down
modulation of activity in the primary visual pathway, possibly at the level of the thalamus
or the primary visual cortex.
The temporal hypothesis of DID is supported by conventional visual EEG studies
(Coons et al., 1988; Mesulam, 1981) as well as some quantitative EEG (QEEG) studies.
In the QEEG study by Lapointe et al. (2006), variability between identity states involved
mostly beta activity in the frontal and temporal lobes. On the other hand, Cocker et al.
(1994) reported increased frontal QEEG delta activity in the hypnotically-induced “baby”
identity in a patient with DID. A QEEG brain mapping study by Hughes et al. (1990)
demonstrated left temporal and posterior-temporal-occipital changes in the theta and
beta-2 frequency range in four of 11 identities in a DID patient. Further partial support
for the temporal hypothesis comes from Hopper et al. (2002) who demonstrated that the
average alpha coherence on QEEG was lower for „alter‟ identities than for “host”
identities in five DID patients in some temporal, frontal, parietal and central regions.
The temporal hypothesis is also supported by some SPECT studies. Saxe et al.
(1992) demonstrated increased activation in the left temporal lobe in four assessed
identities of a DID patient. In Şar et al.‟s (2001) SPECT study the “host” identity showed
28
increased perfusion in the left (dominant hemisphere) lateral temporal region compared
to healthy controls. This lateralisation was not replicated in a follow-up study (Şar, Unal
and Öztürk, 2007).
Imaging and neurophysiological studies have shown discrete brain areas of
interest in understanding DID. No studies that failed to support any of these hypotheses
were found, and it is not clear whether the three hypotheses are competing. The specific
areas identified may reflect technical aspects of the specific methods. For example,
notwithstanding the EEG‟s excellent temporal resolution, it has limited spatial resolution,
which might explain its lack of findings on the deeper brain structures and hence its non-
contribution to the other two hypotheses.
Future empirical studies using combinations of imaging methodologies
specifically in DID might shed light on the relationship between and a possible merging
of the orbitofrontal, cortico-limbic and temporal hypotheses, as well as a possible
amalgamation of these neurophysiological findings with the findings of cognitive
psychological studies.
Cognitive correlates of DID
The cognitive study of DID is emerging from diagnostic, empirical and anecdotal
evidence of memory, attention and information processing anomalies associated with the
disorder (e.g., APA, 2013; Dorahy and Huntjens, 2007). Some scientific consideration
has been given to attention and working memory processes in DID (Stringer and Cooley,
1994). Results are beginning to suggest a cognitive architecture supporting vigilance and
bias for threat stimuli, the nature of which may vary depending on the psychological
29
characteristics of the dissociative identity assessed (e.g., Dale et al., 2008; Dorahy,
Middleton, and Irwin, 2005; Hermans et al., 2006).
A limited number of studies have examined encoding and retrieval processes
within dissociative identities. Case studies show some evidence of generalised childhood
amnesia (Schacter et al., 1989) and that memory retrieval seemingly differs across
identities (Bryant, 1995). After the incipient dissolution of amnesia, traumatic childhood
memories may return initially as sensorimotor fragments (e.g., images, body sensations)
rather than as a verbal narrative among adults with DID (Van der Hart et al., 2005). There
are empirical suggestions that within-identity encoding and retrieval may differ for fear
versus neutral stimuli, with fear stimuli less effectively encoded (Barlow, 2011).
Retrieval appears to be better for „gist‟ information than for specific details (Barlow,
2011). This suggests the yet-to-be assessed possibility that DID might be characterised by
overgeneralised memory (non-specific retrieval) especially for fear narratives, as has
been found in other disorders (e.g., depression, PTSD; see Moore and Zoellner, 2007).
The bulk of contemporary research on cognition in DID has focused on the
specific nature of information compartmentalisation (i.e., the isolation of material within
a dissociative identity) and transfer (i.e., the transmission of material across dissociative
identities; Allen and Iacono, 2001; Dorahy, 2001b). This follows the lead of early
investigations (Prince and Peterson, 1909) and is associated with the well-documented
apparent amnesia between some dissociative identities for cognitive representations of
experience. Research has largely focused on procedural, perceptual and non-
autobiographical semantic and episodic information transfer (e.g., Eich et al., 1997;
Nissen et al., 1988; Peters et al., 1998).

30
Increasing methodological sophistication addressing concerns with external and
ecological validity is beginning to question some of the findings from previous work that
showed evidence of compartmentalisation (especially for more complex information,
such as stories that contained considerable contextual information). For example, in a
reaction time study of nine DID patients, Huntjens et al. (2012) found evidence of
semantic autobiographical transfer across dissociative identities, despite participants
reporting amnesia between identities. Participants provided answers to autobiographical
semantic questions (e.g., names of siblings) in two amnestic identities. Two weeks later,
participants were presented word lists interspersed with autobiographical but irrelevant
words and previously learned target words. They were required to rapidly identify target
words. It was hypothesised that the reaction time for autobiographically-salient words
would be slower than that for non-autobiographical words (including the
autobiographically-salient words of the other identity). However, the DID sample showed
the same slower response to words in both identities‟ word lists, suggesting that semantic
autobiographical information is not compartmentalised despite being experienced as
such. The pattern of findings was not replicated in controls or individuals simulating
DID.
These findings, as well as other studies (e.g., Huntjens et al., 2003; Kong et al.,
2008), challenge complete compartmentalisation of information. In short, research
indicates that dissociative amnesia operates at a metacognitive level, such that the person
subjectively experiences alterations in memory retrieval between identities that are not
verified in the laboratory (i.e., the person believes they are unaware of the information,
31
perhaps due to major alterations in conscious faculties, despite laboratory evidence to the
contrary).
Thus amnesia in DID appears to operate in the same (metacognitive) way as many
symptoms in other disorders (e.g., perceived fatness in anorexia, perceived danger or
amnesia in PTSD, perceived catastrophe in panic disorder). In terms of phenomenology
as well as aetiology, amnesia in DID can be likened to conversion symptoms. Both
amnesia and conversion in DID are functional neurological symptoms. Similarly,
sensorimotor functions vary between identities in DID without structural neurological
pathology, yet functional neurobiological variations are found (Bhuvaneswar and
Spiegel, 2013).
Future research should explore the nature and mechanisms of amnesia, as well as
elucidating the nature of attentional processes in DID. Emotionally-charged episodic
autobiographical memory transfer across functionally amnesic identities likewise merits
thorough investigation.
Treatment of DID
DID treatment outcome has been systematically studied for three decades via case
studies, case series, cost-efficacy studies, and naturalistic outcome studies with follow-
ups as long as 10 years (e.g., Coons and Bowman, 2001; Coons and Sterne, 1986; Kluft,
1984). Research indicates that therapy utilising a phasic trauma treatment model
consistent with expert consensus guidelines is beneficial to DID individuals (Brand et al.,
2009b; International Society for the Study of Trauma and Dissociation [ISSTD], 2011). A
meta-analysis of eight non-controlled DD studies found pre/post within-participant effect
sizes in the medium-to-large range for outcomes including improved dissociation,

32
anxiety, distress, and depression (Brand et al., 2009b). Treatment was associated with
reductions in diagnoses of comorbid axis I and II disorders, suicidality, and substance
abuse; improvements were maintained at two-year follow-up (Brand et al., 2009b;
Ellason and Ross, 1997).
The phasic model of DID treatment involves patients working towards
establishing safety and stability in Stage 1. Some DID patients may lack interest in,
and/or the psychological or practical resources for, moving beyond Stage 1. In Stage 2,
the focus is on maintaining stability while exploring trauma narratives and resolving
trauma-related emotions, beliefs, and behaviours. In Stage 3, the treatment emphasises
integration of identities and living without reliance on dissociation. A survey of
international DID experts coalesced in recommending interventions to be used with DID
patients across the stages of treatment (Brand et al., 2012). Stabilising safety and
containment of traumatic material were highly endorsed in all but the last stage of
treatment. Core interventions recommended at every stage of treatment included:
providing psychoeducation; increasing awareness and tolerance of emotion; developing
impulse control; fostering grounding skills to manage dissociation; nurturing the
therapeutic alliance; and managing stressors, current relationships and daily functioning.
The consistency between these experts‟ recommendations, those described in the ISSTD
Treatment Guidelines (2011), and the interventions documented in the Treatment of
Patients with Dissociative Disorders (TOP DD) study (Brand et al., 2009a) suggest that a
standard of care for the treatment of DID is emerging. Detailed discussions of DID
treatment are also available (e.g., Boon et al., 2011; Chu, 2011; Howell, 2011; ISSTD,
2011).
33
Case studies have yielded critical insights into the treatment of DID (Kluft, 1984).
One of the most rigorous - a single case experimental design - demonstrated that
cognitive analytic treatment resulted in statistically and clinically significant
improvements that remained stable or continued to increase over six months of follow-up
for a woman with DID (Kellett, 2005). The patient also showed sudden improvements
following targeted interventions, indicating that the treatment was central to the
improvements.
The longitudinal, international TOP DD study is providing new understanding of
DID treatment. The TOP DD study prospectively assessed treatment response from 230
DID patients and their therapists from 19 countries, across four data collection points
over 30 months (Brand et al., 2009b; Brand et al., 2013). Over time, patients showed
statistically significant reductions in dissociation, PTSD, distress, depression,
hospitalisations, suicide attempts, self-harm, dangerous behaviours, drug use, and
physical pain, as well as higher Global Assessment of Functioning scores (Brand et al.,
2013).
Even participants with the highest levels of dissociation and the most severe
depression showed improvement over time (Engelberg and Brand, 2013; Stadnik and
Brand, 2013). Younger patients stabilised self-destructive and suicidal behaviours more
rapidly than older patients, suggesting the importance of early diagnosis and treatment
(Myrick et al., 2012). Rates of revictimisation showed a trend towards reduction, and
more patients showed “sudden improvement” than “sudden worsening” (i.e., 20%
decrease or increase in symptoms, respectively; Myrick et al., 2013). Those who
suddenly improved had fewer revictimisations and stressors compared to those who
34
worsened. Only 1.1% of patients showed worsening over more than one data collection
point;, a rate that compares favourably to the 5%-10% of general patients who show
worsening symptoms during treatment (Hansen et al., 2002). The consistency of
statistical improvement across a range of symptoms and adaptive functioning, strongly
suggests that treatment contributed to improvements.
It is important to consider health costs associated with DID. A Canadian treatment
study of DID concluded that annual costs dropped from CAD$75,000 to CAD$36,000
(Canadian) in the three years after treatment for DID (Ross and Dua, 1993). This and
other studies document considerable cost savings even for those who had been
chronically ill before being appropriately treated for DID (Lloyd, 2011).
In summary, research indicates that DID treatment consistent with the standard of
care outlined in the expert guidelines for this disorder is associated with improvements in
functioning and reduction of a wide range of symptoms. Although randomised trials are
difficult to conduct with DID patients due to their symptom complexity and high
suicidality, current evidence suggests that DID treatment accounts for documented
improvements. Studies using systematic treatment with blind assessments are critically
needed to identify how to treat these patients most effectively. Trials could be developed
that compare individual treatment alone to individual treatment plus manualised DID
group therapy or web-based psychoeducational interventions.
Conclusion
The empirical literature on DID emerging over the past 30 years shows that,
beyond the rhetoric and controversy, DID is a valid disorder characterised by amnesia,
identity confusion, and coexistence of dissociative identities which can be differentiated

35
from other psychiatric disorders as well as from feigned presentations of DID.
Characteristic features include a complex array of co-existing symptoms associated with
psychosis, mood, anxiety, affect regulation and personality functioning. A mix of subtle
and overt developmental, interpersonal and cultural drivers produce DID, with childhood
attachment-based trauma appearing to be a universal factor, while social idioms of self
produce components of cultural specificity. DID is found around the globe in almost
every culture in which researchers have carefully assessed for the range of dissociative
symptoms.
Orbitofrontal, cortico-limbic and temporal anomalies are evident in DID, with
different neurobiological profiles found across identities than those in simulation.
Cognitive functioning, while varying across identities, appears to support biases in threat
detection and management. Reported amnesia between identities may be produced by
metacognitive processes, but studies are yet to assess transfer of autobiographical
episodic memories for traumatic events. Despite the complexity of DID at
neurobiological, cognitive, relational and symptomatic levels, assessment and treatment
consistent with the expert consensus guidelines for this disorder (ISSTD, 2011) have
produced consistently positive results. The challenge of randomised, well-controlled
intervention protocols awaits empirical investigation.
While empirical research on DID accumulates, a diverse collection of challenges
impact the development of studies and acceptance of their findings and implications. At
issue are not only matters of „science‟, but the psychological and social challenges of
assimilating and responding to what science comprises. A convergence of contextual
issues relates as much to challenges to existing paradigms as to the principles of scientific

36
inquiry. DID questions the concept of self as an autonomous and integrated entity, and
thus challenges understanding of the nature of scientific enquiry itself. However, it is
clear that research on DID is proceeding and advancing, providing fascinating insights
into the power of the mind to cope with developmental trauma and severe attachment
disruptions in the cultural contexts in which they occur.
Declaration of Conflicting Interests:

The Authors declare that there is no conflict of interest
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DID: An empirical overview

Dissociative Identity Disorder: An empirical overview

Alfonso Martínez-Taboas6, Roberto Lewis-Fernández7 and Warwick Middleton8

RUNNING HEAD: DID: An empirical overview

4800, Christchurch, 8140, New Zealand

investigation. Method: The overview is limited to DID-specific research in which one or

systematically investigated, 2) psychometrically-sound measures were utilised, 3)

or 6) DID diagnosis was confirmed. Following an examination of challenges to research,

markers. It can be accurately discriminated from other disorders, especially when

structured diagnostic interviews assess identity alterations and amnesia. DID is

aetiologically associated with a complex combination of developmental and cultural

highest in emergency psychiatric settings and affects approximately 1% of the general

population. Psychobiological studies are beginning to identify clear correlates of DID

understanding of the potential metacognitive origins of amnesia. Phase-oriented

empirically-guided treatments are emerging for DID. Conclusions: The empirical

literature on DID is accumulating, although some areas remain under-investigated.

developmental and cultural variables, that is amenable to psychotherapeutic intervention.

Dissociative identity disorder, validity, phenomenology, aetiology, psychobiology,

Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association,

This overview is designed to provide a current „broad-brush‟ outline of the

scientific foundation of DID by focusing on DID-specific research. Thus the overview

in searches of major psychological (e.g., Psycinfo) and psychiatric databases (e.g.,

conditions were met: 1) a sample of participants with DID was systematically

investigated, 2) psychometrically-sound measures were utilised, 3) comparisons were

Dissociative Disorders1, 5) extraneous variables were controlled or 6) DID diagnosis was

with reference to the scientific study of DID, are explored.

We have chosen to limit the current overview to empirical research on DID,

thereby bypassing a wide literature on dissociation and dissociative disorders. This

literature provides abundant, consistent evidence that dissociative experiences, symptoms

respondents from 16 different countries. In a review of the cross-cultural assessment of

dissociation, Lewis-Fernández et al. (2007) provide extensive evidence that reliably

(e.g., whether it is best conceived as a continuum, as a set of discrete categories or as a

of areas, including DID‟s construct validity, aetiology, prevalence, psychobiological and

cognitive foundations, and treatment. Challenges in the empirical investigation of DID

Research on DID is constrained by obstacles atypical for those of other

issues, post-traumatic avoidance, cost-benefit issues, and conceptual challenges.

DID is only weakly represented in the 10th edition of the International

Classification of Diseases (ICD-10; among “other” dissociative disorders). In the DSM-5

it is more fully elaborated. The discrepancy of definition hampers international research

polysymptomatic profile may obscure DID unless dissociative symptoms are

systematically assessed. Since major general psychiatric diagnostic instruments used in

developing shorter diagnostic instruments specific for DID is crucial.

Cultural variation in the clinical manifestation of DID remains under-researched

(see „Aetiological Pathways and Influences in the Development of DID‟, below).

difficulty of assessing for diverse modes of dissociative self-representation (e.g., different

idioms in different regions can preclude meaningful comparative research).

A further contextual challenge to DID research pertains to the varying nature of

identity-related cultural differences complicate comparative DID research.

DID is consistently linked to childhood relational trauma (see „Aetiological

Pathways and Influences in the Development of DID‟, below) and post-traumatic

reticence may hinder their participation in research studies.

denial of their occurrence or minimisation of their severity. Such denial, to which

understanding and effective treatment of the impact of such events on victims.

not only in the patient, but in society at large.

biological investigation as any other psychiatric disorder (see „Unique neurophysiological

to pharmacotherapy and short-term treatments, and that are diagnosed by current

Other contextual challenges relate to the concept of self as an autonomous and

abstraction of symptomatology from its social context, the discounting of lived

experience as a form of evidence (and corresponding need for phenomenological

approaches) and the reductionism of standard classificatory nomenclature as accurate