Kim Mills: Dissociative identity disorder is one of Hollywood's favorite psychology-related topics. From movies such as The Strange Case of Dr. Jekyll and Mr. Hyde and The Three Faces of Eve to this spring's Moon Knight TV series, filmmakers and the public have long been fascinated by what used to be called multiple personality disorder. And that's not surprising, the idea that multiple personalities could exist in one person's mind has obvious dramatic potential and might even feel familiar to some of us.
But in real life, dissociated identity disorder does not look like it does on the screen or in books. According to some researchers, it is both more common and more subtle than fictional portrayals would lead us to believe. Meanwhile, its causes and treatments remain controversial among many mental health researchers and practitioners.
So what is dissociative identity disorder? How common is it and what causes it? What is happening in the brains of patients who experience it? What treatments are available and how well do they work? And is there any truth at all to be found in its many portrayals in movies, in literature and on TV?
Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills.
Our guest today is Dr. Bethany Brand, a clinical psychologist and professor of psychology at Towson University in Maryland. An expert in trauma, she specializes in the assessment and treatment of trauma-related disorders, including dissociative disorders. She has published dozens of research papers on dissociative and other trauma disorders. And she is the principal investigator of the largest prospective treatment outcome study to date of dissociative disorders, called TOP-DD. She also maintains a private practice focused on assessing and treating patients with trauma disorders, and she has served as an expert in a variety of trauma related forensic cases.
Thank you for joining us today, Dr. Brand.
Bethany Brand, PhD: Thank you very much for having me.
Mills: Many of our listeners know dissociative identity disorder by its old name, multiple personality disorder, and may not recognize the term “dissociative identity disorder” or DID. So let's start with the definition, what is DID? And more broadly, what is dissociation and how does it relate to the disorder?
Brand: Dissociative identity disorder is one of the five dissociative disorders in the diagnostic and statistical manual of mental illnesses. Let's start with dissociation, which is, well, we can all experience some dissociation. So if we're driving down the highway and just preoccupied, we may not remember much of the drive once we get home, or we may even miss our exit. That's normal, non-pathological dissociation. More pathological dissociation occurs when somebody has experienced very serious trauma, often childhood trauma that's repetitive, so that they learn over time to disconnect. That's what dissociation really is. It's a disconnection or disintegration of what are normally psychologically integrated functions.
So the person may disconnect from their emotions. They don't feel anything, even though they would normally feel terrified, for example. They disconnect from their body. They may not feel as much pain. And so you can understand how in the case of trauma, especially that's very physically painful trauma or emotionally painful trauma, or both, if a child or an adult disconnects from themselves, their body, their emotions, or if they disconnect from their memory, it would help, somewhat, dull the pain, if you will.
It doesn't mean that then trauma is not traumatic, because of course it still is, but over time, if that happens again and again and again, the child—because DID is a developmentally based trauma disorder, it starts in very early childhood. So typically, there's abuse that's occurring before age six, and it's repetitive. And so the child learns again and again and again, to disconnect from themselves. So that over time, those memories of those traumatic events are not integrated into normal memory. And the child may not always recall it. And so eventually they have different states that develop where they don't have to think about that horrible stuff all the time, and they can go to school and seem seemingly normal, like nothing horrible happened in advance of school that day or the night before.
And so it's adaptive in the time during which the trauma is occurring, but over time, it's actually a disorder associated with all kinds of suffering. To go back just to the definition, by definition in that diagnostic manual, the person has to have two or more different, I'm going to call them dissociative self states, but other authors other times, people refer to them as identities or parts or alters, and those parts can take control of their behavior. And at least some of the time, they don't remember what they did in a different state. So there's dissociative amnesia for at least some of that behavior in different states.
Mills: So, as I mentioned in the introduction, there's a long history of literature, movies, and TV portrayals of this phenomenon, and now it's back in the spotlight again with this TV show Moon Knight. How well do you think these portrayals of DID over the years have reflected the reality of the disorder? Has it ever been portrayed well on screen or in books?
Brand: I think there are almost always abysmal, stigmatized, stereotyped versions of the disorder, more so than just about any disorder out there. Men tend to be portrayed as serial killers, monsters. Women can be portrayed that way, but more often as sex fiends. I'm actually doing a study on this right now to ask people living with DID how have they been impacted by these media portrayals, and the stories, the quotes that were getting back are just so painful. Like, they hated themselves, they didn't want their, even their clinicians, their mental health professionals to know about the disorder. And in some cases, even the professionals were scared of them because of these stereotypes. They're very damaging.
Mills: And in the movies, DID is often shown as a dramatic and a sudden switch between personalities. Is that what it looks like in real life to an observer?
Brand: I'm so glad you're asking me that, because that occurs in less than 5% of cases. Of course the media has to show these dramatic shifts that, somebody comes in talking and baby talking, then the next time they come in swaggering and a cigarette draped out of their mouth. So that's so the audience can figure it out. If DID really look like that, it wouldn't be so underdiagnosed and misdiagnosed.
It's often misdiagnosed as schizophrenia because more than 75% of people who have DID hear voices, or it's misdiagnosed, for example, as bipolar disorder, because there's these mood shifts, they look like moody people. Now, neither of those disorders have amnesia associated in, they're not trauma disorders, so it's not—DID is not at all schizophrenia, it's not at all bipolar disorder. And those media portrayals obviously contribute to some of the reason why there's so much under diagnosis of DID.
Mills: So how do patients describe the experience to you? Are they aware that they're shifting from one alter to another?
Brand: They very tremendously when they come in for treatment. Typically, when a person who actually has DID comes in for treatment, they tend to come in with reports of severe crushing depression that hasn't responded to any medications or previous trials of psychotherapy. They often have post-traumatic stress disorder. They tend to be aware of that. They may have a substance abuse problem, they may have an eating disorder, they have problems with sleep. Every so often, there are people who come in and they're aware, or they think they are aware of having dissociative states, but that's actually not so common. Although with all the social media that's out there now, more people are sometimes coming in, at least in my experience, I've been in the field for about 30 years, and I do have some people who have come in and said, I think I have this. And I proceed to do a standardized assessment and find out if it's accurate or not.
They're often very embarrassed about their mood. Well, their mood changes, but even more importantly, the lapses they have in memory. Imagine you or I, we don't know somebody who greets us on the street, who obviously knows us, calls us by name and is referring to a conversation or an interaction we've had, it will be mortifying. They have that happen a lot. And so it's embarrassing and they try and cover that up like anybody else who anytime anybody else covers up something we've done that feels embarrassing.
Mills: As you mentioned, there are tests, there are ways that you determine whether people actually have this disorder. How do you assess patients for dissociative disorders? And then, what kinds of treatments are available?
Brand: Sad to say, but most mental health professionals have not been trained in assessing dissociative disorders. They don't even know that much about dissociation. At the start of the hour you talked about how there's some controversy about dissociation and dissociative disorders. And so that's one of the factors that leads to many graduate programs, medical schools, not doing training about it. So first of all, a person would need to go to somebody who has had training in assessing dissociation. I'm currently actually writing a book for the American Psychological Association on assessing dissociation, this is the first book that's ever been written solely about the multiple ways you assess for it. So that shows you how far behind our field is in really learning about assessing dissociation.
There are a number of scientifically validated self-report questionnaires that a clinician could use. There are also standardized evidence-based interviews, structured clinical interviews for dissociative disorders. And hopefully a clinician would use one or more of those tools to make an accurate diagnosis. It can also be done without those tools, but then there's more errors. There's just more errors, like when doctors do blood tests, you've got a greater chance of getting an accurate diagnosis and the same thing with mental health conditions, especially this one, because it really can sound like and seem like different disorders.
Mills: And then what are the treatments that are available?
Brand: It tends to be a longer-term trauma based trauma informed treatment where there's three stages, roughly speaking. When the client first comes in, they tend to be struggling with profound depression, like I mentioned, but also many of these folks have a lot of self-harm, like cutting or burning, and they often are in research terms. The research is clear, they are some of the most suicidal clients in the mental health field. So there needs to be a lot of stabilization. So they need some help, for example, I talked about problems with sleep.
If you don't sleep, you don't do well in the day. But because nights were often times where trauma occurred or they have nightmares, they're terrified of sleep, and they're hyper aroused, their nervous system is jacked up because of all the trauma and the flashbacks and the nightmares. And so helping them get their sleep regulated, helping them get any self-harm or suicidal thoughts under control, helping them learn not to dissociate so much their, what's called losing time. They're having those gaps in memory.
So you're basically doing a lot of teaching tools that help the person manage their symptoms, function day to day. And also another thing is addressing profound shame, self hatred, and taking it out on themselves basically, that's through the self harm, for example. And so trying, you do a lot to try and educate them about the impact of trauma. So they don't feel like they're just this evil, awful person, but they understand the things they're struggling with are symptoms. Anyway, all of that is stage one stabilization and safety.
If they get stable, and there are some folks that's the stage they stay at, but if they get stabilized and they want to move on to actually processing the trauma, that stage two work. So having them start with talking about and working through their traumas, like with other trauma focused treatments, but less emphasis on just going over traumas as intensively, the pacing has to be done carefully because they've gone through so much trauma.
And so, this is again where a clinician really needs to know what they're doing and needs to have training in treating traumatized, especially dissociative clients, because you don't want to flood somebody. And if that happens, they can get more symptomatic. So that's the trauma processing and grieving stage. There's a ton of grief that goes along with that, as they recognize and work through all these traumas, it's incredibly painful.
One thing I didn't mention—when they have DID, they have these dissociative self states. So throughout this process, they need to be gradually getting to know their parts and understanding all of those parts are them, and learning to gradually shift from sort of parts fighting each other, which is often the case when they first come in, to gradually learning to cooperate and collaborate and work more smoothly so that the whole person's functioning is supported and it's not just one against another. And then the third stage is, there's less focus on trauma and it's more on living a full life, having healthy relationships, establishing or furthering their career, that sort of thing.
Mills: Is any drug therapy involved as part of this?
Brand: Because most of them have very serious depression, very serious anxiety, very seriously problems, there are many of these individuals are on a cocktail of antipsychotics. Sometimes it's not that they're psychotic, but to help calm them, they may be used. It's more common for them to have antidepressants and something that helps with anti-anxiety medications. There's a class of those called benzodiazepines that are addictive. There's mixed feelings about using those long term. A lot of people, of course, don't want clients to be on those long term, but there are some other types of anti-anxiety medications that are not addictive. And so it's very common for them to have several medications that they're taken. None of them, there is no medication that's anti-dissociative. So we've got anti-depressants, anti-anxiety, anti-psychotics, we don't have an anti-dissociative.
Mills: I understand that there are some people who have other mental conditions who may pretend to have dissociative identity disorder. And certainly there's the infamous story that became the book Sybil and was later a movie starring Sally Field. Some of our listeners may have seen it. How can a clinician tell if someone is faking it?
Brand: One of my lines of research has been on establishing data across various tests, psychological tests, some are what are called malingering tests, and they're supposed to pick up on the possibility of malingering. With students in my lab, we have developed data that shows, this is what genuine patients with DID score on these various tests, and here's what people who are imitating faking DID score, and this is how you distinguish them.
So there is evidence that helps, a whole body of evidence across, I forget, six or seven or eight tests nowadays, where we've shown ways to distinguish the two. And also if clinicians use those evidence based measures I was talking about earlier, that helps them have some idea of how does this person's report of symptoms compare to other people who have dissociative disorders. So it goes back again to know the science, follow the science, and use the science.
Mills: And clearly there's a need for the book you're working on.
Brand: Thank you. Yes, I think so. Let's hope I get my deadline on time.
Mills: There has been a lot of advancement in the study of psychological disorders through brain imaging, and I'm wondering, has much brain imaging been done with people who have DID? And/or do their brains look markedly different?
Brand: There are three labs that are working on that in particular. I'm sure other labs as well, but there's a Harvard lab working on this, Ruth Lanius up in Ontario is working on it and a woman in the Netherlands and her team. And there's a couple of other people in the Netherlands. Summarizing very briefly, they are seeing that there are brain network patterns that distinguish people who are highly dissociative from those who have what I'm going to refer to as classic or simple PTSD, post-traumatic stress disorder.
So there's, now in the more recent diagnostic manual, there's dissociative PTSD and regular PTSD. And the dissociative folks, as it might sound like, they tend to—When they go in the brain scanner, for example, and hear their trauma stories read to them while they're in the brain scanner. So they're essentially having a flashback and they're warned about this upfront. They're very brave, and they do the studies, which helps us tremendously understand traumatic brains.
And what we see in the scanners is that some areas of the brain start shutting down, going offline, if you will, there's less connectivity there, there's less brain flow, those sorts of things. And there are different patterns of neural activation, different network patterns, different blood patterns that distinguish these two types of trauma reactions. So one is an emotional aroused, as I was referring to earlier, sort of a jacked up hyper-aroused flooded state, and then the shutdown state.
Well people with DID can actually go back and forth between those states. Some personality states will remember the trauma intend to be much more the hyper aroused, highly flooded emotional states, and others will be really numbed out, may not even remember the trauma and their brains look different. The group in the Netherlands has repeatedly brought in professional actors and tried to get the professional actors to imitate the brain scans and they can't do it, which helps really validate that it's a genuine disorder, you can't just fake it. On psych testing, we can distinguish it. And in the brain scanners, we can distinguish it.
Mills: Clearly, I mean, DID is in the DSM-5, but as you've just said, it's one of the more controversial diagnoses. And some researchers and clinicians really disagree with a lot of what you're saying right now, that it's not caused by trauma, that it doesn't really exist, and clearly you disagree. Why is this such a fraught topic?
Brand: To be brief because I could go on and on and on, I don't think the listeners want that. It is an uncomfortable topic. The whole idea of child abuse that is profound is really distasteful, nobody likes to think about it, and know about it, and hear about it. You think that even sexual harassment, sexual assault, just in recent years, the Me Too movement have made it so much clear how much of that has been going on unknown to many. And without a lot of awareness and suppressed by some of the people in power, like some of the people in power have done these things. So of course the same thing is going to be happening with children, of course, but there's many who just don't want to know about that, and some of them have been accused of child abuse and some haven't. We've seen with the institutional betrayal, all the movements looking at how coaches and churches and scouting groups, and there's been all sorts of institutions where youth have been abused for decades.
As a society, as humans, we don't want to know about trauma, people who've gone through trauma don't want to know about trauma. Part of PTSD, one of the required symptom clusters is avoidance, disconnection, not knowing, not feeling, amnesia is included in that PTSD symptom cluster. And so it's human nature to not really want to think and know about awful stuff. Many listeners can probably relate to, after a while, hearing about the coronavirus, maybe after a while they just got sick of hearing about it, and they just had to stop. Or after 911, seeing the planes crash again and again and again in media coverage, you just have to stop. Some people maybe start to feel that about the Ukrainian war, it's natural to after a while feel like I can't know anymore.
In addition, when a lot of the controversy started, we didn't have anywhere near the research we have now on the brain and the impact of trauma. And we didn't have all the research on dissociation around the world. And DID found around the world, even when it's not in the diagnostic manual, even where they never saw that movie Sybil. And so it's validated it, the fact that there are types of DID found in every single culture around the world where it's been studied scientifically with standardized measures, they found it. It can look differently, for example, in some Eastern countries or even in our own. Even in the United States, in some subcultures, it's often experienced as possession. So there are cultural variations, but it exists around the world. Just like child abuse exists around the world.
Mills: There have been some news stories lately about how some viral TikTok videos about DID have led to an uptick in people diagnosing themselves with the disorder. How should mental health providers respond to that?
Brand: I have heard about this and I've been consulted on a number of these cases and it's true. It's an issue we have to be really thoughtful about because some people are accurately self diagnosing and then there's others that may not be accurate. And so I go again, back to science and these validated measures, I urge any clinicians out there to learn about these measures and use them and help clients understand whatever they're presenting complaints are. Some of the cases I've heard about related to TikTok are individuals who really don't have a cohesive sense of themselves, they don't understand themselves, and they do relate to some of what they've seen, whether it's DID or not, there's some aspects of who they are that sound similar.
And so it's really up to the clinician to do a good job of assessing, does the person have all the co-occurring or—it's called comorbid symptoms you'd expect? Do they have that kind of trauma history? And to be thoughtful and listen. Unlike in some of the studies I've done where some clients who have DID have reported up to 35% report that a clinician has been dismissive or downright hurtful, or in some cases just laughed and said, you're making this up, this isn't real. So I urged clinicians, obviously, not to harm clients who are coming for help, but to use evidence based measures, to do a careful, accurate assessment process.
Mills: What is the estimated prevalence of DID in the population?
Brand: It is slightly above the prevalence of bipolar disorder and schizophrenia, which shocks people. It's slightly above 1% in the general population studies that we have. Now we need more studies, this is not an area that's been well funded in research. And that kind of epidemiological research is expensive, but it is not uncommon.
Mills: And where can people go if they think they might have a dissociative disorder, whether it's DID or something related, is there some place special, some particular kind of a practitioner they should look for?
Brand: Yes. As I was saying earlier, try to locate somebody who has had training in trauma related disorders, including dissociation. There's a professional organization, I'll say the name slowly, it's the International Society for the Study of Trauma and Dissociation. It's abbreviated, ISSTD. And if you just search for that online, they have a website, they have all sorts of information, frequently asked questions, they have some questionnaires, resources that clinicians can access. And they also have treatment guidelines for treating children as well as adults. It's a really good referral reference resource space for both mental health professionals as well as loved ones of somebody who has dissociative disorder or an individual who thinks they might have one.
Mills: What are the big unanswered questions? If you had your druthers, what would we be looking at and learning now to better understand DID?
Brand: Do I get unlimited funding? Please, Kim?
Mills: I think that's everyone answer.
Brand: We're just now—some researchers and I, are just now starting the first randomized controlled trial for the treatment of dissociative individuals, not just DID, but DID folks are invited and encouraged to come along and try out the study with their therapist. So that's called the top DD study, you referenced it earlier. What we need to find out is, does that standardized treatment help individuals. And that was just for the beginning phase, stage one of treatment. We need to develop standardized interventions and training for the therapist, for the whole range across the years of treatment stages one, two, and three.
We need to learn a lot more about the neurobiology of dissociative disorders. And it will be fantastic if we can find some ways to have some markers like a biological marker, and folks, including the Harvard researchers, Lauren Lebois and Milissa Kaufman, they are researching biological markers that might be like a signature of biological signature for serious dissociation, which would aid in the assessment process tremendously.
Mills: Well, Dr. Brand, thank you. This has been really fascinating and I appreciate your taking the time to talk to me today.
Brand: It's been fun. Thank you very much for having me.
Mills: You can find previous episodes of Speaking of Psychology on our website at www.speakingofpsychology.org or on Apple Stitcher, or wherever you get your podcasts. And if you're listening on Apple, please leave us a review. If you have comments or ideas for future podcasts, you can email us at speakingofpsychology@apa.org. Speaking of Psychology is produced by Lea Winerman. Our sound editor is Chris Condayan.
Thank you for listening. For the American Psychological Association, I'm Kim Mills.
Bethany Brand, PhD, is a professor of psychology at Towson University and maintains an independent practice in clinical psychology in Towson, Maryland. She is an expert in trauma, specializing in trauma-related disorders, including posttraumatic stress disorder and dissociative disorders. Her current research focuses on the assessment and treatment of trauma-related disorders, including complex trauma and dissociative disorders, distinguishing feigned from genuine trauma disorders, and evaluating the accuracy and adequacy of trauma-related content in psychology textbooks. Additionally, Brand serves as an expert witness in criminal, civil, disability, and employment matters.
