The Debate Over Whether Dissociative Identity Disorder Is "Real"

In psychiatry, there’s no more controversial diagnosis than dissociative identity disorder (DID), the disorder formerly known as multiple personality disorder (MPD). First appearing in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) published in 1980, proponents of the disorder have claimed that DID is woefully underdiagnosed, especially among those with a history of sexual trauma, with a true prevalence upwards of 20% across inpatient and outpatient psychiatric settings.¹

But others have suggested that DID is by definition overdiagnosed because they claim it isn't a real disorder.^2-4 Instead, they argue, it’s a diagnosis manufactured by those claiming to have it based on a blueprint established in Hollywood with the “based-on-a-true-story” films The Three Faces of Eve (1957) and Sybil (1976). A related charge is that DID is largely “iatrogenic”—that is, a product of a small handful of self-proclaimed experts that have managed to “sell” the disorder to psychotherapists and their patients, similar to how hysteria based on false memories of ritual Satanic abuse in children sprang up in the 1980s and later faded.

Why is there so much disagreement over this controversial entity? The main point of contention is that while we’re all familiar with dissociation—the idea that we can have out of body experiences in the face of trauma like sexual assault or can zone out, seemingly unconscious of our surroundings while driving on the freeway—it’s more difficult to fathom the kind of extreme dissociation that’s a defining feature of DID. Indeed, it can seem incredible to those who have never seen or experienced DID that one's identity and sense of self can fragment into two or more, or even dozens of, distinct personalities or “alters” with different names, genders, ages, and recollected pasts, each potentially unaware of the other.

After all, we might ask ourselves, "If multiple personalities go by different names, who it is that gives them those names?" Just as there’s only one logical answer to that question, skeptics likewise claim that the other characteristics of alters must likewise be manufactured by the individual who purportedly has DID.

A Sociocognitive Perspective

How then can we best understand the undeniable fact that some people do present with the symptoms of DID? There's no doubt that such people exist, but in what sense do their dissociative identities exist and if they don’t, does that mean that those who manifest them are “faking it?”

University of Wisconsin psychiatrist Dr. Charles Raison offers an answer that reflects how many psychiatrists think of DID:

“There is no doubt that some people behave as if they have multiple personalities. And not all of them have been to therapists who have trained them to interpret their dissociative experiences in this way. Does this mean that dissociative identity disorder exists? In my opinion it depends on what we mean by "exists." Yes, dissociative identity disorder exists if by exists we mean there are people who complain of its symptoms and suffer its consequences. Do I think that some people have many biologically distinct entities packed into their heads? No. I think that some people dissociate so badly that either on their own or as a result of therapeutic experiences it becomes the case that the most convincing way for them to see their own experience is as if it is happening to multiple people.”⁵

In 1994—the same year that DSM-IV replaced the term "multiple personality" in MPD with "dissociative identity" in DID—Carlton University psychologist Nicholas Spanos published an influential paper that similarly characterized MPD through a sociocultural perspective:

“In short, the sociocognitive perspective suggests that patients learn to construe themselves as possessing multiple selves, learn to present themselves in terms of this construal, and learn to reorganize and elaborate on their personal biography so as to make it congruent with their understanding of what it means to be a multiple.”⁶

Spanos chose the word “enactment” to describe how people identifying as having DID follow “rule-governed social constructions” with “multiple identities [that] are established, legitimated, maintained, and altered through social interaction.” People with DID, he wrote, are “actively involved in using available information to create a social impression that is congruent with their perception of situational demands and with the interpersonal goals they are attempting to achieve.”⁶

While there are many psychiatrists and psychologists who agree that DID is socioculturally constructed as Spanos argues,^{2-4, 7-8} there are many others—often including clinicians who work with DID and researchers who study it—who dispute the sociocognitive account in favor of a trauma model.^9-13 Within this seemingly two-sided debate, there are several legitimate and meaningful points of contention—such as to what extent DID is really iatrogenic or how to best treat it—whose resolution is thwarted when the debate is reduced to arguments about whether DID is “real” or “fake.” In fact, the sociocultural model and the trauma model aren't really mutually exclusive—according to a unifying biopsychosocial model, DID can be both a trauma reaction as well as highly shaped by sociocultural factors—and may share some potential overlap.^14,15

Enacted Identities

Within the sociocognitive model, “enactment” doesn't mean the same thing as "fabrication" or “faking it," which suggests more of a conscious and deliberate act of deception. If, as Spanos suggests, we instead think of DID as similar to other phenomena including hypnotic suggestion, past-life regression, spirit or demonic possession—to which I would add speaking in tongues, alien abduction experiences, or having imaginary friends as children—we can better appreciate how the enactment of multiple identities might arise consciously, unconsciously, or semi-consciously within the bounds of a certain sociocultural framework.

In other words, while asking whether DID exists or not and whether those with DID are faking it or not implies only two possible answers, the reality is something more nuanced and complex. For example, when people are “possessed by a demon” or the “Holy Spirit” during a culturally-sanctioned trance ritual or describe “past lives” during psychotherapy, they’re not simply “making it up” for the sake of making it up or for “attention.” While that could be the case (e.g., it is possible to simulate or “malinger” DID¹⁶ just as the woman upon which the movie Sybil was based later admitted to “lying” about her alters¹⁷), enacting demonic possession, like enacting DID, instead suggests an experience that involves tapping into something within one’s psyche that draws upon an existing sociocultural framework such as a religious practice, séance, psychotherapy session, or something else.

While none of those examples of cultural ritual imply that anyone is “faking it” or merely "acting," the sociocognitive model does make clear that demons, past lives, or distinct personalities don’t really exist apart from being enactments—or creations—of one’s mind.

This perspective isn’t actually very far afield from that of psychiatrist and psychoanalyst Richard Kluft, one of the leading proponents of the trauma model and the legitimacy of DID as a “real” mental disorder (see Kluft's interesting backstory on the fight to keep DID in DSM-III-R here). For example, Kluft characterizes the personalities or identities of DID as:

“…behaviorally enacted with noteworthy role-taking and role-playing dimensions and sensitive to intrapsychic, interpersonal, and environmental stimuli… The personalities are not unconscious in the traditional psychoanalytic sense… [and] arise as desperate coping strategies in an overwhelmed child [that] initially have an adaptational and defensive design… The patient forms and auto-hypnotically envisions an illusory embodiment of an identity that could manage the adaptation that is believed to be required. What is envisioned with a great sense of reality is believed to be real, and the mind undergoes a cognitive restructuring that accepts and interprets what is believed to be real as real, and makes it possible to act as if it were real.”¹

So it is that both Spanos and Kluft use the term “enacted” to account for the multiple identities of DID. The devil of what exactly that means—that is, why and by what mechanism those enactments occur—is in the details, with variability between models as to whether or to what extent such enactments are best understood as volitional fantasies or unconscious creations and whether or to what extent they’re causally linked to trauma.

In addition to conceding overlap, another way to resolve these differences is to acknowledge that such diversity not only reflects variations from one from model to another, but also from one culture, social setting, or individual to another. For those with DID, the term "enactment" will no doubt resonate with some better than others.

In my next post, we’ll take a closer look at how culture, social factors, and individual differences are changing how we think about and understand the concept of “multiplicity” in DID and to what extent this phenomenon is best understood or framed as a mental disorder.

To read more:
► Enacted Identities: Multiplicity, Plurality, and Tulpamancy