JOSH FEDER: Welcome to the Carlat Psychiatry Podcast. This is another special episode from the Child Psychiatry team. I'm Dr. Josh Feder, the editor-in-chief of the Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice, second edition, 2023, and the other book, Prescribing Psychotropics.  

MARA GOVERMAN: And I'm Mara Goverman. A licensed clinical social worker in Southern California with private practice and an avid reader of the Carlat Psychiatry Report.   

JOSH FEDER: Our podcast today is inspired by my experiences over the last couple of years with patients who come to me with various difficulties but report as part of their history that they are themselves a collection of several personalities that know each other and take turns being a the front of their stage, as if these are all characters in a theater production.  This led to an interview with Dr. Paroma Mitra which appeared on our July/August/September 2023 newsletter, which focuses on topics related to dissociative identity disorder (DID). In this podcast we will look at DID and also think about this idea of plural identity. 

MARA GOVERMAN: Dissociative Identity Disorder or DID, is a clinically significant topic, which can often be misrepresented in the media. So, let's begin by defining it. Dr. Feder, what is DID?  

JOSH FEDER: Dissociative Identity Disorder (DID) is a condition in which a person experiences the presence of multiple personalities within their own mind. A diagnosis of DID by DSM-5 criteria requires that a person must have at least two of these personalities. Each character has its distinct personality, memories, and way of interacting with the world. It is similar to having a group of characters sharing the stage of one's mind, and since an individual has more than one personality, it’s more like an open mike night than a theater troupe. These performers do not know each other and steal the microphone from the current performer at times. There can be gaps in the memory and recollection of day-to-day events, due to shifts in consciousness from one personality to another.   

MARA GOVERMAN: It can be challenging to maintain employment, relationships, and daily tasks due to the shifts between thes emultiple personalities. As you mentioned, an individual with DID may appear to have multiple personalities residing within them, each taking turns in control. They might experience memory gaps or act in ways that seem inconsistent with their usual behavior. So, the person will struggle with maintaining coherent relationships with others.   

JOSH FEDER: Why DID appears in a particular individual is another area of clinical interest. DID is often associated with severe childhood trauma, like abuse or neglect. One theory is that the manifesting of different personalities is a way for the mind to cope with overwhelming experiences by creating separate identities to manage distress.  

MARA GOVERMAN: Individuals, but particularly children, who have experienced trauma may exhibit a tendency towards fantasy-based thinking, dissociation, media influence, social isolation, and therapist expectations. There is evidence to suggest that (Kluft RP, Psychoanalyt Inquiry2000;20(2):259–286) there are four primary factors that can predispose someone to DID. The first factor is how well the individual learned to dissociate, the second factor is traumatic experiences during childhood, and the third factor is a lack of stable external emotional support and validation. These three factors combine to create the fourth factor, which is the presence of independent alters with distinct names and identities.  

JOSH FEDER: As many as 1-1.5% of adults have DID (Sar V, Epidemiol Res Int 2011;2011:404538), and like many conditions, a proper diagnosis can be challenging, particularly as DID symptoms mimic other mental health conditions. For instance, DID may be misdiagnosed as PTSD because both conditions involve cognitive dissonance and an inability to recall certain events. In the course of assessments, most of us often think about PTSD, and when we come to the criteria that include dissociative phenomena, that when we need to think about the differential diagnosis of dissociation and wonder with the patient about DID symptoms. If we suspect that the dissociation might be something beyond PTSD, we need to try to differentiate PTSD from DID  There are scales available to help clinicians differentiate dissociative identity disorder (DID) from other conditions. One such scale is the Dissociative Experiences Scale, which is a self-reported questionnaire consisting of 28 items (Bernstein EM and Putnam FW, J Nerv Ment Dis 1986;174(12):727–735). The questionnaire primarily covers topics such as absorption, imaginative involvement, depersonalization, derealization, and amnesia. Another scale we see used is the Dissociation Questionnaire, which consists of 63 questions and measure's identity confusion and fragmentation, loss of control, amnesia, and absorption (Vanderlinden J et al, Clin Psychol Psychother 1993;1(1):21–27). The Difficulties in Emotion Regulation Scale is another self-reported measure that has 36 items. It measures nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, and lack of emotional awareness (Hallion LS et al, Front Psychol 2018;9:539). Other tools that might be useful in diagnosing dissociative disorders include the Minnesota Multiphasic Personality Inventory and the Posttraumatic Diagnostic Scale for DSM-5.  

MARA GOVERMAN: These scales themselves do not make the diagnosis of DID but they help you in your clinical diagnosis, including the possibility that a person has a combination of different conditions.  

JOSH FEDER: Let's dive into treating DID. Treatment for Dissociative Identity Disorder usually involves therapy to help the different identities integrate into one cohesive sense of self. Although medications such as mood stabilizers, antipsychotics, or antidepressants can help alleviate symptoms like depression or anxiety, there is not significant evidence to support only using medication to treat DID. We also avoid using benzodiazepines with DID as, in addition to the usual concerns with benzos such as addiction, falls, and car accidents, they may contribute to co-morbid mood instability which is common in these patients along the lines of borderline personality problems.   

MARA GOVERMAN: The usual therapy for DID involves the therapist getting to know the different personalities (often called alters), learning about the history that preceded their arrival, and working to resolve past traumas so that the alters can integrate into one dominant personality.  This is difficult work and the research into the specific techniques is not generally sophisticated enough to give us clear estimates of effect sizes for various approaches in teens and young adults, whether cognitive behavioral, psychodynamic or otherwise.  Research surrounding effective treatments for DID has however uncovered more insight into the condition. Some patients are seen as naturally hypnotic, and hypnosis may be helpful for them. They can use hypnosis to access separate alters and work on the problems that each alter is experiencing. There is also a technique called Eye Movement Desensitization and Reprocessing (EMDR) which has been shown to help reduce symptoms, especially those related to mood (Paulson S. Treating Dissociative Identity Disorder with EMDR, Ego State Therapy, and Adjunct Approaches, In: Forgash C and Copeley M, ed. Healing the Heart of Trauma and Dissociation With EMDR and Ego State Therapy. New York, NY: Springer Publishing; 2007:141–180). Any treatment for DID requires a process of finding what works best for each person. 

JOSH FEDER: We want to ensure our patients with DID are safe from problems that might crop up due to their symptoms. These might include not taking necessary medication because the current persona is not aware of them or not reliable. They might also be more naive or vulnerable to mistreatment, place themselves in unsafe situations, or engage in risky behaviors.  Patients with DID do better with a solid support system.  Our hope is to engage other people as much as possibly, while respecting the patient’s privacy. This is often challenging with family members, teachers, and caregivers, who may have very mixed or negative feelings about DID. Ideally there are people who know what's going on and understand how stress can trigger shifts between different identities. For some patients, such as young adults living alone, community health workers might check in regularly and provide that extra layer of support and safety.

MARA GOVERMAN: These days when we talk about DID, we need to address the emerging phenomenon of plural identity. Plural identity is not recognized in the DSM-5, but it is gaining popularity on social media.  A TikTok community known as "A System" has 1.1 million followers as of 2021, with 910 million views on the hashtag #did. In plural identity or multiplicity, the alters refer to themselves as "headmates" or "system mates." They are co-conscious of each other and generally remember the events that occur during the day. This is different from DID, where memory gaps are present. Individuals who identify as plurals claim that they can consciously switch between headmates, whereas in DID, switching occurs in response to a traumatic event or stressor. This allows people who identify as plurals to function in day-to-day life, work, and relationships since there is less strongly partitioned memory. 

JOSH FEDER: The emergence of plural identity on social media platforms is driving a growing interest in this phenomenon. Some related research exists, particularly studies on Internal Family Systems Therapy (IFST). The IFST model proposes that individuals possess different internal "parts" or personalities. The idea is that these parts are in conflict and need to be identified and helped to resolve their conflicts. Many of us use this kind of metaphor in everyday practice: ‘So, a part of you is afraid of leaving for college and another part really needs to get away from home be independent.’ IFSP elaborates on this kind of thinking in a manner that conceptualizes all of us as living with an entire community or tribe of fully developed internal personas, and the research on identifying and resolving conflicts between them is impressive, metaphor or not. These ideas make the concept of plural identity sound quite typical or even normal, despite the air of exceptionality that proponents from this community often exude. In any case, plural identity to these people is not a problem but a way of being and while families may be confused by the idea, the patients, who are coming not for plural identity but perhaps for other difficulties such as depression, typically just want to feel understood.  

MARA GOVERMAN:  What is the difference in functional impact between DID and plural identity? 

JOSH FEDER:  Dissociative Identity Disorder (DID) may cause impaired function, with treatment aiming to foster consciousness among alters and facilitate integration into a unified whole, whereas individuals with plural identity perceive their alters as intrinsic to their being, maintaining functionality in their daily lives. While seeking treatment for conditions like depression, they typically do not prioritize integrating their headmates, viewing plurality as a form of diversity rather than pathology. To differentiate between the two, look for shared memories among the entities – that is what people typically report when they identify with plural identity. It is also important to think about whether the person is experiencing distress due to disparate personalities, or are they content with their coexisting headmates?   Assess the person’s function across daily living skills, academics, and social interactions. Listen for the role of social media influence on the person’s thoughts about their identity, and explore the websites where the person gets their information and support.  

MARA GOVERMAN: When assessing either of these conditions, it may be necessary to consider the dynamics within relationships, particularly familial ones. Families exhibit diverse reactions to both Dissociative Identity Disorder (DID) and plural identity, ranging from understanding to resistance. For example, the amnesia between personalities in DID often confounds family members, who may struggle to grasp the concept of identity shifts. Moreover, families may find it challenging to comprehend when individuals lack insight into their own identity transitions. In cases of plural identity, families may encounter responses reminiscent of those seen in discussions about gender diversity. Individuals embracing plural identity may use terms such as "coming out" and adopt alternative pronouns, introducing complexities for families as they process and accept this facet of their loved one's identity. 

JOSH FEDER: We hope you enjoyed today’s Podcast. You can read more about plural identity and Dissociative identity Disorder and how to navigate it in Dr. Mitra’s article in our July/August/September 2023 newsletter.  Hopefully, people will check it out.  

MARA GOVERMAN: Everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.  

JOSH FEDER: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust.  

MARA GOVERMAN: As always, thanks for listening and have a great day!

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