PARIS — The 2023 Encéphale Congress devoted a session to dissociative identity disorder (DID). It's a fascinating condition that has been depicted in countless movies and TV shows. And while it may be the key to success at the box office and in the ratings, DID nonetheless remains a controversial topic within the psychiatric community.
In fact, a survey of 800 French psychiatrists found that 51% either have doubts about the existence of the disorder — one that is becoming more and more prevalent among adolescents, at least on the internet — or do not even believe that DID exists. So, psychiatry or fantasy? This is the question posed in the session's title. No matter which domain this phenomenon of multiple identities falls within, what is clear is that DID is part of the broader "plurals culture" movement that has been seen among adolescents for several years now (see box).
DID, formerly known as multiple personality disorder, is included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). DID is characterized by the presence of more than two personality states within a single individual, leading to instances where the person "switches" between their different "alters" (also called self-states, identities, or parts).
People with DID have frequent episodes of amnesia regarding traumatic events as well as elements of everyday life. A video played at the beginning of the session showed Coraline Hingray, MD, a psychiatrist at the University Hospital of Nancy, interviewing a young woman named Maïlé Onfray. Onfray, who grew up in a cult, was diagnosed with DID and posttraumatic stress disorder in 2017. She defined her dissociative parts as completely separated from one another, each having its own world, its own experiences. But she did not want to count or list them all because "this would mean separating them even more whereas what she hopes to be able to do is reunify them."
Although she indicated that she constantly switches throughout the day, she said that these changes — for example, her voice or her speech — were "something subtle, and not a show." Onfray mentioned episodes during which she does not have her usual skills and abilities — teaching children, using a computer — only to then find them again, without any memory of what she had done in that moment. DID is very often associated with overwhelming childhood trauma — such as, in Onfray's case, psychological, physical, and sexual violence within the cult. For the patient with DID, this results in "a great deal of suffering and loneliness."
A Controversial Disorder
From Alfred Hitchcock's Psycho to M. Night Shyamalan's Split, Hollywood has long been fascinated with DID. In recent years, the condition has been widely publicized by young adults on social media. But the scientific community remains unconvinced.
The results of several studies clearly point to this disorder having specific characteristics. They also suggest that the condition may affect up to 1% of the general population. Psychiatrists, however, question whether DID exists, viewing it as fashionable phenomenon that has grown so much in recent years that one wonders whether it is an "epidemic" in child and adolescent psychiatry.
What about French psychiatrists? Which side do they fall on? Are they with the skeptics or are they with the convinced? To find out, Hingray surveyed 800 of them. Their responses will be published in the journal Encéphale. In the meantime, here are the main findings.
For starters, Hingray said, French psychiatrists categorized DID as a "rare diagnosis" among the patients they've seen. Indeed, two thirds of the practitioners responded that they have never treated a patient with DID. For those who have, 24% said that they'd seen between one and four patients with the condition. Almost half of the respondents (48%) reported that the patients seen over the course of the year had diagnosed themselves.
Do psychiatrists believe that, broadly speaking, they were trained in dissociative disorders? The answer for 61% of them was no. Of those who said that they were, 37% mentioned that they had taken steps to educate themselves, for example, by attending congresses or reading about the subject.
When asked about the epidemiology of the disorder, most psychiatrists (67%) put the prevalence at 0.15%. About 32% responded that they thought 1.5% of the population had DID. According to a 2018 article by Richard J. Loewenstein, the actual prevalence ranges from 1% to 1.5%.
Is DID Real?
The survey asked the psychiatrists about their knowledge of DID. The majority were familiar with the DSM-5 definition and were aware that trauma is the underlying etiology. In addition, they knew that psychotherapy is the recommended first-line treatment.
While most practitioners say they have an interest in the condition, things start to get a bit more complicated when they're asked whether they believe the disorder exists. "Here, things are pretty evenly split, 50–50. That is, 51% very strongly doubt that DID exists or simply don't believe that it exists," Hingray explained.
So, is it something created by the media? Again, the psychiatrists are divided. "They continue to hold that this disorder has emerged as a result of what people see in movies — for example, Split — in the mass media, and on TikTok. That said, it's quite reassuring that an overwhelming majority, 80%, of those surveyed consider that patients are not pretending or faking."
Can this condition be confused with another? Absolutely. While psychiatrists are divided as to DID's similarity to schizophrenia, they are, on the other hand, more certain about DID's similarity to borderline personality disorder (BPD).
In conclusion, Hingray stated that her view is that, as Goethe put it, "You only see what you know." She acknowledged that the chameleon effect is in play in DID. This is because dissociation is a protective mechanism: it allows the person to engage in avoidance, and it can take all possible forms (such as panic disorders, obsessive–compulsive disorder, treatment-resistant depression, atypical schizophrenia).
Given all of this, Hingray called on her colleagues to be attentive to atypical psychiatric symptoms. And as someone who believes that DID is real, she encouraged them to look into the disorder, to read up on it. The more they know about DID, the better they'll be able to see the symptoms for what they are and treat them accordingly.
The Plurals Culture
Julie Rolling, MD, is a child psychiatrist at the University Hospitals of Strasbourg. In her presentation, "DID: An Epidemic in Child and Adolescent Psychiatry," she gave an overview of the literature on the phenomenon concerning the presence of alters. In exploring the topic even further, she tackled the issue of the relationships that teens have with DID and, more broadly, with the so-called plurals culture. The past few years have seen this culture grow and the aforementioned phenomenon send teenagers, in particular, into a "frenzy."
"Plurals" is the nonmedical term used to describe people who have the distinctive characteristic of possessing multiple "identities" without having DID. "These individuals are more likely to self-diagnose. They have a very elaborate inner world, and relationships between 'parts' is something that Plurals find soothing," explained Rolling. She wondered whether it could be that teens, being teens, are particularly susceptible to the influence of this "Plurals" phenomenon. Indeed, this phenomenon appears to be a new globalized online culture, its philosophy of life claiming "the plurality of identities as a normal psychological preference" with its own language (e.g., "functional multiplicity" and "nonhuman alters"), its social group (mainly on social media), and, for some, a political dimension involving activism.
Teens could be attracted by the "desire for originality" that comes with this new culture. "This concept of dissociative 'parts' would provide an explanation for the identity confusion, the emotional conflicts, and the interpersonal difficulties they may be experiencing. All these things would then make sense," she suggested. "A diagnosis of DID could, then, bring structure to the inner chaos."
Rolling says that DID may also hold a certain allure for the kind of teenager who would be likely to make good use of the mutual help on social media and the interest thus generated, or even the kind of teenager who would acquire a new status as a patient who is an expert in DID. "So many key themes — being recognized as having an identity, narcissistic promotion of the self — that can constitute responses to the psychological changes that occur in adolescents," she explained.
Finally, Rolling mentioned this disorder's similarity to a new diagnosis: reality shifting (RS), an emergent online daydreaming culture that appeared during the COVID pandemic. RS is "the experience of being able to transcend one's physical confines and visit alternate, mostly fictional, universes." Rolling concluded by acknowledging that DID — a complex disorder — gives rise to a lot of questions, in particular, "the relevance of the diagnosis at a key stage of development." But, more generally, she added, "This poses a challenge about the impact of online communities and social media on the diagnosis of younger patients."
This article was translated from the Medscape French edition.
Lead image: Moment/Getty Images
Medscape Medical News © 2023 WebMD, LLC
Send news tips to email@example.com.
Cite this: Dissociative Identity Disorder: Fad or Fact? - Medscape - Feb 27, 2023.