Neurological consequences of psychotrauma
  The Dissociative Spectrum
  What are Dissociative Disorders - DSM IV & ICD 10
  What is DID/MPD?


The most serious and pathological form of dissociation is the Dissociative Identity Disorder (DID, former called the Multiple Personality Disorder (MPD).

  • As seen above, dissociating is something which can happen to anyone: it is something like creating or experiencing a distance from oneself (a reality outside oneself, a reality at a distance) and sometimes one has suppressed certain experiences from his or her own personal history.
  • Someone with a DID/MPD on the other hand, creates or experiences a distance within him or herself, dissociates in him or her self, cause of the fragmentation of the personality or identity and has amnesia for all or some split-off personality parts (also called alters).
A Dissociative Identity Disorder (MPD) is a disorder originating from an evolutionary survival strategy. With regard to extreme traumas, it develops in the early stages of child development.
The D.I.D. is found at the end of the dissociative spectrum and is distinguished by many forms of dissociation. It involves at least two different identities or personality states, also called alters.

The basis of every (also normal) identity or personality is memory.
D.I.D. demonstrates a (more or less) loss of memory and changes in identity. The normal integrated functions of identity, memory and/or consciousness are broken. This means that DID patients often have difficulties in remembering (or cannot remember) important personal experiences from their own life history.
Personal (traumatic) experiences, with their connected behaviours, are stored and carried out by different personality parts. At the same time, the main person (or host) may not necessarily be aware of those experiences or behaviours. Because D.I.D. has different identities or personality states one can speak of a fragmented personality.

Alters, Personality parts.

Although the term “personality state” (or “part”) is probably more accurate, I will use the term 'alter' here, simply because it is shorter.
While undergoing a trauma, the original person hides, in a manner of speaking, in the mind to escape the life-threatening situation of that moment. (see: neurological consequences of psychotrauma)
Subconsciously, an alter is created then who can handle the traumatic event and can cope better with it. This alter, in fact, lives through the traumatic event about which the original person (later) can remember nothing.
It can also happen that this “new” alter takes over from the original person for a shorter or longer period, sometimes (but not always) with other specific character traits such as being more extroverted or introverted, more fearful or fearless, and so on. During the period that this new alter exists, he or she experiences new things in life and develops new skills, talents and behaviours. Mostly, however, these are attached to the defence skills used while undergoing the experienced trauma.

Often (but not always) alters have their own names and sometimes different gender identities or preferences from those of the original person. It can also happen that alters are animals, because an animal is somehow safer or stronger than a human, especially when he or she had to undergo an 'inhuman' traumatic experience. In addition, alters can have completely different physical conditions. Thus, in people with D.I.D. it can happen that one is sick with fever and another is not;, eye measurements show different results from one day to the next; blood pressure measurements show significant differences, and so on. Incidentally, such differences can be extremely puzzling to physicians.

DID/MPD as shown in popular movies and media probably give laymen the impression that the different alters should be distinguished easily, but this is rarely the case. Someone with a D.I.D. did not only learn in life how to hide his/her own existence (playing dead), but also how to hide the differences between alters as part of the survival strategy. It is not difficult to understand what would happen with a victim, when perpetrator(s) would notice that a person to whom their aggression or sadism is directed, is actually not there at all. So although subconsciously, patients with DID are often remarkably capable of hiding the alters or where the pain and suffering is.

When pointing out the whole of an alter-structure, often the term 'system' is used.


Alter Structure.

There are alters who deal with daily functioning like work, housekeeping, etc., and those are normally not aware of the underlying traumas of other alters within the system. Highly functioning alters are sometimes called 'host' but a better description is so called A.N.P.'s (Apparent Normal Personality). (v.d.Hart; Nijenhuis, Steele).
They are somehow kept away from the traumatic content(s) in the system and therefore also completely or partly amnesiac with regard to traumas. And mostly these are alters who are afraid to loose control, are very rational and/or superficial emotionally. It is believed that A.N.P.'s are phobic with regard to the traumatic memory or memories and, accordingly, to the alter who experienced it. So in most cases the A.N.P. is functioning more or less apart from the others in the system.

There can also occur (often more) alters who lived through the traumas and are more hidden in the system. These are called E.P.'s (Emotional Personality). It often seems as if those alters are stuck in the traumatic event (as if time has stood still), complete with the feelings and defenses of the traumatic event of that moment. In these alters one can often see: freezing, flight and fight etc. and among them one finds the more or less well known little children personality parts.

The more extreme and ongoing the traumatic history was, the more extreme or complex the dissociative disorder usually is. An A.N.P. can alternate with E.P. (primary structural dissociation = PTSD). Or it happens that one or more E.P.'s are split but not the A.N.P. (secondary structural dissociation = complex PTSD, B.P., DDNOS).
Or the A.N.P. is also split into different parts and sometimes some of the E.P.'s are extremely well hidden and sheltered behind another E.P. or A.N.P. (tertiary structural dissociation = complex D.I.D.). (v.d.Hart; Nijenhuis, Steele)

Someone with a D.I.D. also often shows signs of other disorders in the dissociative spectrum. (see: dissociative spectrum).

Hearing voices

In relation to DID one often hears the notorious term, "hearing voices".
People with schizophrenia and psychosis often say that they hear voices which come from outside and which sometimes give them “assignments”.
This is rarely or never the case with people diagnosed as D.I.D. These patients are well aware that the voices they hear are coming from inside the system.
What is meant here is voices like “strangers” in the head. (“Strangers” in this case are the alters).
These voices are very distinct from the thoughts belonging to the person (-part) who is present at the time.


Switching or alter changes.

The changing between alters is called switching.
It can happen to someone with a D.I.D., and often to their own terror and revulsion, that he/she can in reality hear an inner alter speaking and taking over.
The shock probably has something to do with the threat of the A.N.P. losing control and being so frightened of that, that he/she cannot even hear this alter voice while other people in her/his environment can. This A.N.P. will often react with: "I didn't say that at all!", and then suspicion and insecurity regarding the outside world will often increase in the A.N.P. The same happens when an inner alter executes one or more actions in the outside world without the knowledge of the A.N.P.
Internally it also can be a sign for the A.N.P. that someone is threatening to take over (the daily functioning) or that he/she apparently is not functioning well. In regard to that, often the A.N.P. reacts with more intense concentration and fierce attempts to keep control.
So one can imagine that, when this goes back and forth, this A.N.P. gets very tired or exhausted in the end. Therefore one can often see extreme fatigue phenomena in someone who is dissociating a great deal.

A layman could think: “Why bother, let the other alter come forward”, but unfortunately it doesn't work that way. First, because it has become a way of lifetime coping. And second, other alters usually have a different preoccupation, lifestyle, etc., so that a conflict arises with regard to functioning within society. For instance it can mean that one cannot do the job that one has been used to doing for years; one doesn't know how to handle things, doesn't know people or certain skills anymore; not to mention E.P.'s who are preoccupied with their trauma's. Often in a safe therapy setting and with an empathic therapist may they come forward.
There are alters (mostly A.N.P.'s) who are well aware of reality 'now', often automatically coming forward and alternating with the other A.N.P., with or without his/her knowledge or being noticed in the outside world.


It often happens that someone with DID has to endure so called 'triggers'. A 'trigger' can be a smell, sound or image which brings a partial or whole traumatic experience into memory. As mentioned above, an A.N.P. will react fearfully to this and with evasion. But the urge of the E.P.'s traumatic memory can be so strong that one gets flashbacks, nightmares, panic attacks, eating problems, relationality problems (where none were before), depressions and so on. In short the whole range of symptoms as seen in multiple dissociation. (see dissociative spectrum above).

Also, feelings can arise such as not fitting in one’s body anymore; one feels too big or, for instance, certain limbs like arms and legs feel as small as if they belong to a toddler or 10-year old, while the rest of the body seems of normal length. It sometimes also can happen that one is easily lost, finding oneself back in strange and unfamiliar places.
In contrast with normal memories, these kinds of traumatic memories have, in fact, always been stored in a separate box, where nothing could get in or out, and in some cases are so detailed that it seems as if they just happened or one is still in the middle of them.



Especially when the patient feels safe and is an adult, partial or whole memories of former traumatic experiences (E.P.) can arise in the consciousness of the A.N.P.('s) or sometimes called hosts. With the guidance of a psychiatrist or therapist who is familiar with trauma treatment these traumas can be worked through. Unfortunately, it is often a long road with many pitfalls, for the patient as well as the therapist.
Whether one can work on and process the traumatic content(s) in therapy also depends on the will and strength of the patient and the circumstances in which he/she is living.
Sometimes it can be better or preferable to stabilize the patient first. That is, one first learns to deal with daily problems and one’s dissociative phenomenon.
The eventual result of therapy will depend on the severity of the traumatic history, the complexity of dissociation, the circumstances in which the patient lives and the quality of the therapist.
In any case, and in the end, it is possible to cope with DID in a more healthy way or to be healed under the guidance of a skilful and empathic therapist.

It should be obvious that it can be devastating for the patient if the therapist treats DID as having little importance, shows little interest, gives a wrong diagnosis, or when a patient chooses a vague alternative therapy.

In origin, D.I.D. is a survival strategy and dissociating happens subconsciously. Often people who claim they have D.I.D. frequently and in public switch easily among the different alters. However, publicly displaying the alters seems more like copy cat behaviour than a survival strategy, and serious doubt about the authenticity of the disorder is warranted. Often in such cases appalling numbers of alters are also mentioned. D.I.D. is a disorder which is often imitated in order to get attention.


There are a lot of misdiagnosis and in the past a lot of people with DID got the diagnosis, schizofrenia. Nowadays it is often 'borderline'.

  1. F.i. because the therapist doesn't believe in the existence of DID/MPD;
  2. thinks that DID and BPD are on the same continuum (despite several studies and research which proves otherwise)
  3. or the therapist finds it too difficult or the problems too complicated and makes it borderline.

Depersonalization - Derealization can be a dissociative symptom by many personality disorders. Some researchers and therapists think that DID and BPD are on one continuum. But this is in contradiction with the opinion of a lot of DID patients who experience several differences between someone with BPD. Differences between the two are also experienced in DID support groups. Besides that it is a wellknown fact that a DID is often faked, sometimes unconsciously. This can happen when patients think that having egostates is the same as having alters. However only between alters (from the word; alter ~ change, changing) there is amnesia and having egostates is normal.
A lot of DID patients f.i., can get the diagnose BPD cause of automutilation. But the latter is seen in a lot of personality disorders. Besides that, patients with BPD do have an egostructure, which is fragmented in a DID. And there are more specific differences.

For example; ego states are not dissociatied alters and alters are no moodswings and dissociation is a different process than repression. In genuine cases of DID there is fear (or phobia) and embarrasment about having other personalities. "In contrast, those individuals who show up on TV talk shows, touting their “diagnosis,” raise the most suspicion of having ulterior motives, such as a craving for attention and money, to be seen by others as “special” and different". Raymond Lloyd Richmond, Ph.D.



D.I.D. has many features which can manifest themselves in different ways and differently in each patient. One could say that D.I.D. is a personality disorder which above all is caused by extreme human (mis)treatment. This can include or be exacerbated by silencing, denials (and therefore denial of identity and existence), life threats, extreme and/or sadistic violence, humiliation, accusations of madness and fantasy, and so on. If children who undergo such traumatic events were allowed to speak out and be treated with understanding, fragmentation or identity splitting (D.I.D.) would probably never occur.



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