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Fragmented Identity Disorder, Multiple Self-States and Their Origins
Abnormal Psychology · Chapter 15: Dissociative Disorders: Fragmentation of Identity and MemorySection 15.2 · lesson 56 of 9715 min · free with a free account
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In this lesson
The most contested diagnosis in the course - presented without taking sides.
- Describe the diagnosis and self-states accurately
- Present the trauma-related and sociocognitive models at equal strength
- Explain the iatrogenesis concern, and where the 2 camps agree
- Describe assessment and the phased treatment approach
Transcript
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Dissociative Disorders: Fragmentation of Identity and Memory
Dissociative Identity Disorder: Self-States and Their Origins
This section covers dissociative identity disorder. It is the most contested diagnosis in the whole course. We describe the diagnosis accurately, and separate it from the popular portrayal. Then we present two competing accounts of its origin, at equal strength, without taking sides. And we finish with how it is assessed, and how it is treated, where, strikingly, both sides largely agree.
Read This First
What This Section Will Not Do
Some things need saying first. Two models of this condition's origin are presented here in equal depth, each with its strongest evidence and its strongest objection. The field is divided. This section does not resolve the disagreement, and neither model is presented as correct. The diagnosis is recognized in current classification while the debate continues. And clinicians on both sides agree that the distress is real. This section will not present the condition sensationally. It will not describe self-states as separate people, because they are not. And it will not link the condition to violence. That popular association is unsupported and stigmatizing, and it is set aside here directly. The condition is associated with elevated distress and self-harm risk, which requires professional care. If you are affected by anything here, please speak with a qualified professional.
Terminology
Why "Multiple Personality" Was Dropped
The condition was formerly called multiple personality disorder. It was renamed dissociative identity disorder, and the change was not cosmetic. Multiple personality implies multiple people inhabiting one body. That is inaccurate, and it shaped both public understanding and clinical practice in unhelpful ways. The current name places the condition where the evidence places it. As a dissociative condition, in which the normal integration of identity is disrupted. What is fragmented is one person's identity. Not a population sharing a body. The old name also encouraged a second error that persists today. It suggested that the interesting clinical feature is the existence of distinct states, and dramatic switching between them. As we will see, that is not what most presentations look like. The core of the condition is discontinuity in the person's experience of themselves.
The Diagnosis
Discontinuity of Self and Agency
Dissociative identity disorder is described as a disruption of identity, with two or more distinct personality states. In some cultural contexts, this may be described as an experience of possession. It involves marked discontinuity in the sense of self and the sense of agency, with related changes in emotion, behavior, memory, perception, and functioning. There are recurrent gaps in recall, for everyday events, personal information, or past events, that are inconsistent with ordinary forgetting. And it causes clinically significant distress or impairment. Two exclusions complete the description. First, the presentation must not be a normal part of a broadly accepted cultural or religious practice. Possession experiences within a sanctioned religious framework are not this diagnosis. Second, it must not be due to substances or another medical condition. That is the exclusion pathway from the previous section, applied here.
Accurate Descriptions
Self-States vs. the Popular Portrayal
Self-states are widely misunderstood, and nearly every misconception comes from the same source. The popular portrayal. Distinct personality states are often imagined as separate people, each with an independent life. They are better described as fragmented aspects of one person's identity. Switching between states is imagined as dramatic and obvious. In reality it is usually subtle, a shift in manner or in what is accessible, and often never observed at all. The number of states is often treated as the interesting feature. It is clinically unimportant. The discontinuity of self-experience is the core. Amnesia between states is sometimes read as convenient ignorance. In fact it is one of the more consistently reported features. And people are imagined presenting by announcing multiple identities. In practice, they usually present with depression, anxiety, post-traumatic difficulties, or self-harm. Identity complaints are often not raised at all.
In Practice
Subtle, Not Dramatic
Most presentations are subtle rather than dramatic. People commonly come to services for depressive symptoms, anxiety, post-traumatic difficulties, or self-harm. The identity difficulties emerge over time, or only on careful enquiry. Many people are in contact with services for years before the question is raised. The popular portrayal has real costs. Clinicians expecting the dramatic version do not recognize the subtle one. And people whose presentation is subtle may be disbelieved for not matching fiction, which is a poor basis for any clinical judgment. The amnesia is described by people as periods of lost time, finding evidence of things they do not remember doing, and being told about conversations they cannot recall. These experiences are described as distressing and disorienting, not neutral. Co-occurring conditions are common, including depression, post-traumatic conditions, and personality-related presentations. That complicates both diagnosis and research.
Trauma-Related Model
Fragmentation Before Identity Consolidates
The first account of origin is the trauma-related model. Its proposal is that repeated overwhelming experience in early childhood, before identity has consolidated, prevents the normal integration of self-experience. Identity is not present at birth. It consolidates through childhood, in conditions that help a child make sense of what happens. Where overwhelming experience is repeated, and the environment does not support integration, the model argues the normal process does not complete. The timing is essential. The same experiences in adulthood are proposed to produce other trauma-related conditions instead. The evidence offered includes high rates of reported childhood adversity in this population, neurobiological group differences, and continuity with the wider trauma literature. The objections are serious too. Adversity histories are almost always retrospective, and often obtained in clinical settings where the topic has already been raised. Independent corroboration of childhood events is rarely available. And reported adversity is elevated across many psychological conditions, so its presence here does not identify a mechanism specific to this one.
Sociocognitive Model
Form Shaped by Context
The second account is the sociocognitive model. Its proposal is that the presentation is substantially shaped by expectation, cultural narrative, media portrayal, and clinical influence. A person in genuine distress, in a context where this presentation is recognized and responded to, comes to experience and report their difficulty in that form. This is not a claim that people are pretending. The experiences are genuine. What is disputed is where their form comes from. The evidence offered includes the historical and geographical distribution of cases, which tracks professional interest. It also includes experiments on suggestion and role enactment, and observations that features can develop over the course of treatments that attend to them. The objections are serious too. The model does not obviously explain presentations in people with no prior exposure to the concept. The historical rise could reflect improved recognition of a previously missed condition. And even when its advocates insist the distress is real, the account has been used to justify withholding care.
Agreement and Iatrogenesis
Narrower Disagreement Than It Seems
The public argument suggests a wider gap than actually exists. Both camps agree that the distress and impairment are real, and that adversity histories are commonly reported in this population. They agree that suggestive clinical practice is harmful, and that people presenting this way warrant care. What remains disputed is the origin of the presentation. That is a substantial disagreement, but a narrower one than usually assumed. Both also take seriously the risk of iatrogenesis, meaning features elaborated or created by treatment itself. Repeatedly asking about states, using hypnosis or suggestive interviewing to contact them, and naming and cataloguing them can elaborate the presentation being investigated. For the sociocognitive model, that is close to the central claim. For the trauma-related model, it is a recognized risk of poor practice. Either way, the guidance is the same. Even the historical rise in reported cases fits both readings, which is exactly why it has not settled the question.
Differential Diagnosis
What It Must Be Distinguished From
Several conditions must be distinguished from this one. Borderline personality presentations share identity disturbance, rapid shifts, and self-harm. But there, it is instability of a single self-concept, with reactive shifts over hours, not discontinuity with recurrent amnesia. In psychotic presentations, voices are typically experienced as coming from outside, with other features of psychosis present. In rapid mood cycling, the changes are in mood and energy, lasting days, rather than in sense of self. Culturally sanctioned possession experiences occur within an accepted framework, and are not distressing or impairing in themselves. And feigned presentation is a different kind of question entirely. It is a specialist, sometimes forensic, judgment. It is explicitly not a student's task, and it is never judged by how a presentation looks.
Assessment
Neither Dismissal nor Reinforcement
Assessment here requires an unusual stance. It must neither dismiss, nor reinforce. Dismissal treats the presentation as fabricated or attention-seeking. It denies care to someone in real distress, and it is the error the trauma tradition warns about most. Reinforcement means asking repeatedly about states, naming and cataloguing them, or responding with marked interest to identity material. It risks elaborating the presentation, and it is the error the sociocognitive tradition warns about most. The stance between them is to take the distress entirely seriously, without making the identity features the object of enquiry. Ask open questions. Follow what the person raises. Do not supply the framework. Validated instruments are used by trained clinicians, as screening and description tools, not diagnostic tests. And observation over time is especially valuable. It gives better information than intensive questioning, and it is the approach least likely to shape what it observes. Notice that both traditions endorse this stance, from different directions. That is a strong reason to adopt it.
Figure 15.2.5
The Phased Approach
Treatment follows a phased approach, and clinicians on both sides broadly agree on it. Phase one is safety and stabilization. Current safety, containing crises, treating co-occurring conditions, and daily functioning. Most of treatment is spent here, and for many people it is all of it. Phase two is processing difficult material, only where indicated, and only once stability is secure. Entering it early is associated with worsening, not improvement. Not everyone proceeds to this phase, and not proceeding is not a failure. Phase three is integration, or improved cooperation between states. Its goals are stated in terms of function and safety, never as a target number of states. Treatment is long-term and specialist. And approaches aimed at recovering memories, or eliciting states, have the poorest evidence and the clearest capacity for harm. Here is the most useful practical point. If the trauma model is right, stabilization must come before processing. If the sociocognitive model is right, stabilization addresses the distress without elaborating the identity features. So a clinician who is uncertain which model is correct, a perfectly reasonable position, is not uncertain what to do first.
1 Presentation, Read 2 Ways
Lorna, 31
One composite case, read both ways, brings this together. It describes no real person, and refers to no published case or film. Lorna, thirty-one, has been in contact with services for nine years, for low mood and self-harm. Without being asked about identity, she described lost hours, finding evidence of things she did not remember doing, and feeling like a different person. She reported childhood adversity, and had no known prior exposure to the concept. She was assessed with open questions, over several appointments, with nothing named or elicited. The trauma-related reading sees early adversity preventing integration. Her lack of prior exposure counts in its favor. Treatment is stabilization now, with phased work later if indicated. The sociocognitive reading sees her distress and self-harm as real and primary, with the identity features as one way of construing discontinuities that have several possible sources. Her lack of prior exposure is a genuine difficulty for this reading, and its proponents would want it checked. Treatment is stabilization now, without focusing on identity features. So the two readings disagree about origin, and agree about what to do first. That is the practical lesson of this section.
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