Many Rooms: One House

Today I am going to talk about dissociative identity disorder.

In both popular media and clinical spaces, Dissociative Identity Disorder or DID is often framed as anomalous or sensational and something to be afraid of. However, within trauma-focused psychiatry and psychology, DID is increasingly conceptualized as a coherent developmental adaptation to overwhelming and chronic threat.
(Putnam, 1989; van der Hart, Nijenhuis, & Steele, 2006)

This episode approaches DID not as a collection of dramatic symptoms, but as an organized response of the developing mind to conditions in which integration of developing parts of personality was neither safe nor biologically feasible.

I will use clinical metaphor with formal theory—not as simplification, but as fidelity to how dissociation is structured and experienced. According to Howell in their 2011 publication, Dissociation does not manifest as criteria; it manifests as lived organization.

I would like to begin with conceptualizing DID — beyond the diagnostic criteria found in the Diagnostic and Statistical Manual which is the primary guide for diagnosing dysfunction, illness, injury, and mental health.

From a diagnostic standpoint, dissociative identity disorder is defined by the presence of two or more distinct identity states, accompanied by recurrent amnesia and disruptions in consciousness, memory, affect, and sense of self.
(DSM-5-TR; American Psychiatric Association, 2022)

Yet the diagnostic description alone does not adequately capture the internal logic or developmental function of the disorder or establishment of multiple personalities.

Some of the clinical presentations include long histories of treatment resistant depression or anxiety, multiple mental health diagnoses over time and inconsistent responses to therapy or medication. Many times, clients report things like “parts of me feel separate”, “I lose time”, “I’m not always in control”, and most fear that they are crazy.

Clinically, DID can be conceptualized using an architectural metaphor. The mind develops like a house under construction. Under sufficient safety, rooms remain connected, allowing flexible movement between affect, memory, and identity. And the personality develops normally, well integrated.

In the context of chronic, inescapable trauma, certain experiential ‘rooms’ become intolerable to enter because of the trauma that happened in them. Initially, access is restricted. Over time, access is structurally eliminated or the rooms are sealed off. In DID, the architecture itself changes. Separate compartments are constructed to contain specific survival functions like attachment, threat detection, daily functioning, or traumatic memory and each is isolated to preserve overall system viability.

These compartments correspond to dissociative self-states, as described in the theory of structural dissociation by ver der Hart et al. (2006): “psychobiological subsystems organized around distinct action systems and these distinct action systems operate independently of the rest of the systems.”

According to Putnam (1989) and Siegel (2012), “Identity integration is a developmental achievement rather than an innate state. Early self-states are naturally discrete or separate and become integrated through consistent co-regulation, attachment security, and narrative continuity.” This is provided usually by primary care givers and is sustained throughout childhood development, adolescence and young adulthood.

One Metaphor we can use is to think about DID like an Orchestra

Early identity development resembles an orchestra without a conductor. Different instruments play independently. Over time, a coordinating system emerges, allowing modulation and coherence and the end result is a symphony with depth and character.

In severe developmental trauma, this coordinating system does not consolidate. The conductor never appears which motivates certain instruments to continue to play in isolation because the material they carry—terror, pain, rage—cannot be safely integrated into the whole and it feels like disorganization and instruments working at cross purposes. The goal then is to organize the instruments into a rock band where all of the players have equal status and importance and as time goes on begin to produce their own music with no one of them as the sum total of the band. However, like with rock bands, they can have a front man or lead vocalist.

Empirical literature consistently links DID to “early, repeated interpersonal trauma occurring during sensitive periods of neurodevelopment”. (Dalenberg et al., 2012; Putnam, 1997) “From this perspective, dissociation represents an adaptive neurobiological response, not a primary pathology.” (Nijenhuis, 2015)

I would like to demonstrate this by asking you to consider this composite case of ‘Anna,’.

Anna presents as high-functioning and reflective. She also reports recurrent amnesia for everyday actions for example written notes, purchases, conversations and chores that are done but she has no recall of doing them.

What becomes apparent over time is not disorganization, but functional specialization like a hospital system with many specialized physicians or departments.

In some dissociative states, Anna experiences herself as a young child where she is hypervigilant, fear-dominated, and preoccupied with immediate safety. In others, she is emotionally constricted, procedural, and task-oriented.

According to van der Hart et al., (2006)and Liotti, (2004)“Each state corresponds to a specific action system: like an attachment cry, defensive mobilization, daily living, and threat monitoring.” That can look like a pediatrician, emergency room doctor, general medicine doctor, and radiologist in a hospital system.

Eich et al., (1997) and Reinders et al., (2003) state, amnesia between states reflects state-dependent encoding and retrieval. Memory remains intact but inaccessible across dissociative boundaries. This looks like the structure of hospital system departments. They are separated by and have their own specializations where movement is possible from one department to another but never occupying more than one department at a time with no recall of having visited any of the other departments.

Let’s talk for a minute about what DID is not. It is not schizophrenia although many with DID are diagnosed as “schizophrenic”. It is not psychosis although many are diagnosed with this because of the internal voices. It is not attention seeking or roleplaying. It is not a personality disorder. And, it is not caused by suggestion or therapy.

Let’s address some of the persistent clinical myths about DID.

Despite a robust evidence base, misconceptions about DID persist within both public discourse and clinical training. Even many behavioral health professionals hold the mythical perception that folks with DID are just pretending or making stuff up. This is frequently stated by professionals as they don’t “believe in it”. Some of the clinical evidence is clearly demonstrated in the Apple+ miniseries, the Crowded Room which is an adaptation of the Billy Milligan story who was the first person with multiple personalities to go on trial for attempted murder. It ended with him being confined to a mental hospital instead of prison because he had DID. It was a major uphill battle for his psychiatrist and attorney to get the court and jury to understand the nature of what was going on with Billy’s development as a child that created the need for multiple personalities. And it is true, that other accounts of his story portray him a lot of different ways, but when we view them in context of the multiple identities it makes sense that his behavior would vary and be inconsistent.

Many times, I will hear clients say that they sometimes think they are making stuff up and my question to them is always, if you were going to make something up why would you pick this? And as a follow up I ask how is it then, that you are so disturbed by the memories of something you made up?

Another myth is symptom fabrication.

Neuroimaging and psychophysiological studies demonstrate state-dependent differences in brain activation, sensory processing, and autonomic regulation. (Reinders et al., 2006; Schlumpf et al., 2014) There is a miniseries on YouTube and A&E, called The Many Sides of Jane where the documentary folks followed her for a bit documenting the multiple parts. At the end of the series, she went to have brain imaging done where they found that when they caused or triggered a switch, the activity in the brain moved to another location at the initiation of the switch. (https://www.aetv.com/shows/many-sides-of-jane)

Another myth to talk about is the idea of “multiple people”.

“DID reflects one individual with a fragmented internal organization of self, not multiple independent identities.” (Putnam, 1989) Many times my clients will talk about feeling like different people however, I can help them understand the structure of their identity by using the metaphor that personality is like a car engine. The engine is an engine consisting of several functional parts like the pistons, carburetor, of fuel pump. These parts have their job to do for the engine to work. If we take the parts individually and give them a standalone presence, they are only what they are, which is not helpful or realistic for an engine to be operable. All the parts of the engine must be attached to the engine for it to work or the engine isn’t an engine at all but a bunch of parts that are incapable of doing their job apart from the engine. And when all the parts are attached it is an engine not the names of the parts.

Dr. Colin Ross, who was part of the committee that worked on the DSM for mental health diagnoses, stated in a training that I attended that he thought the worst thing they did was to pathologize DID. By that he was talking about the transition from multiple personalities as a descriptive diagnosis to dissociative identity disorder. Making it a disorder is how the medical community pathologized it and made it seem bad, wrong, or a deficit. Part of the struggle with my clients is getting them to understand that they are not sick or unwell, which is what the medical model does by pathologizing. There is nothing about the dissociative response for survival to ongoing trauma that is a pathology, it is an amazing ability of the brain to adapt and survive.

Another myth is that integration is erasure.

Contemporary treatment emphasizes cooperation, co-consciousness, and functional integration—not elimination of parts. (ISSTD Guidelines, 2011) Years ago, the stance used to be to eliminate the parts of the personality by forcing an integration into one singular sense of self. However, we know today that it does not work. I do not have DID and frequently will say a part of me feels, thinks, or wants, so to tell someone that survived some of the most horrendous things in their life that they don’t get to have a part of them that differs in feeling, thinking or wanting is a double standard in healing and not useful at all.

So, we can look at the DID system like a clinical team where effective treatment resembles coordinated teamwork rather than hierarchical suppression. When accessibility is granted to the different parts of the hospital system and there is a flow of information and integration of care, then functioning in a unified way is possible. The same is true for establishing an integrated, unified way for the parts of personality to function in an integrated way.

Now, in regard to treatment considerations, the international consensus guidelines as put forth by the International Society for the Study of Trauma and Dissociation (of which I am a member) endorses a phase-oriented treatment model for DID. (ISSTD, 2011)

The Phases are:

• Stabilization and safety

• Gradual trauma processing

• Integration and rehabilitation

Brand, et al (2013) caution “We have to remember that premature trauma processing increases risk of destabilization and symptom exacerbation.” We must go slow in the process and take care that we are not forcing but allowing the parts of personality to establish connection over time.

Effective modalities for working with DID are phase-oriented trauma treatment as mentioned before, ego state therapy, modified EMDR, parts-informed therapies, and sensorimotor and somatic approaches as adjunctive therapies.

When working with DID we have to remember to not treat DID like standard PTSD, not to rush trauma exposure, ignore dissociation during EMDR, invalidating parts as “not real” nor over focusing on parts at the expense of stabilization.

In review let’s remember that like remodeling during an earthquake, structural work cannot proceed during ongoing seismic threat. And, according to Howell, (2011) “An effective therapeutic stance is collaborative, respectful of protective functions and explicitly paced.

In conclusion, dissociative identity disorder does not represent a deficit of identity, but a system of parts that adapted for survival with remarkable precision under conditions of chronic threat.

Each dissociative self-state exists because it once served for survival.

And finally, treatment involves creating sufficient safety for it to become possible for parts to have integration in functioning—not forcing unity but allowing it.

Below I have provided citations for the information mentioned in the blog.

  American Psychiatric Association. (2022). DSM-5-TR.

  Brand, B. L., et al. (2013). A naturalistic study of dissociative identity disorder treatment.

  Dalenberg, C. J., et al. (2012). Evaluation of the evidence for the trauma and fantasy models of dissociation.

  Howell, E. F. (2011). Understanding and Treating Dissociative Identity Disorder.

  ISSTD. (2011). Guidelines for Treating Dissociative Identity Disorder in Adults.

  Liotti, G. (2004). Trauma, dissociation, and disorganized attachment.

  Putnam, F. W. (1989). Diagnosis and Treatment of Multiple Personality Disorder.

  Reinders, A. A. T. S., et al. (2003; 2006). Neuroimaging studies of DID.

  Siegel, D. J. (2012). The Developing Mind.

  van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The Haunted Self.