Symptoms of dissociative identity disorder (part 1)

In another article I talked to you about dissociative identity disorder (DID), and today I want to go over its main symptoms. The symptoms of DID can be grouped into five broad categories:

• Symptoms related to memory.
• Symptoms related to consciousness and identity.
• Bodily symptoms.
• Intrusions.
• Emotional regulation and belief systems.

I’ll describe each group briefly so that by the end you have an overall picture, however schematic, of how this disorder usually presents. Don’t forget that having a clear grasp of a disorder’s symptoms is essential for a correct diagnosis.

Symptoms related to memory

Dissociative amnesia (psychological cause) differs from organic amnesia (physiological cause) in that the former can be reversible and can be partial. Most of us remember almost nothing from before the age of 5, but when, from that age onwards, there are significant memory gaps covering certain periods of childhood, together with other dissociative symptoms, some authors interpret this as a possible sign that a traumatic situation occurred during that time and the mind has “blocked out” that stage as a defence mechanism. That said, we need to be cautious: having gaps in childhood memory is quite common and doesn’t on its own indicate that there was trauma. What’s more, the idea of “blocked” traumatic memories being recovered years later is the subject of intense scientific debate, because memory is reconstructive and memories can be distorted or even created unintentionally (for example, through suggestion). That’s why, in therapy, a trauma should never be “searched for” on the basis of a memory gap.

As well as this amnesia for certain stages of childhood, a patient with DID may experience micro-fugues, that is, small memory lapses in everyday life. For example, something as simple as having cooked a meal, putting it in the fridge and then not remembering where that food came from or what it’s doing there. Or going somewhere and not remembering how or why you got there.

These types of amnesia can be combined with hypermnesia for the traumatic situation, meaning that the person with DID remembers the trauma in extraordinary detail. These hypermnesias appear spontaneously in the form of flashbacks. In fact, it’s as if the patient relives the traumatic situation rather than remembering it, because of the extraordinary vividness with which they recall it. As I explained in other articles: the traumatic situation wasn’t properly stored in memory when it should have been, and that’s why it comes out involuntarily and is relived in this way, instead of being remembered as a past situation that is no longer part of the person’s present.

Symptoms related to consciousness and identity: fragmentation and disconnection

What do we humans need in order to be aware of our own identity and of what is around us (and to tell one from the other)?

• Being able to access our own memories voluntarily.
• The existence of an observing/thinking self (the most introspective part of our identity, the inner dialogue that evaluates our thoughts, feelings, experiences…) and of an experiencing/bodily self.
• A sense of agency and control over our mental world and our own bodily movements.
• A connection between our mind and our body.
• A sequential sense of experiences: if I’m at home writing this article, I would know the whole sequence of steps that led me to be here, right in front of the computer.

The points I’ve just described are affected in DID, which means the person has many problems with regard to their own identity. A person’s identity has a lot to do with how they see themselves and with the ownership of their own actions. In DID there is no central identity; it is fragmented into several identities.

• If the degree of fragmentation is moderate, we speak of identity confusion: in these cases there is a continuous inner struggle to know who one is. Lots of inner dialogue about one’s own existence and difficulty making decisions.
• If the degree of fragmentation is more severe, then we speak of identity alteration: here we are talking about dissociative parts (identities). These parts are dissociated because each identity is independent of the others, with its own way of thinking, feeling and experiencing. This is what most of us, as laypeople, would know as DID. The central identity has fragmented into several pseudo-identities, each independent of the others. When this fragmentation is extreme, the patient may genuinely believe they are another person and call themselves by different names depending on which identity emerges at the time. Sometimes all this fragmentation of personalities exists without showing on the outside, because the patient fears being taken for mad. So it isn’t always evident to professionals, and sometimes a lot of investigation is needed to reach a correct diagnosis of DID.

Disconnection would stem from these identity problems and is a core symptom of DID: emotional disconnection may be due to alexithymia (the inability to identify and express one’s own and others’ emotions) or to a general emotional numbing from which the person emerges at certain moments, reconnecting intensely with their own emotions and thoughts, something that completely bewilders the patient because they don’t feel them as their own. Depersonalisation and derealisation, which are not exclusive to DID but are very common in these cases, would be two clear examples of disconnection.

A small note to bear in mind: whenever we mention depersonalisation, it is usually described as “as if I left my own body and saw myself from outside”, but it can also show up in other ways, for example: looking in the mirror and not recognising myself; looking in the mirror and seeing someone else’s face; seeing parts of my body as a different size from what they are; not feeling physical pain in situations where I should…

In the second part we’ll look at intrusions and bodily symptoms, as well as emotional regulation and belief systems.