by Karissa Song
art by Yixin (Cynthia) Jia
CHARLES: Shoot him!
TOBIAS: I don’t want to!
CHARLES: I said “Shoot him,” you weakling. He’s a Satan!
TOBIAS: He didn’t do anything.
CHARLES: I won’t tell you another time, boy. Shoot him!
In episodes fourteen and fifteen of season two of Criminal Minds, Dr. Spencer Reid got kidnapped by the suspect, Tobias Hankel, who had dissociative identity disorder (DID). His personality was split into three distinct personality states, or alters: Tobias; Raphael, the angel; and Charles Hankel, his abusive father. When Tobias’ father became very ill, he ordered Tobias to kill him to end his misery, leaving Tobias to cope through drugs that were believed to fracture his identity. Tobias’s grief and guilt manifested in the creation of Charles––a separate personality in the same body. Because of his religious extremism, Charles had suffocated Tobias with his harsh evangelical values, which caused Tobias to internalize them and form the alter Raphael, who murdered people for their sins. The show’s portrayal of DID is incredibly exaggerated and inflated—it depicted Tobias switching alters instantly in front of Dr. Reid, even getting into arguments with his father as the two personalities fight for control of the same body to yell at each other.
In reality, dissociative identity disorder (DID) is classified as a dissociative psychological disorder in which a person has two or more personality states that can recurrently “front,” or take control of their behavior [1]. Dissociation, coined by psychologist Pierre Janet in 1889, is a defense mechanism against a traumatic experience. It involves removing one’s consciousness from the situation to avoid fully confronting it, resulting in feelings of numbness or detachment from one’s body, environment, or self [2]. However, DID is one of the most controversial diagnoses in psychiatry [1]. Pop culture portrayals, such as in the Criminal Minds episode or movies like Split or Three Faces of Eve, have heavily skewed public perception of the disorder, often representing patients as violent or even homicidal. In actuality, DID is significantly more complex and overall very misunderstood.
DID in History
Originally added to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3) in 1980 as multiple personality disorder (MPD), DID has a complicated history. DID used to be attributed to demonic possession, such as in the case of Jeanne Fery, a nun from the sixteenth century. Fery had multiple alters that could converse with each other and take control of her behavior [3]. She also demonstrated intermittent amnesia, or short-term memory loss, and somatic symptoms, which are physical manifestations of psychological disorders like nonepileptic seizures and headaches [3, 4]. These are all classic symptoms of DID, and because of the extensive documentation of her exorcism, psychologists in the 1990s were able to diagnose Fery with high confidence retroactively [3].
Presently, the modern theory of the origin of DID, called the trauma model, includes four main components: traumatic experiences, usually in childhood; lack of external stability or of social support; the ability to dissociate, detaching oneself from the situation; and the creation of alters with distinct personalities [11, 1]. However, in the past, because of the link between fantasy-prone individuals and dissociative behaviors, psychiatrists widely accepted the fantasy model of DID, which stated that the origin of the disorder was likely due to certain personality traits [5]. If fantasy-prone patients tended to daydream, exaggerate, or distort their experiences, no wonder they tended to dissociate and or even create alternate personalities, right? However, this belief was later discredited by the trauma model since DID patients often exhibited smaller hippocampal volume, which is the most consistent neurostructural indicator of childhood traumatization [6]. The hippocampus, which mainly assists with long-term memory storage, is vulnerable to stress and damage, especially at younger ages [7, 8]. In fact, many psychiatrists also classify DID as a posttraumatic disorder [9]. The trauma model stems back to Janet’s theory of dissociation, hypothesizing that individuals traumatized as children have difficulty developing a unified sense of self, which is a major developmental milestone in infancy and early childhood [10, 2]. Thus, the likelihood of dissociation increases the earlier the trauma occurs. Additionally, when parents utilize an authoritarian or negligent style of parenting, the child often develops a disorganized and insecure attachment style, predisposing them to dissociation [10].
DID in the Brain
Because of the variability in symptoms between patients and the frequent overlap with other disorders, DID remains difficult to diagnose. The DSM-5—the most current edition of the Diagnostic and Statistical Manual of Mental Disorders—presents five main diagnostic criteria. The most significant item is that there must be a “disruption of identity characterized by two or more distinct personality states,” which differ in “affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.” The other diagnostic criteria in the DSM-5 emphasize that the symptoms must not be caused by substances, such as alcohol or other medical conditions, or be part of a broadly accepted cultural or religious practice [12].
When a threat is perceived, or high levels of stress are experienced, alters may “switch” which personality fronts, appearing to be in a trance for a short period, blinking, rolling their eyes, or changing their posture [11]. A case study conducted by Savoy et al. (2012) studied a woman with DID who could voluntarily switch alters [13]. They used functional magnetic resonance imaging (fMRI), a neuroimaging technique that tracks cognitive activation in the brain by identifying the regions of the brain with increased blood flow, to examine brain activity during transitions between personality states [14, 13]. Although this case study featured only one participant and thus is not generalizable, it uncovered some interesting neural correlations; for example, in addition to the primary sensory-motor areas, which control movement, there was nominal activation of Brodmann’s areas 9, 10, and 11, regions of the frontal cortex that regulate functions like memory recall and coding, switching mannerisms, and adapting behaviors [13].
Because of the switches, amnesia is another common symptom since alters may not be aware of each other, although a meta-analysis highlights variability between subjects (Beker et al., 2024). If the patient experiences inter-identity amnesia, DID personalities may exhibit no information or memory flow amongst themselves, especially for explicit memories—ones that are intentionally recalled [15]. For example, if one alter went to school, the other may remember nothing from the event. However, implicit or procedural memories—skills remembered unconsciously, like riding a bike—can bypass the amnesic barriers [15]. In addition, many patients display somatic symptoms like headaches and nonepileptic seizures, as well as gastrointestinal, genital, and urinary issues, and may be diagnosed with anxiety and depressive disorders, which can significantly impact their quality of life [1].
Along with outward symptoms, we can witness how neurological structures differ between those with DID and those without. In one study by Reinders et al. (2018), which was conducted to identify biomarkers of DID, researchers discovered that the brain scans of women with DID have less overall regional volume in grey and white matter throughout the brain [16]. Additionally, the widespread abnormalities and noticeable size differences across the frontal lobe in grey and white matter are indicative of long-term trauma as they both play a crucial part in the functioning of the central nervous system [16, 17]. In particular, although grey and white matter are similar, grey matter gets its color due to the high concentration of neurons that allow it to process and release information and control movement, memory, and emotion [17]. As a result, irregularities in these areas, such as the bilateral middle and superior frontal regions, lead to issues in memory, spatial processing, impulse control, and inhibitory control [16, 18]. The frontal lobe controls motor functions, drives decision-making, and only reaches terminal development at age 25, meaning trauma during childhood and adolescence can greatly affect its development [19]. In the parietal lobe, which influences sensory perception, reduced size or overstimulation correlates with dissociation and depersonalization [9]. Atypical sizes are also observed in the amygdala, and basal ganglia in individuals with DID [9]. The amygdala regulates certain emotions, such as fear, anger, and aggression [20]. Hence, a smaller amygdala may lead individuals to rely on a defense mechanism, like dissociation, to cope with distress [9]. Brain scans demonstrated that the putamen and pallidum, two parts of the basal ganglia that impact motivation, movement, decision-making, and memory, are significantly larger and positively correlated with depersonalization and dissociation [9].
Moreover, DID patients exhibit abnormal connectivity and interaction patterns between neurobiological structures. For example, individuals who experience depersonalization and dissociation also exhibit inhibited limbic system functioning by the prefrontal cortex. The prefrontal cortex regulates emotion and arousal, and the limbic system activates when exposed to threats or other stimuli [21]. For instance, if a bear confronts you, the limbic system will activate your fight-or-flight response, hopefully allowing you to survive the situation. However, with inhibited limbic functioning, there is an overmodulation of emotion and arousal, an indicator of dissociation as it leads to the person feeling numb. On the other hand, patients with other dissociative disorders, such as depersonalization or derealization symptoms, experience increased activity between the ventrolateral periaqueductal gray areas and prefrontal cortex regions involved in threat detection at rest. This means they exhibit more unconscious defensive behaviors and fewer conscious defensive behaviors. When in danger, they unintentionally remove themselves from the situation; when not in danger, they stay hypervigilant [21].
DID in Real Life
The reality of DID extends beyond clinical evaluations. One blogger, Stephanie Yeboah, opened up about her experience with DID. Due to severe bullying in school and a lack of familial support, she describes creating an alternate reality in her head as a child to escape to, talking to herself as if talking to other people, leading to her diagnosis at age eighteen [22]. “To this day, there are many times when I talk to people who aren’t there, but I don’t talk to them as myself, Stephanie. Instead, it’s like my true self is unable to do anything but watch as this other entity takes over my thoughts and actions.” Having a West African, Caribbean background, Yeboah implores others to speak up to reduce the stigma surrounding mental disorders. “My community’s reluctance to talk about mental health meant it took years for me to get a diagnosis, but once I started going to therapy, it made a significant difference in my life,” she states [23].
Her perspective, like that of countless others who bravely share their stories, sheds light on the reality of having DID. A large part of the taboo surrounding DID, and mental health in general, is caused by the lack of accurate information. Opening up about mental health may not only improve your own life but can also break down harmful misconceptions that bar others from seeking help, so don’t hesitate to reach out.
DID in Treatment
Although DID treatment options range from hypnosis to eye movement desensitization and reprocessing (EMDR), a type of talk therapy called cognitive behavioral therapy (CBT) tends to be the most common approach, encouraging patients to identify and modify their unhelpful thinking patterns and harmful behaviors [11, 31]. In this case, it encourages the patient to communicate with their alters, find healthier coping strategies for times of high stress, and identify cognitive distortions to reevaluate their perception of the world and gain
control over dissociation [1]. Studies on schema therapy (ST), a form of treatment primarily used to treat BPD that blends CBT with a focus on the patient’s past to reframe their different identities, have shown promising results in reducing DID symptoms [32]. In terms of medication, psychiatrists mainly prescribe antidepressants, antipsychotics, or anxiety medications to treat other symptoms, such as anxiety or mood destabilization [11]. Additionally, some evidence suggests drugs that block the effect of the opioid receptors, such as naloxone, reduce dissociation since opioid receptors are involved in stress response and immune function [21].
DID in Question
Despite the very real experiences of patients and extensive research, DID remains one of the most debated diagnoses in psychiatry. Many scientists completely question the existence of the disorder itself, likely due in part to the fantasy model, which makes it appear fictitious.
Because its symptoms overlap with those of similar diagnoses, DID is often overdiagnosed or misdiagnosed. Differential or comorbid diagnoses, meaning conditions that have similar symptoms or co-exist with other disorders, include schizophrenia, borderline personality disorder (BPD), and bipolar disorder [6]. For example, the diagnostic criteria for BPD list items like impulsivity, dissociation, identity disturbance, an unstable sense of self, and a pattern of unstable and intense interpersonal relationships [24]. Because of this, a majority of patients with DID also meet the criteria for a BPD diagnosis. Individuals with BPD dissociate far less frequently than those with DID and with more variability in terms of severity, and they have lower levels of identity confusion [25]. Furthermore, amongst those with dissociative-type posttraumatic stress disorder (PTSD), which affects around 15% to 30% of afflicted patients, around half experience extensive dissociative symptoms or fit the criteria for a DID diagnosis. Their brain scans demonstrate increased connectivity between the same regions when compared to the non-dissociative subtypes, demonstrating significant overlap between DID and PTSD [26].
Furthermore, another critique of DID is that it is a “psychiatric fad” with cases occasionally spiking or overall appearing more frequent in the Western world. One instance that skyrocketed DID’s prominence was Sybil, a book that was later adapted into a film, leading to a significant increase in cases. This novel was based on an actual patient named Shirley Mason, who was diagnosed with MPD, the term at the time. In transcripts of Mason’s therapy sessions with Dr. Cornelia Wilbur, however, it is clear that the narrative of DID was forced onto her by Wilbur, who insisted that her symptoms stemmed from having multiple personalities. She later admitted that she went along with the diagnosis to please her therapist. Additionally, she never endured the horrific abuse as a child that Wilbur said she must have [27].
Hollywood has a pattern of incorrectly depicting what it means to have DID. As mentioned earlier, Criminal Minds aired a real episode featuring a criminal with DID that manufactures a completely false narrative about the disorder. Considering their popularity, Criminal Minds and Tobias Hankel very likely were many people’s first impressions of DID—including mine. If those misconceptions are never corrected, they perpetuate dangerous
stereotypes about real people. Because of this, distrust is often harbored towards patients with DID. Many argue that DID is largely iatrogenic, meaning it develops or worsens as a result of therapy or treatment, similar to Mason’s case. When presented with cognitive suggestions, patients may subconsciously behave differently in response, leading to the development of these traits [11].
Additionally, the phenomenon of false memories complicates the discussion because memories are malleable. Imagine recreating a figurine out of Play-Doh. The new version will not be an exact replica, although it will be similar. It’s the same idea with memories—each time they are retrieved, the brain reconsolidates and modifies them slightly [28]. Small differences in question framing or priming can completely change or create false memories, memories that never happened. In a famous study by Elizabeth Loftus, participants viewed a video of a car crash, and depending on the question the researchers asked afterward, the participants reported seeing different stimuli, demonstrating the suggestibility of memory [29]. Thus, the memories of childhood trauma Mason supposedly experienced could have easily been fabricated by Wilbur’s constant insistence that it must have happened. Wilbur likely assumed that Mason had repressed the memories to avoid the pain they brought and that she needed to bring them back to light [27]. However, the idea of repressed memories, popularized by Freud and Janet, lacks experimental evidence and scientific credibility, especially since uncovering them can lead to false memory formation [30].
DID in Conclusion
Ultimately, one of the most fascinating aspects of DID is the staggering amount of contention surrounding it. Despite its history and current research, DID is incredibly misunderstood and misrepresented—but why? Why is DID so heavily disputed? Clearly, there is still a lot to understand about this diagnosis. It opens the opportunity to investigate further research questions, such as how DID can be diagnosed through neurological biomarkers, what new treatment forms are most effective, and which medications are proven to accurately target dissociative symptoms. Ultimately, increased knowledge and awareness of DID have the potential to exponentially increase the quality of life of individuals with this disorder. The intrigue of DID stems from the never-ending areas to study and the peculiarity of its findings.
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