One of my great pleasures in life is reading scientific discourse. Specifically, when great minds discuss scientific theories and approaches and everyone picks on the problems in each other’s theory or framework. If you like these things, please make sure to read Dissociation and the Dissociative Disorders, articles by various specialists collected by Paul Dell. It can teach you a lot about the history of DID science, how far we have come and where things are still being discussed to this day. It is a pleasure to read if you like research and science and multiple perspectives and knots in your brain.
One of the long-term discussions is between Ellert Nijenhuis, who co-authored the theory of the structural dissociation of the personality and Paul Dell, who developed the MID, an excellent screening tool for DID. Both are brilliant and witty and have very sharp minds. Their conflict is about which view of DID is the best and most correct for diagnosing it and I will simplify it as much as I can.
Nijenhuis says that inner structure is key. Without an inner separation of different parts of the personality, there is no DID diagnosis. It is absolutely necessary to base the diagnostic criteria on an inner structure that is not easily visible because that is what it is all about. And no effective DID treatment ignores this inner structure.
This is how we ended up with the criteria we have right now. A lot of therapists feel lost when they see them because there is no indication what such an inner structure would look like. Every other diagnosis in the book lists signs (things you can see from the outside) and symptoms (inner experiences reported by the patient) and the specific pattern they create leads to the diagnosis. Missing signs and symptoms within the diagnostic criteria make a diagnosis vulnerable to the expertise and good will of the diagnostician, or their lack of.
Simplified, Dell says that structural dissociation is what creates a certain pattern of signs and symptoms. We need a realistic chance to detect structural dissociation and an invisible inner structure is not practical. Research has given us an overview of the most common ways DID shows itself. They are the same signs and symptoms we will be asked about in a diagnostic interview or test. So why not make them diagnostic criteria.
It is one of these situations where both make very important points. The inner structure is essential and there are people with this structure who will not be aware of their symptoms and therefore unable to report them. The majority of people with DID are covert with only small time frames of diagnosability during crisis situations. The signs are not constantly visible. DID is best grasped in structure. And I am suspicious of treatment approaches that don’t include structure and try to only treat symptoms. But I agree that this is highly impractical for general clinical practice. It demands diligence and expertise that is honorable but rarely found outside specialist offices.
As patients, we are often facing a lot of denial. Other people deny the existence of our inner structure because the signs and symptoms were not broadly communicated and they don’t know how to recognize them. And we experience our own denial, because it is hard to recognize our own experience in the diagnostic criteria.
Whenever I share the criteria that were suggested by Dell, people respond with relief, recognition and a new sense of security about their diagnosis. These are not the official criteria but they are a very good reflection of what people with DID experience. In a time when ‘inner child’ work is rediscovered and many people work with ‘parts’ within therapy, these criteria might also help to differentiate between regular ego states and structural dissociation.
Some specialists prefer Dell’s suggestions for clinical practice and the group seems to grow in influence. That is why I want to show you what Dell did there. It is based on thorough research about the most common signs and symptoms of DID and I will simplify the clinical vocabulary a bit to make it easier to understand.
A Criteria
In this section we get asked about more general dissociative symptoms. 3 or more would be needed for a diagnosis:
- amnesia about past life events (not remembering childhood or single events)
- depersonalization
- derealization
- trauma flashbacks
- dissociative symptoms of the body (like not sensing pain or body flashbacks)
- trance states (zoning out)
B Criteria
The second group of symptoms cover the existence of parts which can be recognized by intrusions from these parts (intrusions are experiences that enter our consciousness even when we don’t actively create them ourselves. A flashback is a special kind of intrusion where memories enter our experience, but it can happen in all areas of experience). Self-report is considered as valid as the observation by a clinician and it needs one or the other. We will look at 1) the things clinicians could observe and then 2) what we could report ourselves.
- Switching: someone (clinician or witness) reports that they have seen another part of the personality. This can happen in 3 ways:
a) it is visible that someone else showed up because they announced themselves or because there is a sudden change in 2 or more of these areas:
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- facial expression
- body posture
- tone of voice
- mannerism
- emotions
- opinions or
- attitudes
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b) the patient shows awareness of different self-states by
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- reporting co-consciousness for what another part did
- remembering afterwards what the other part did
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c) experiencing the other states as ‘not-me’ or ‘other’
- Patient reporting awareness of intrusions or influences from other parts . To qualify you need at least 5 of these experiences:
a) hearing child voices inside
b) sense of an inner struggle between parts (could include arguments but also major conflict and what feels like power struggles)
c) hearing hostile voices
d) hearing yourself say things you didn’t want to say or didn’t say ‘yourself’
e) feeling that thoughts are taken from your head (blank) or added (but nor ‘yours’)
f) feeling like emotions are taken (numb) or added (but not ‘yours’)
g) ‘made’ impulses that don’t feel like yours
h) ‘made’ actions that don’t feel like yours or getting blocked from being able to act
i) weird changes in your experience of yourself (like feeling small, not recognizing yourself in the mirror, not being who you usually are)
j) being confused about all these experiences
C Criteria
The C criteria cover amnesia that is connected to intrusions by other parts and switching. Again, it is 1) possible for the clinician to observe that or 2) for us to report it
- A different part shows up and later the person has amnesia for what happened in that moment. What it can look like:
a) visible presence of another part
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- part introduces themselves
- sudden change in presentation (like in the list above: face, posture, voice, mannerism, emotions, opinions, attitudes)
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b) person is unable to remember it afterwards
- Self-report of repeated amnesia, needs 2 incidents of 2 of the following experiences
a) ‘losing time’, noticing gaps in memory with no knowledge of what happened, could be an hour, could be a year
b) ‘coming to’, gaining awareness in the middle of doing something that you don’t remember starting
c) fugues, coming to in an unexpected place with no memory of going there
d) being told about things you have done but not having any memory of doing them
e) finding evidence that you have done something that you can’t remember doing
f) not remembering who you are or what your name is
g) inability to remember skills you usually have like reading or playing an instrument
h) inability to recall personal information that goes beyond ordinary forgetfulness
D Criteria
To make sure that the diagnosis is correct the clinician needs to check a number of other diagnoses to make sure it is none of those. Listed are:
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- Schizophrenia
- Schizoaffective Disorder
- Psychosis
- Mood disorders with psychotic features
- Borderline Personality Disorder
- Substance abuse
- medical conditions like neurological disorders
E Criteria
Like all disorders it only counts as a disorder if it causes suffering or limits functioning in a significant way.
The discussion about diagnostic criteria is a difficult one and I am glad to leave it to scientists. I believe that both the current official criteria and this set of alternative criteria are important to know. Dell’s suggestions can make it a lot easier for patients to accept the diagnosis because we recognize experiences from our everyday life, things that do happen to us and that we cannot easily deny. This is useful, even if it is not official.
You can find this and more about partial DID in ‘Dissociation and the dissociative disorders’ in chapters 24 and 25.
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