Dissociative Identity Disorder in the DSM 5 TR | Symptoms and Diagnosis

Hey there everybody, and welcome to this presentation on the dissociative disorders in the DSM 5TR. I'm your host, Dr. Donnellice Snipes. In this video we're going to learn about the diagnostic criteria for dissociative identity disorder as well as other disorders in that category. We'll explore differential diagnosis, identify some common co occurring issues and discuss current evidence based treatment options. Dissociative disorders are characterized by a disruption of and or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control and behavior. So that's a lot of things, and we're going to talk as we go through this more specifically about what that means. Dissociative disorders are frequently found in the aftermath of a wide variety of psychologically traumatic experiences in children, adolescents and adults. It's important to remember that dissociative disorders can be diagnosed at any age. Dissociative symptoms are experienced as unwanted intrusions into awareness and behavior with accompanying losses of continuity in subjective experience. What does that mean? Well, positive dissociative symptoms. Now remember, positive and negative are like positive and negative and schizophrenia. Positive means the addition of something. Negative means the subtraction of something. We're not saying it's a good thing, that's not what positive means. But positive dissociative symptoms include division of identity. So going from having one identity, one personality to two or more, depersonalization and derealization. So maybe you're not going from having one personality to multiple, but you're going from being one entity to being a body and then sort of a fly on the wall, if you will. Negative dissociative symptoms, such as inability to access information, amnesia or control mental functions that are normally readily amenable to access or control. You may freeze when the person switches into a dissociative disorder. They may unhook, if you will, from their body. In dissociative amnesia, there's an inability to recall important autobiographical information, usually of a traumatic or stressful nature that is not better explained by just ordinary forgetting. You know, you may forget some things that happened when you were five or six years old, but what we're talking about are significant events and or aspects of events that you probably wouldn't normally forget. Dissociative amnesia may be apparent to others. For example, the person does not recall something that others witness. Or maybe the person can't recognize significant others. Now we want to differentiate, and I'm going to talk in differential diagnosis, we do want to differentiate this dissociative amnesia from, from what we see as blackouts in substance use, for example. So there are a lot of times when people who heavily use substances will get to the point of intoxication where they have a blackout, they don't remember what they did, and they wake up the next morning and people tell them, oh, let me tell you, that's not dissociative amnesia, that's substance use. The dissociative amnesia is not attributable to a medical condition, a substance disorder or other mental health issue, including ptsd. In ptsd, there is going to be some forgetting of particular events of the trauma. So we want to rule out or differentiate between PTSD where the amnesia is specifically associated with a trauma, other aspects. Dissociative amnesia causes clinically significant distress or impairment and may or may not include dissociative fugue. In dissociative fugue, the person leaves their home, for example, or maybe goes to a different place in their home, but has no memory of the movement they get from one place to another, and then they kind of snap out of it in that new place. They don't remember how they got there, they don't remember wanting to go there. Again, we want to separate this from normal, maybe what someone might call highway hypnosis or autopilot, where you're driving, for example, to work and you don't think about where you've got a turn. You don't think about, you know, what street you're on, you know this. So you get from your house to your office, and you may not really remember the drive, but that's because you were lost in your own thoughts. You weren't completely checked out. You weren't in an amnesiac state. You were dealing with monkey mind. So we do want to separate the typical from the diagnostic issues. In depersonalization or derealization disorder, there's persistent or recurrent experiences of depersonalization or derealization. In depersonalization, there's a detachment or being outside of one's own thoughts, feelings or actions. So the person may feel more like a fly on the wall. They don't feel like they're part of that person anymore. They've somehow separated. In derealization, the person has a detachment from their surroundings. It may feel dreamlike, foggy, lifeless, or sort of visually distorted. Now, you may see some of these depersonalization or derealization symptoms, for example, after the use of hallucinogenic type drugs, not terribly uncommon. How, however, the depersonalization and derealization is attributable to that substance when there is no history of substance use, then obviously, especially hallucinogens, then obviously we need to look for other explanations. During these experiences in depersonalization and derealization, reality testing remains intact. They recognize that the world is not actually foggy. They recognize that they're not actually outside of their body. It just feels that way. It's not attributable to a medical condition, substance use or another mental health issue including ptsd, and it causes clinically significant distress. People with PTSD with borderline personality with although it's not an official DSM diagnosis, CPTSD often experience episodes of depersonalization and derealization and as well as they may experience some elements of dissociative amnesia. So we do want to recognize those symptoms exist and figure out do they have the other criteria, for example of borderline personality or do they have the other criteria for PTSD or is it, I hate to say simply, but is it? Are the symptoms confined to what is present in depersonalization or dissociative amnesia? So dissociative amnesia and derealization are very symptom specific disorder presentations. When we get to dissociative identity disorder, in a minute you're going to see elements of depersonalization, derealization, dissociative amnesia, plus some more things. Likewise in ptsd, borderline personality and a lot of these other disorders we're going to talk about in differential diagnosis there may be elements of dissociative amnesia and, or depersonalization or derealization and there are additional symptoms. So there's. You have to meet a lot more criteria, for example, for a PTSD type diagnosis, a lot of people with CPTSD, which again is not a official diagnosis of the DSM5TR. A lot of people with CPTSD experience e.g. depersonalization, derealization and maybe even some dissociative amnesia. So let's talk about the big one, dissociative identity disorder. And I say the big one because there are a lot more symptoms in this and it is the one that people talk about more often. Whereas dissociative amnesia and depersonalization are often somewhat more common. Dissociative identity disorder is the one that gets a lot more attention in this group. So for did this used to be called multiple personality disorder way back in the DSM maybe, maybe even the DSM 4 I don't remember when it changed, but now it's called dissociative Identity Disorder. The individual has two or more distinct personality states observed by others or by the individual. The Other people don't necessarily have to perceive it, so the individual may experience it. They experience themselves as a 30 something year old adult, but they also at times experience themselves as a five year old child. They feel like they're in the. They feel like they are that five year old child. So they're actually switching. It's not like, it's not that they want to act like a five year old child. They feel like they are a five year old child. They have two distinct personalities and they have done brain scans on people with dissociative identity disorder. And with each personality there, different aspects of the brain light up and the brain lights up in different ways. So there is definitely some a neurological differentiation between the different alters, if you will. So the individual has two or more distinct personality states observed by others or experienced by the individual, characterized by alterations in sense of self. So who they are, how old they are, and personal agency, what they have control of. When they switch to an altar. A lot of times the host, for example, may not feel like they've got control where they can pull back and become themselves again. They can't just switch back to being the host. They lose a sense of personal control when that other alter. When the alter takes over, affect, behavior, memory, perception, cognition and or sensory motor functioning may also change. So in people with two alters or two different personalities, a host and an alter, which is obviously the simplest form, they may write very neatly, they may be very organized, they may be very professional in their host personality. When they're in their altar, they may have sloppier writing, they may be more argumentative and aggressive, they may be more reactive. They act and perceive the world very, very differently. And interestingly enough, there's been a theory proposed that each personality, each alter, develops its own schema because they experience, remember and encode the world through their eyes. So the four year old alter is going to have different schema and it's going to react differently to the world than the 34 year old alter, which is kind of interesting. So whenever those alters are engaged, that means that they are forming new schemas that may or may not be beneficial to the recovery process. The individual may have a feeling that they suddenly become depersonalized observers of themselves and feel powerless to stop. Mentioned that already. They may have perceptions of voices. We're going to talk in a little while and on and off about differentiating Dissociative identity disorder from schizophrenia spectrum disorders. The perception of voices could be a child's voice. They may hear a child's voice, talking to them, persecutory voices or command hallucinations. So these are common. Now, remember I said you have to have the symptom and all the other symptoms for schizophrenia. In schizophrenia, you typically don't have the two personalities. And in dissociative identity disorder, you don't have a lot of the other characteristics of schizophrenia. So when you sit down and you look at them on paper, you can more clearly differentiate. I find looking at them on paper, I like checklists and comparisons. You can more clearly differentiate. In some cases, the person reports multiple independent thought streams over which they feel they have no control. Think about going to a cocktail party or a luncheon, whatever you go to, and you are in the middle of a conversation and there are multiple people talking, and you have no control over what they say. You're just kind of. You're almost invisible to them. And that's what it may be like to some people. That's one way it's been described to me from people who have been diagnosed with dissociative identity disorder. They may also have hallucinations. In all sensory modalities. They may have strong emotions, impulses, thoughts, and even speech or other actions that suddenly materialize without a sense of personal ownership or control. The person suddenly starts acting a certain way and they're not sure why they're acting this way. They feel like they are being driven by a remote somewhere. Conversely, thoughts and emotions may unexpectedly vanish and speech and actions are abruptly inhibited. So if their altar, for example, is very talkative and gregarious and then they switch back to the host or they switch to a different altar, they may find that they are. They become abruptly inhibited. They go from being that gregarious personality to one that is not so much. Attitudes, outlooks and personal preferences, including food, activities, and their perception of gender identity. And, and I want to be very clear on this, this is from the DSM 5. A person's gender identity may change when they are in an altar. They can have what they define as male alters. They can have what they define as female alters. They can have what they define as any, you know, other permutations. So it's important to recognize that you may not have all female alters in someone who is biologically female. They may also report that their bodies feel different. They suddenly feel like a small child, a different gender or different ages simultaneously. They feel like a kid and an adult, or even an adult and an older person all at the same time. Dissociative fugues with amnesia for travel are also common in people with Dissociative Identity disorder where they will enter into this dissociative state. So maybe an altar will take over, they go somewhere or maybe they even if an altar takes over, maybe it's the small child alter that was abused and they hide under their bed and then the host may come back and be hiding under the bed and not remember how they got there, why they got there, etc. Individuals may report suddenly finding themselves in another city, at work, or even at home, in the closet, under the bed, or even running out of the house. Those things are important to explore. If the person remembers, you know, when they came to, what were they doing a lot of times, not always a lot of times. That may give you some clues as to traumas that may need to still be processed in Criterion B For Dissociative Identity Disorder, the person has frequent gaps in the recall of daily either ordinary or traumatic events. They may not remember going to work that day, or if there's a traumatic event, they may not remember aspects of that event or the event itself. They may not remember important personal information. And this is also inconsistent with ordinary forgetting. It's not something that they just can't recall. Most of us don't know our driver's license number, for example, so you wouldn't expect somebody to be able to recall that. You would expect someone to be able to recall their birthday. Gaps in any aspect of autobiography Autobiographical memory may be present. So the person may not remember important life events, their birthday, the birth of their child, their wedding, or they may lack a recall of all school experiences before high school. They try to remember junior high or elementary school or any of those times and it's just blank. There's nothing there. They may experience lapses in memory of recent events or well learned skills. This is another thing that's important to take a look at. A lot of times there are memory problems in people with dissociative Identity Disorder. In both recent memory as well as long term memory. There may be gaps, especially around that traumatic time, but there also may be gaps in the present and that represent when one or more of the altars took over. And well learned skills could be for example, one of the altars may know how to type and another one may not. One may know how to play the piano, another may not. And there may be a discovery of possessions that the person has no recollection of ever owning. They go into their jewelry box and they've got a necklace there. They don't remember ever getting. They Go into their closet and there are clothes there they don't remember buying. We also, again, we need to differentiate this and make sure that there's no other explanation for it. There's ordinary forgetting. With early onset dementia, with Alzheimer's disease, the majority of time remote memory stays intact. Recent memory becomes more difficult. People get have more confusion in what's going on. Asking them what they did today is more problematic than tell me what happened when you were in High School 50 years ago or even for early onset 20 years ago. These experiences are frequently reported as ego dystonic and puzzling. Now one of the things that I found puzzling was in the DSM5TR they seem to contradict themselves. The criterion B very clearly says they're ego dystonic. So the person recognizes that something is not quite right. It doesn't make sense what's going on. Or when they experience the depersonalization, it's they recognize their reality testing is intact. So they recognize that this is not typical. I always try to avoid using the word normal. They realize it's not typical to feel like they are a fly on the wall. So that's ego dystonic and they're not sure why they're experiencing it. However, in another place in this same write up in the DSM 5tr in the associated features, it says individuals with Dissociative Identity Disorder often can see seal or are not fully aware of disruptions in consciousness, amnesia or other dissociative symptoms. It's hard for them to be ego dystonic and puzzling and for the person to not be aware of them at the same time. So I was a little confused by that, but I figured I would put that out there. I personally have not directly worked with anybody with dissociative Identity Disorder. I've talked to people who have been diagnosed with it, who have worked with other therapists, but I have not personally worked with it in, in my practice. Minimization or rationalization of amnesia is really common. If somebody finds something in their possession that they don't remember ever getting, they can often make a rationalization for how it got there or why it must be there. Oh, somebody must have given this to me and I just put it aside and forgot about it. The symptoms in criterion A and B cause clinically significant distress or impairment in one or more areas of functioning. If it didn't, they probably wouldn't be in your office. So, okay, so if they're presenting, then likely it's causing them problems. The experience is not a normal part of Broadly accepted cultural or religious practice in children. Symptoms are not better explained by imaginary playmates or other fantasy play. In the possession form of dissociative identity Disorder. There was a caveat in the DSM 5tr for cultural explanations and in certain cultures there may be times which the person is possessed, for example by a, by a spirit or an entity. However, it doesn't cause clinically significant impairment or distress. It is culturally recognized and embraced in whatever format they're in. For example speaking in tongues or in seances, for example. When someone from the beyond, I don't know what to call it is speaking through the medium that would be considered culturally sanctioned. It's not something that happens just kind of willy nilly, if that's a technical term. The symptoms are not attributable to the effects of a substance or another medical condition. Additionally, symptoms worsen during times of internal or external stress. So internal stress could be pain, it could be illness, it could be a variety of different substances that may, especially disinhibitors like alcohol that may make it harder to suppress some of the memories which increase internal stress or external stress, such as being too tired and or having a lot of environmental demands that are impairing them. Most individuals with non possession DID do not overtly display or only subtly display their discontinuity of identity. So most people with DID are not going to be like what you would think of, like what Hollywood portrays it as is going to often be relatively subtle. You're not going to have somebody who at who is talking to you and drinking coffee one moment and then all of a sudden has regressed into a four year old altar just spontaneously. That rarely happens now. Could it happen? Yes, but it rarely happens. And the person has often developed compensatory strategies to kind of be able to keep things under control. In a lot of cases they are distressed by their discontinuity of identity. They recognize that this doesn't happen in other people they know. Many people with DID have dissociative flashbacks and subsequent amnesia for the content of the flashback. So they may have a flashback to something that their alter did and then when they come out of the flashback, when they get regrounded, they won't remember. They know they had a flashback, but they can't really remember the content of it. You want to differentially diagnose dissociative identity disorder from dissociative amnesia. In dissociative amnesia, the person maintains a continuity of personality and that is going to be the predominant feature that differentiates dissociative identity disorder from everything else we're fixing to talk about. In depersonalization and derealization, the person does not experience the presence of different personality states, nor do they typically report dissociative amnesia. So if you've got depersonalization and dissociative amnesia, but only one personality, then you may have somebody who has both of these, or ptsd. I would probably look at that too. But they're not going to have DID unless they have at least two distinct personalities. In bipolar disorder, the relatively rapid shifts in behavioral state in individuals with DID usually within minutes or hours, are atypical even for the most rapid cycling individuals with bipolar disorder, that is something to really pay attention to. There's a lot of misdiagnosis of people with bipolar 2 who actually have dissociative identity disorder from what the research says. So we want to pay attention to this rapid cycling. If somebody is going in several hours or even a couple of days between depressed and hypomanic, we want to take a look at that because that is really, really, really, really fast. Even for cyclothymia or bipolar 2, and fictitious disorder or malingering, the person is relatively undisturbed by, or may even seem to enjoy having the disorder and become angered. If you try to rule out the diagnosis of dissociative identity, one of the first things you want to ask yourself, if they're presenting in your office with dissociative identity, is there a material gain to it? Are they trying to excuse themselves from a violent outburst? Are they trying to excuse themselves from theft or from something else they did? So that's the first question to try to differentiate it a little bit. Now, it's possible somebody with dissociative identity may have a bad actor, if you will, in their. In their alters. But we do want to consider, most of the time that's not the case. We do want to consider, is there a gain that the person hopes to achieve by having this diagnosis? Remember I said that most people with dissociative identity disorder recognize that it is not typical of most other people and therefore are greatly distressed by it, and they don't want to have the disorder. And they'd be thrilled if you could say, no, it's this over here, and here's this easy peasy treatment. But we can't. A person who is malingering or has factitious disorder may ask clinicians to find traumatic memories. Most people with dissociative identity disorder, they don't want to remember. The DID developed as a way to Block those memories is to help them survive and to cope. They don't want to go there. So somebody who is curious and really wants the therapist to dive in again may have an ulterior motive. People who have factitious disorder create limited stereotyped identities, and feigned amnesia is often related only to the events for which the gain is sought. So the only time they have amnesia is when they engaged in this violent episode or when they did this other thing. And sometimes it'll be generalized a little bit. Like they may talk about having dissociative fugue where they go. They end up going from one place to another. They totally don't remember getting there. They don't remember doing whatever they did during that period of time. And they may say it's frequent, but the other episodes of amnesia are related to or additional instances of the one that they are trying to excuse or mitigate, if you will. Increase knowledge evidently impacts dissociative identity disorder presentation. Now, this isn't from the DSM 5TR. This is from an article I read that if somebody does not have did they have fictitious disorder, then the more they start to learn about did, the more they're going to embrace it, the more symptomatic they're likely to become. And for the person who is malingering, fragmented personality is often an important topic of discussion. They want to talk about all of their alters. They want to talk about what's going on and how curious it is. People who have DID often don't want to. They don't want to acknowledge it. They don't want to. That's just too painful and too stressful to think about in terms of ptsd. Depersonalization and derealization symptoms in dissociative Identity disorder may occur not only in response to PTSD reminders, but also in an ongoing fashion in daily life, including in response to stressful situations. So in ptsd, a lot of times the depersonalization derealization happens in response to a trauma trigger. Totally get that. In dissociative identity disorder, the degree of emotional dysregulation is so intense that any stressor of a certain level depending on the person will often trigger the emergence of the alters, the emergence of depersonalization or derealization. So we want to identify when the depersonalization or derealization is happening. Is it in response to trauma triggers? Now, you might be able to argue that ongoing traumatic events in someone's childhood may have coded pretty much everything to be a trauma trigger. So especially if you're talking about cptsd then we may need to be a little cognizant of that. Borderline obsessive Compulsive Personality disorder, Antisocial personality disorder and narcissistic personality Disorder have a lot of features in common with dissociative identity disorder. But personality disorders according to the DSM are more stable and pervasive. Whereas the person with DID switches personalities. The person with borderline may have an unstable sense of self and they may alternate from valuation to devaluation. But it is a relatively cohesive package and there is not as much non trauma related depersonalization or derealization. It was interesting in one article I found that said up to 17% of dissociative identity disorder patients are initially diagnosed with borderline personality Disorder. Let that sink in for a second. How many people have you diagnosed or have you come across that are diagnosed with borderline personality disorder? 70% of those, 7 out of 10 of them may likely have dissociative identity Disorder, not borderline personality. Interesting fact in terms of schizophrenia spectrum disorders, the symptoms in schizophrenia are ego syntonic. If a person is having hallucinations in schizophrenia, if the way they're experiencing the world makes sense to them, they don't understand why you don't see it the same way. Whereas in dissociative identity disorder the reality testing is intact. They recognize that what they're experiencing experiencing is not really how it is. And in schizophrenia spectrum disorders there's often not the dissociative amnesia. Amnesia is not one of those big things in schizophrenia. Now I added hallucinogen persisting perception disorder. I always hate saying that one because I get tongue tied. Because people who have taken hallucinogens, particularly lsd, may have sporadic hallucinations years after the initial substance dose. However, there is no splitting of personality. There is no amnesia. So you would differentiate hallucinogen persisting perception disorder from depersonalization disorder and or dissociative amnesia. But more the depersonalization and derealization disorder in addiction we want to examine are the symptoms caused by a blackout? Are the symptoms of the two distinct personalities, if you will, caused by or do they occur one when the person is using or using a particular type of substance and one when they're using a different type of substance or when they're detoxing or in withdrawal? Remember, in dissociative identity disorder the personalities switch pretty rapidly. But in addiction there's definite triggers, if you will. There's definite precursors to the presentation of one personality. Somebody may get very Angry and hostile, for example, when they drink. But when they're not drinking, they are. Susie Sunshine and as I mentioned in dementia and delirium, people start having more difficulty processing information, understanding what's being said, and their near memory and their ability to learn new things is compromised. But a lot of times their historical memory, if you go back a few years, that is not as compromised as much. If there is a rapid onset of cognitive symptoms, it's really important to get them evaluated by a physician to make sure that they're not experiencing Wernicke Korsakoff syndrome or early onset Alzheimer's or dementia. We certainly want to rule out any of the organic causes in terms of comorbidity. Anxiety is very common in people with dissociative disorders. Not just dissociative identity disorder, but dissociative disorders in general. And you know, that makes sense. If their condition, whichever one we're talking about, if the condition developed as a result, most commonly to trauma, then that means they were stripped of a sense of feeling safe, stripped of a sense of personal empowerment. And so they're going to continue to be anxious until they can feel safe and empowered once again. And what did I keep saying in depersonalization, for example, they feel like their body is just kind of gone off on being remote controlled from somewhere else and they have no control over it. They may feel like their emotions or their actions or their thoughts do the same thing. So yeah, that would make just about anybody anxious. Addiction is not uncommon because people are trying to quell silence, suppress the distress that's caused by, by the fragmented personalities or the dissociative experiences and, or they may be trying to self medicate to cope with the memories of the trauma. Depression. Remember, depression mainly is the key features. A sense of hopelessness, helplessness and even anhedonia, difficulty really feeling much of anything, and low motivation. People who are experiencing these switches or depersonalization may feel depressed, they may feel exhausted. That's not uncommon. PTSD is of course, often very common because the cause or trigger for the development of dissociative disorders is often trauma itself. So we, we can diagnose PTSD and one or more dissociative disorders. Self injury, unfortunately, is also very common in people with dissociative disorders. For some people, they use it as a tool to try to help them stay grounded and not dissociate. For others, it's a coping mechanism to deal with the distress that's caused by, by the, caused by the dissociation. But it is very, very common. And very, very problematic. It needs to be a focus of clinical attention. Brief psychotic symptoms are not uncommon. Hallucinations and delusions, we talked about those and it's important to help the person recognize them for what they are and develop tools to deal with them. Atypical antipsychotics have been found to be helpful for people who are having a lot of or frequent psychotic symptoms. That can help. However, atypical antipsychotics also tend to be very sedating. So not everybody wants to take them all the time. It may be one of those things that people take when they're having an exacerbation that is between the person and their psychiatrist. Interestingly, of all of the personality disorders, avoidant personality disorder is most commonly co occurring with dissociative disorders. It makes sense though. I mean, you would think it might be borderline or antisocial. But avoidant also makes sense because if the person has been exposed to severe trauma, then they may not trust other people, they may not trust the world, they may not have the energy or desire to engage with other people. It's just, they're over it. Eating disorders and obsessive compulsive disorder are also common co occurring issues in dissociative identity disorder. And you can hypothesize for quite a while about why that might be. But in each individual presentation, and I emphasize this a lot, in each individual presentation, it's important to look at that person as an individual, look at that person's symptoms and say, what are these symptoms communicating? Behavior is communication. What are these symptoms communicating? What function are these symptoms serving for this person at this point in time? Now, prevalence very interesting. In the US the prevalence is for dissociative identity disorder is identified to be 1.5. So three out of every 200 people. And for some reason the DSM5TR also highlighted that women in Turkey, the prevalence is 1.1%. Not exactly sure why they just plucked that out of thin air. However, I mentioned before that more than 70% of people with dissociative identity disorder are initially diagnosed with borderline personality disorder. Now this doesn't even include all the people that are misdiagnosed with borderline with bipolar 2. But if we just take into account 70% of the people, the people who are diagnosed with borderline personality disorder, that means that in the general population the prevalence of dissociative identity may be as high as 2.62%. So almost three out of every hundred. And in the clinical population it could be as high as almost 32%. And that is just taking into account the misdiagnosis of people with bpd, not any other diagnosis out there. So, wow, if those researchers are right, then we are missing the boat in a big way. Because treatment is somewhat different for dissociative identity disorder than other disorders. Very different than bipolar disorder, for example, in terms of development and course, children usually don't present with identity shifting. Instead, they may present with an independently acting imaginary companion or as personified mood states. In adolescence, dissociative identity commonly comes to clinical attention because of externalizing symptoms, suicidal self destructive behavior or rapid behavioral shifts. Now think about adolescents. They have a lot of rapid behavioral shifts anyway developmentally. Their hormones are all over the place. They are going through Ericksonian psychosocial development crises. There's a lot of stress. Teenage years are really difficult. So we do want to differentiate expected behavioral shifts from unexpected ones. And what we're looking at really is the frequency, the rapidity, how quickly they happen, the intensity. Generally, in dissociative identity disorder in adolescence, you're going to see a more intense demarcation between the alters. Remember I said in adults a lot of times it's pretty, the shift is pretty mild according to the DSM 5tr, but in adolescents it may be more pronounced because they have even fewer emotional regulation skills and because that prefrontal cortex is still developing, they have more difficulty with impulse control. So a lot of the things that may come out in an alter may be highlighted more exaggerated more in an adolescent. 90% of individuals with dissociative identity disorder report early neglect and childhood abuse, often extending into late adolescence. So this isn't a one time traumatic event. This is ongoing abuse or neglect. Maltreatment may occur in or outside of the family and may include severe bullying, whether it's at school or even by siblings. Multiple painful medical procedures. I've known children and adults who've had to have, for example, multiple open heart surgeries, and that is extraordinarily painful. Children who have had to go through cancer treatment, that can be extremely painful. Children who've experienced war andor terrorism or being trafficked, well, those you know, definitely are significant. Additionally, the DSM 5 goes on, TR goes on to state, after prolonged and often transgenerational exposure to dysfunctional family dynamics. So we have this dysfunctional family that's been dysfunctional for multiple generations and they're passing down the dysfunctional interactions and the dysfunctional behaviors and which also means that there's no one to go to for the child. They can't go to grandma, say you know, things are really bad at home because grandma was behaved the same way towards mom or dad. So there's prolonged transgenerational exposure to dysfunctional family dynamics, including over controlling parenting, insecure attachment and emotional abuse. Even if these behaviors do not rise to the the level of clear neglect or sexual or physical abuse, the ongoing and inescapable nature of the dysfunction may precipitate enough of a crisis to trigger the development of Dissociative Identity Disorder. Another interesting but disturbing disheartening fact is over 70% of outpatients with dissociative identity disorder have attempted suicide. Not have had ideation they've attempted it. If you're working with somebody who was diagnosed with did, who has dissociative symptoms, who has trauma, who has borderline personality or bipolar too, especially if you haven't ruled out that it's Dissociative Identity Disorder, it's important to be extremely aware of how frequent and common suicide attempts are in this particular population. Multiple attempts are common and other self injurious and high risk behaviors are highly prevalent. In terms of diagnosis, the Dissociative Experiences Scale, the des, the Structured Clinical Interview for Dissociative Disorders Revised or the SCID D R or the Dissociative Disorders Interview Schedule are some of the most common diagnostic tools but more instruments if you're looking for self report or screening tools, you can go to the Dissociative Identity Disorder Diagnostic Guide. The link is in the PowerPoint, but you can also just search for that online and it comes right up in terms of treatment. Direct engagement with dissociative identity self states to repair the identity fragmentation and decrease dissociative amnesia needs to be, according to the literature, one of the treatment goals. So reintegration is going to be really important. One of the strategies to do this and one of the important strategies in a trauma focused approach is to allow the alters to be heard. Remember I said each alter has their own experience and perceptions of what happened and what the world is. So it's important for every alter as well as the host to receive support and be able to feel safe and be able to tell their story as they see it as they experienced it, so they can process their trauma. Once that happens, then it is it can be easier to integrate those Think about at a crime scene when officers interview multiple different bystanders, each bystander has a slightly different account of what happened and the officer takes all of those accounts and can put it together to get a better picture of exactly what happened. Or if you want to think about cameras, cameras from different aspects, different angles are going to get different perspectives. In order to get a 3D image, you need to put together multiple different aspects. And that's really what integration is about. It's about hearing the different experiences and integrating them so all parts of the person can feel safe again. Trauma focused psychotherapy that includes dialectical behavior therapy and even EMDR can be very helpful for the older alters. Those alters that are able to participate in emdr, each one of them may benefit from participating in emdr. Now, that is not something that's really common for EMDR practitioners to work with. So it would take some time to find one that is trained in actually and capable, competent and actually handling that. You don't want just any old EMDR practitioner working with an alter, for example, and not able to handle if there's a switch in the middle of session. In terms of medication, I mentioned atypical antipsychotics can be very helpful for hallucinations and delusions, those psychotic symptoms. And opioid antagonists like naltrexone have been found to be somewhat helpful for reducing dissociative symptoms. Now that can be helpful. But I also want you to remember that dissociative symptoms, when somebody dissociates, they have become all of their systems have gotten overwhelmed. They are in system shutdown. And if you prevent them from shutting down, they need to have some way to cope that can be terrifying and painful and overwhelming if they can't dissociate. But they don't have a way to deal with what they're experiencing. So it is important to have an integrated approach to treatment. Dissociative identity often represents a survival strategy defined, developed to cope with overwhelming stress or trauma. The defining feature of DID is the presence of two or more distinct personalities. It's potentially twice as common as currently diagnosed. And treatment involves trauma processing with the host and the alters in a safe, supportive environment.