The Truth about Dissociative Identity Disorder

Dissociative identity disorder (DID, formerly known as multiple personality disorder), is a fascinating disorder. The movie industry and Hollywood are enthralled with it, with the recent psychological thriller, Split, raising many questions about DID. The trailer portrays a man with 23 personalities kidnapping and terrifying three teenagers. M. Night Shyamalan, who wrote and directed the movie, includes a plot twist, as always. It is supposed to soften the audience’s heart towards the villain. The movie, and particularly its trailer, play on the public’s worst fears and myths about DID. The director and studio stand to make millions of dollars on this terrifying (and inaccurate) portrayal of DID. Is it justifiable to create “entertainment “ that reinforces stigmas about mental illness, particularly when it exploits people who have developed DID directly due to exploitation as children?

The cost of ignorance about DID is high not only for individuals who live with the disorder, but for the whole support system in which they live. However, treatment of DID is associated with cost reductions over time, according to cross-sectional and longitudinal analyses and reports from both patients and therapists [9]. Fortunately, research about DID is replacing outdated myths, outside of sensational Hollywood movies (see Brand et al., Harvard Review of Psychiatry [7] and Webermann & Brand, in press [8], for the studies supporting the evidence described below).

MYTH	EVIDENCE-BASED FACT
1. People with DID are violent	People with DID are more likely to be victimized by others than to victimize them, according to research. For example, very low rates of incarceration, convictions or probations were found in the last six months among a sample of dissociative disorders patients in treatment. People with DID are at high risk to repeatedly attempt suicide and hurt themselves, according to research. Research with other psychiatric disorders indicates that risk factors for violence to others is often associated with male gender and substance abuse, among other variables. More research is needed to clarify under what circumstances an apparently small minority of people with DID pose a risk for violence.
2. DID is primarily diagnosed in North America by DID experts who over-diagnose the disorder	DID patients are consistently identified in outpatient, inpatient, and community samples around the world. DID is diagnosed by clinicians around the world with varying degrees of expertise in DID. Studies show that most individuals who meet criteria for DID have been treated in the mental health system for 6 to 12 years before they are finally correctly diagnosed.
3. DID is rare	The prevalence rates of DID have been studied in community samples, psychiatric inpatients, psychiatric outpatients, the general population, and a specialized inpatient unit for substance dependence suggest otherwise. DID is found in approximately 1.1 – 1.5% of representative community samples. Studies assessing groups with particularly high exposure to trauma or cultural oppression show the highest rates of DID.
4. DID is an iatrogenic disorder rather than a trauma-based disorder	Researchers concluded from their review and a series of meta-analyses that little evidence supports the position that DID is created by suggestion, fantasy, or iatrogenesis; these ideas are put forward by proponents of the “Fantasy Model” [FM] (sometimes also called the “Sociocultural Model” or “Iatrogenic Model”) of DID of dissociation [47]. The correlations between trauma and dissociation were as strong in studies that used objectively verified abuse as in those relying on self-reported abuse. This strongly contradicts the FM hypothesis that DID individuals fantasize their abuse [47]. Dissociation predicted only 1 – 3% of the variance in suggestibility, thereby disproving the FM’s notion that dissociative individuals are highly suggestible. [47] Additionally, no study has been conducted in any clinical population that strongly supports the FM of dissociation.
5. DID is a “fad”	DID is not a “fad” that has died. The authors browsed PsycInfo and Medline using the terms “multiple personality disorder” or “dissociative identity disorder” in the title for the period 2000 – 2014. The search yielded 1,339 hits for this fifteen-year period. The high number of publications about DID indicates an enduring scholarly and clinical interest in DID. DID patients can be reliably and validly diagnosed with structured and semi-structured interviews including the Structured Clinical Interview for Dissociative Disorders-Revised (SCID-D-R) and the Dissociative Disorders Interview Schedule (DDIS).
6. DID treatment is harmful to patients	This claim is inconsistent with empirical literature which documents improvements in the symptoms and functioning of DID patients when trauma treatment consistent with expert consensus guidelines is administered [46] [61] [160]. Early case series and inpatient treatment studies demonstrate that treatment for DID is helpful, rather than harmful, across a wide range of clinical outcomes.

*For a comprehensive list of references used in Brand et al., please see here.

Taking a closer look: DID treatment is harmful to patients?

There is no study that shows that DID patients are harmed by treatment. The authors who state this are relying on each other’s theoretical or opinion-based papers, not actual data (see Lambert, & Lilienfeld, 2009; Lynn, Lilienfeld, Merckelbach, Giesbrecht, & van der Kloet, 2012; Paris, 2012 as examples).

The cross-sectional, longitudinal prospective, and meta-analytic DATA (see Brand & Loewenstein, 2014; Brand, Loewenstein, & Spiegel, 2014; Brand et al., 2019; Myrick, Webermann, Langeland, Putnam & Brand, 2017; Myrick et al., 2017) indicate that patients with DID who are provided treatment that is consistent with expert consensus guidelines show:

• Decreased symptoms of dissociation, PTSD, self-injury, suicide attempts
• Decreased hospitalizations
• Decreased treatment costs
• Increased adaptive functioning, including better regulation of emotions and unsafe impulses
• Increased engagement in volunteering or paid work
• Increased feeling good

Research also shows that treatment of DID by clinicians who are aware of the patient’s dissociative disorder show decreased costs over time (Myrick, Webermann, Langeland, Putnam, & Brand, 2017).

Contrary to what the false memory advocates write, there is no research that shows that focusing on dissociative self-states makes people with DID more dissociative or amnestic. In fact, research shows just the opposite. For example, people with DID feel less fragmented and report hearing voices less often over time in treatment if their dissociative disorder is treated according to expert consensus guidelines (see more from the International Society for the Study of Trauma and Dissociation here).

The evidence about the assessment and treatment of dissociation is strong and consistent. Clinicians who do not properly assess for and treat dissociative reactions to trauma may be subject to claims of practicing below the standard of care, and possibly harming a patient, rather than the other way around.

What does the media get right about dissociative identity disorder?

Almost nothing!

Most movies depict people with dissociative identity disorder (DID) as comical (e.g., Me, Myself and Irene) or sociopathic (e.g., Split, Psycho, Fight Club, Dr. Jekyll and Mr. Hyde). Few convey the degree of suffering of these people. Only some capture that the disorder is almost always the result of severe and chronic childhood trauma.

Movies portray therapists who treat DID as being overly fascinated with the disorder, and as having poor boundaries (e.g., becoming over-involved and too friend-like). No movie has depicted treatment that is consistent with treatment guidelines developed by DID experts around the world (see ISSTD’s Guidelines for Treating Dissociative Identity Disorder here).

Many media accounts mislabel DID as schizophrenia, even though they are entirely different conditions.

Many interviews of people with DID feature individuals who are much more attention-seeking and dramatic than is typical among DID. Some of the people in interviews seem to enjoy sharing personal details about trauma and their personalities that most people with DID are reluctant to reveal. Research shows that most people with DID are avoidant of people and attention, and hide their inner world of personalities as much as they can.

Outrage about Split

Over 20,000 people have signed a petition to boycott Split.

“Moviemakers like M. Night would do well to move past this tired and offensive trope… At a time when so much attention is being paid to mental illness and gender identity, we’ve reduced both conversations to a horror movie trope.”

See the petition here: http://www.thepetitionsite.com/944/537/866/

Mental health professionals criticize Split.

See ISSTD’s press release here: http://www.isst-d.org/downloads/Statement%20on%20Split-final.pdf

The media decry Split pushing back decades of progress by the health field.

“In a world where Silver Linings Playbook showed that people with mental illness deserve love and United States of Tara portrayed the everyday struggles of people living with dissociative identity disorder, we don’t need Split setting the bar for mental illness in films back to 1960.”

https://mic.com/articles/149959/m-night-shyamalan-s-split-trailer-suggests-a-movie-rife-with-mental-illness-stigma#.B9nqPcKm7

CNN raises awareness about what Split gets wrong about dissociative identity disorder.

http://www.cnn.com/2017/01/23/health/shyamalan-split-movie-dissociative-identity-disorder/index.html

Individuals with dissociative identity disorder challenge Split’s stereotypes.

“It makes us targets and encourages violence against us… As long as films like “Split” continue to be made and distributed, tens of millions across the world will suffer for it.”

https://themighty.com/2016/12/letter-to-m-night-shyamalan-did-dissociative-identity-disorder/

Those with dissociative identity disorder continue to speak out.

“What if someone made a movie about you – only you were the villain? Not a brilliant, super-villain who is kind of cool, but someone horrifyingly bizarre and dangerous. That’s what M. Night Shyamalan’s new movie “Split” is doing to me and everyone with dissociative identity disorder (DID). Whatever happens with the movie — fame or flop — the ads and trailers are already driving home the message that everyone needs to fear people with DID.”

https://themighty.com/2016/12/split-dissociative-identity-disorder/

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[1] Nijenhuis, E. R. S., Vanderlinden, J., & Spinhoven, P. (1998). Animal defensive reactions as a model for trauma-induced dissociative reactions. Journal of Traumatic Stress, 11, 243-260. 

[2] Putnam, F.  W. (1997). Dissociation in children and adolescents: A developmental model. New York: Guilford.

[3] Spiegel, D. (1984). Multiple personality as a post-traumatic stress disorder. Psychiatric Clinics of North America, 7(1), 101-110.

[4] Giesbrecht, T., Lynn, S. J., Lilienfeld, S. O,, & Merckelbach, H. (2008). Cognitive processes in dissociation: An analysis of core theoretical assumptions. Psychological Bulletin, 134, 617-647. 

[5] Merckelbach, H., Horselenberg, R., & Schmidt, H. (2002). Modeling the connection between self-reported trauma and dissociation in a student sample. Personality and Individual Differences, 32, 695-705. 

[6] Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Cardeña, E., … & Spiegel, D. (2012). Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychological Bulletin, 138(3), 550.

[7] Brand, B. L., Sar, V., Stavropoulos, P., Kruger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating fact from fiction: An empirical examination of common myths about dissociative identity disorder. Harvard Review of Psychiatry, 24(4), 257-270.

[8] Webermann, A. R., & Brand, B. L. (in press). Mental illness and violent behavior: The role of dissociation. Borderline Personality Disorder and Emotion Dysregulation.

[9] Myrick, A. C., Webermann, A. R., Langeland, W., Putnam, F. W., & Brand, B. L. (2017). Treatment of dissociative disorders and reported changes in inpatient and outpatient cost estimates. European Journal of Psychotraumatology, 8(1).