Self Splintering: Dissociative Identity Disorder

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In the modern age of the Internet, it has become popular amongst users on social media websites, such as TikTok and Tumblr, to self-diagnose with different disorders. The most popular example of this is TikTok, where many who claim to be medical professionals or have a certain disorder say statements such as “Scientists say if you can’t see the illusion in this video, you have depression,” or “If you show XYZ trait, you have autism.” A disorder that is commonly brought up when talking about self-diagnosis is Dissociative Personality Disorder (DID), previously known as Multiple Personality Disorder (MPD). The name change occurred in 1994, due to learning new information about the disorder [1]. MPD implies that many personalities are in one person, while DID implies that one personality has been split into many parts. 

A person with DID has more than one personality state, with the different states called “alters” [2]. The alters all reside in the same body, which is known as the “system” [2]. One of the most well known examples of a system on social media is the Wonderland System on TikTok, with this specific system containing 271 alters [3]. DID is not a disorder that is commonly discussed, and in media such as M. Night Shyamalan’s Split and Alfred Hitchcock’s Psycho, those with DID are often portrayed as villainous and crazy. The rise in self-diagnosis has brought this disorder into a more positive light but also has many questioning the validity of the disorder. Many inquire how it is possible for alter states to form, and more skepticism has emerged as some who claim to have DID have been exposed for not actually having the disorder. This controversy is not only present in social media, but also in the scientific and medical fields. While DID is recognized within the DSM, many scientific and medical professionals debate on the criteria needed to diagnose the disorder [4]. Some are conflicted over how symptoms should be classified, and others believe a DID diagnosis manifests due to patients being affected by hypnotic suggestion, or social contagion [5]. In order to evaluate the validity of this controversy, it is important to discuss what DID is, why DID diagnosis is controversial in the scientific field, and the future of DID in the age of self-diagnosis. 

Dissociative Identity Disorder (DID) is a disorder that affects a person’s functioning and perception of the world. In order to diagnose this disorder, physicians use the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the DSM. This manual contains information about many mental disorders and is used by psychiatrists in order to diagnose a mental disorder in a patient [6]. Currently, the DSM is on its fifth edition, which is referred to as the DSM-5. According to the DSM-5, a DID diagnosis is made when a person’s identity is disrupted by two or more distinct personality states, which consists of notable differences in areas such as behavior, memory, perception, cognition, and/or sensory-motor functioning [6]. The person has trouble remembering both everyday events and important personal events or milestones, which is not caused by ordinary forgetfulness [6]. For example, the person could have a lapse in remembering the death of a parent. Rather than forgetting large events, the person could be unable to recall what they did today or other skills such as driving a car [6]. Those with DID may also suddenly find themselves in new places that they do not remember going to, or they may find evidence of tasks or actions they do not remember doing [6]. Additionally, the symptoms cause significant distress or impairment in social, occupational, or other areas of functioning [6]. These symptoms are also not a normal part of the culture or religion that the person follows, cannot be explained due to substance use or another medical condition, and cannot be explained through imaginary playmates or other fantasy play if the person is a child [6]. 

Typically, it is difficult to know if someone has DID or not. A person who has DID may not notice that there are differences in their identity and memory, minimize the amnesia they have, or try to hide these differences when they are around others [6]. For these reasons, it is important when other people notice these symptoms, as they can help a person realize that they may have DID. Symptoms that others may notice include the person with DID not remembering something they saw or said, an inability to remember their own name, or an inability to recognize their close friends or family [6]. Within the United States, it is believed that 1.5% of the population has DID [6]. While anyone can develop DID, there is a strong correlation between experiencing trauma and emotional neglect as a child and developing the disorder [7].

History of DID

While DID has only recently entered public awareness, the disorder’s history dates back several centuries. Evidence from the writings of Benjamin Rush suggests that DID was present in individuals as early as the 16th century [8]. Rush was a medical professional who interacted with three patients that showed extreme cases of dissociation; two of these cases specifically showed symptoms related to DID [8]. While Rush did not identify these cases as DID or MPD at the time, the patient’s symptoms were similar to those who have the disorder today. One example of a patient Rush observed was the daughter of an officer, who seemingly had two personalities [8]. Her “madness” personality was a woman who spoke French, engaged in actions associated with homosexuality, and denounced Methodism, which was the religion she followed [8]. Her normal personality did not have the memories her “madness” personality had [8]. She was dedicated to Methodism and renounced her homosexual actions [8]. While never officially diagnosed, this patient shows core symptoms of DID, with shifting into distinct personalities described as madness, as well as memory loss that corresponded to when the patient shifted. 

In 1811, Mary Reyonds was officially documented as one of the first people to have a dissociative disorder [9]. When she was younger, her family moved from England to America to escape religious persecution, which was believed to cause trauma related to the development of her DID [9, 10]. Reyonds was described as a sorrowful child that spent much of her time reading the Bible [9] and when Reyonds was older, she caught an illness that caused her to completely forget every part of her life before, including how to talk [9]. After her family reeducated her, she began to shift between two states, one where she acted as she did originally, and one where she expressed more positive emotions but lacked real world knowledge [9]. She kept shifting personalities until the age of 44, where she was in her second state permanently until she passed at the age of 69 [9]. Interest in dissociative disorders began to grow, and in 1980, DID was introduced in the DSM-3 under the name of MPD [11]. The entry in the DSM would be updated multiple times over the 19th and 20th century, mostly notably in 1994 with MPD being renamed to DID to accurately describe the disorder [12]. In 2013 with the release of the DSM-5, the definition of DID was updated to include other symptoms that may cause differences in DID from one person to another, changes in personality that are observed by others or self-reported, and gaps in being able to remember everyday events, not just traumatic experiences [13].

While DID is officially in the DSM, many do not believe in the existence of DID. Many factors go into this belief, such as popular DID cases that were revealed to be faked years later. An example of this is the publication of the book Sybil in 1973 [14]. The book describes a woman named Shirely Mason known as “Sybil”, who believed she had different alters, and as she was given medication by her doctor, she began to uncover more [14]. It was widely believed that this case was true at the time, however, in 2011, the book Sybil Exposed revealed that the story was a lie [14]. Mason knew she did not have multiple personalities, and brought this up to her doctor [14]. However, her doctor wanted to make a book about Mason and threatened her to stay quiet otherwise she would lose the financial support the doctor had been giving her [14]. Other factors, such as believing DID is actually iatrogenic (caused through a person’s medical care), believing that the patient was misdiagnosed, and believing that DID treatment actually harms patients explains why some do not believe DID is real [4]. However, there is evidence to suggest that these statements could be false. When looking at DID potentially being an iatrogenic disorder, there is a strong correlation between DID and childhood trauma across multiple countries that disproves this idea [15]. Some believe that symptoms thought to be DID are actually Borderline Personality Disorder (BPD) symptoms, however, unlike those with DID, those with BPD have less extreme shifts in emotions compared to those with DID and are able to remember what they did in different emotional states [16]. When looking at how harmful DID treatments can be, studies show that DID treatments are actually helpful, and there is no peer-reviewed study that supports the idea that DID treatment could potentially be harmful to patients [16]. 

Biology of DID

The lack of information regarding DID’s biological basis in the brain causes much of the conflict that comes from diagnosing the disorder. Currently, there is little research that focuses on how a brain with DID may differ from a brain without DID. There are many difficulties in studying DID patients due to the disorder’s extremely low prevalence in the population. Additionally, many DID patients have other illnesses or disorders, such as depression or substance abuse, that may influence symptoms displayed [6]. However, considering work from previous studies and current research, there is enough evidence to suggest that brains of those with DID are different compared to those without. A variety of studies using methods such as PET and fMRI found that there are significant changes to brains with DID compared to their normal controls [7]. In the PET study, those with DID who had an identity with memories of their trauma had increased blood flow in areas such as the amygdala and anterior cingulate cortex [7]. The amygdala is important for memories related to emotional responses, such as fear, while the anterior cingulate cortex is important for processes such as emotion, decision-making, and impulse control. Given that DID is a disorder caused by severe traumatic events, it makes sense that these areas, which are associated with emotion, would have increased blood flow when the person is currently the identity that has memories of their trauma. When those without DID tried to simulate this, they could not produce the same blood flow seen in those with the disorder [7]. In the fMRI study, women with DID were asked to view neutral and angry faces; these faces were viewed by both the host (ANP), and the identity that had memories of their trauma (EP) [17]. When the women were EP, larger activation in the parahippocampal gyrus was measured when viewing neutral and angry faces compared to when the women were ANP [17]. The parahippocampal gyrus is important for memory encoding and retrieval, so deficits in this area could explain the memory loss that comes with the disorder.

The use of biomarkers may also provide evidence on how a brain with DID differs from a normal brain. A biomarker is an objective measure for capturing what is happening in a cell or organism at a given moment [18]. This is significant, as much of what we know about DID is through subjective measures, which can vary from person to person. One study used MRI scans to compare the brains of females with DID and matched controls [19]. Specifically, the researchers examined the differences between white matter and gray matter in the participants’ brains [19]. When analyzing the brains of those with DID, gray matter levels were lower compared to their matched controls in areas such as the frontal gyrus, anterior cingulate gyrus, and fusiform gyrus [19]. When examining white matter levels, those with DID had lower levels in areas such as the frontal region, temporal region, and the connection between the hippocampus and amygdala [19]. These studies suggest that there are neurobiological differences between those with DID and those without, and provide a framework for studying these areas for future DID research. While there is not enough research to come to a definite conclusion on parts of the brain that underlie DID, the data we currently have strongly suggest differences in neurological function in those with DID compared to those without DID. 

Treatments for DID

While there is no known cure for DID, therapy is commonly used to help patients deal with their symptoms. A variety of therapies can be used to help the patient, such as Phasic Trauma Treatment and Cognitive Behavioral Therapy (CBT) [20]. In Phasic Trauma Treatment, the patient works on stabilizing their DID symptoms in phases, to ultimately try to merge identities and learn how to live a life with DID [20]. In CBT, the patient learns how to change their thought process in order to fix negative ways of thinking, and learn how to cope with difficult situations [21]. Unfortunately, there is little data regarding the effectiveness of therapy for DID, and the data we have now are primarily through case studies regarding how those with other dissociative disorders have been affected by therapy. However, from these data, therapy is shown to have a positive impact. Typically, the main goal of therapy is to integrate all of the parts of the system into one functional person [22]. The therapist must learn about all of the alters that make up the system in order to make a well-thought out treatment plan, as a high amount of psychotherapy sessions are needed to help those with the disorder [23]. In addition, many patients tend to stop treatment due to issues such limited insurance coverage and disbelief from medical providers about their condition [24]. Treatments that adapt to the patient are shown to improve wellbeing, even when the patient has major dysfunction [23].

There is no drug that can be directly used for DID, however medication may be used to help with other symptoms that result from the dissociative disorder. Typically, antidepressants and anxiolytic (anti-anxiety) medications are prescribed to help those deal with the depression and anxiety they may experience [23]. Other medications, such as naloxone and paroxetine, may help with dissociative symptoms, but the data shown are not concrete, and the study conducted on these medications primarily focuses on other dissociative disorders, such as PTSD [25].

Future of Self-Diagnosis

The advancement of the internet has led to an increase in self-diagnosis of various conditions and illnesses, over the years, due to how easy it is to access information online. In 2012, “do-it-yourself” health applications were the second hottest trend [26]. These applications are designed to self diagnose for diseases, such as Alzheimer’s disease and cancer [26]. Today, social media drives a lot of self-diagnosis seen on apps such as TikTok, primarily from those who claim to be a medical professional or who have a certain condition. It is unknown why TikTok specifically has pushed self-diagnosis to light, but the way TikTok shows its users content regardless of who they follow may play a role [27]. So, if you are randomly scrolling through the app, you may encounter videos about self-diagnosis even if you do not follow anyone that posts about the topic.

Many of the posts claim that if you show certain traits, or perceive something in a different way, that you may have a certain condition. However, many factors go into a diagnosis that are not as simple as results from a kit you can order, or learning information from one post online. When looking at DID self-diagnosis, the complexity of the disorder makes it extremely hard to simply self-diagnose based on information from one or two posts. Additionally, these methods are not always accurate. In a study involving symptom checkers on websites, correct advice on what the symptoms could be were only given in 58% of cases, and some websites only suggested emergency medical treatment for serious symptoms 64% of the time [28]. While it may help you with a problem, jumping to conclusions with the limited information a social media post or a test kit provides will most likely lead you to a conclusion that is misguided, and may even harm you. 

While there are many negatives to self-diagnosis, that does not mean it is all bad. Self-diagnosis can be a useful tool depending on how it is used. For example, someone may know they may have a problem, but may not have the resources to be able to get a professional diagnosis. As well, a person may have certain characteristics that cause them to be overlooked when considering a mental health diagnosis, such as their gender or race. As an example for gender, males are more likely than females to be diagnosed with ADHD, due to the symptoms that are commonly associated with the disorder presenting more often in males compared to females [29]. For race, African Americans are more likely to be misdiagnosed with schizophrenia compared to non-Latino white patients, potentially due to racial bias [30]. If a person experiences bias from one doctor due to their personal characteristics, it might be useful for them to conduct research on what they might have, and approach a different doctor about their symptoms. The healthcare system is not perfect, and bias within the system can overlook those who are suffering but do not know what is wrong. Self diagnosis can be both advantageous and disadvantageous, and it is a lot harder to diagnose yourself with a problem as complex as DID compared to other disorders, such as depression. 

Conclusions 

DID is a disorder that splits a person into multiple personalities, affecting how they function in the world. While there is little information about the disorder, there is enough evidence to show that the disorder is real when looking at the disorder’s biology and history. Self-diagnosis has helped to spread awareness of DID, but DID is not something that a person can easily determine if they have or not. If you feel you may have a mental illness or disorder, you should conduct thorough research, consider characteristics in your history that may match to what you might have, and get the consideration of a mental health professional if possible.

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