Dissociative Identity Disorder in the DSM-5

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.

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Dissociative Identity Disorder in the DSM-5 by Kelley R. Bailey

With the new Diagnostic Statical Manual of Mental Disorders (fifth edition, released in May 2013) comes changes in several categories.  My job is to explain the changes that occur under the category of Dissociative Identity Disorder (DID).  The diagnosis had four criterion specifiers in the DSM-IV but in the DSM-5 there are now five criteria.  Two criteria out of the DSM-IV are completely gone and two new ones have been added to the 5th edition.  So, if you are following me mathematically we have three general criterions that have remained the same, but with each of these three the DSM-5 has broadened the definition.  The three that remain the same are:

1. Two or more distinct personality states are experienced in the individual.

The DSM-5 broadened the description and added that the personality state is one way of viewing the alter personality or that it could be an “experience of possession.”  Either of these two states, according to the DSM-5 (but not IV), “involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.  These signs and symptoms may be observed by others or reported by the individual.”  By referring to ‘experience of possession’ this new definition encompasses DSM-IV’s Trance and Possession Disorder and makes it more globally useful.

So now, according to this broader definition, in criterion A the person diagnosed with DID can report their own symptoms of transition from one personality state to another along with others who may also report they have observed the transition.  The thought behind this broader definition is that it will help to decrease the use of Dissociative Disorder Not Otherwise Specified.

2. Gaps in recall or the person is unable to recall important personal information, and this inability is too severe to be attributed to mere ordinary forgetfulness.

The DSM-5 broadens the definition to say the person is unable recall important personal information and/or traumatic events that are inconsistent with ordinary forgetting.  It used to be the inability to recall only traumatic events, now the criterion includes events not necessarily traumatic.

3.  These disturbances are not an outcome of substance abuse or general medical condition.  

The DSM 5 further explains the symptoms of DID as being “not attributable to the direct physiological effects of substances (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or another medical condition (e.g., complex partial seizures).”  Now we have a differentiation between completely drunk and blacking out or wild and crazy behavior while being intoxicated. (Not sure this was needed, but apparently the writers of the DSM thought so, either way that’s cleared up.)

Taken out of the new definition was the DSM-IV criterion B, which stated “these distinct identities take control over the behavior recurrently.” Added to the DSM-V definition are criteria C and D.

1. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
2. The disturbance is not a normal part of a broadly accepted cultural or religious practice.  (Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play).

In other words they’re saying “Hey, if you’re good with a possession or your culture accepts this type of behavior and it doesn’t interfere with your job, family, or other important areas of life then we are good with it too.”  This helps to delineate between those who are distressed over their multiple personalities and those who are not.

It appears some of the changes in language also helps to clarify some somatic symptoms often seen in DID.  This is beneficial for several reasons, as depending on the somatic symptom there could be cause for a different medical diagnosis and therefore, different treatment.  It is often the case that those who do have DID also have conversion symptoms (experiencing physical distress with no biological or medical reason for them).  These are generally directly related to their DID and call for other treatment.  The language used in the new DSM will help facilitate these demarcations in-house, culturally, and globally.

The chart below (adapted from Durand & Barlow, 2013) is a breakdown of the changes from DSM-IV to DSM-5 in a succinct form.

Diagnostic Criteria for Dissociative Identity Disorder
MAJOR CHANGES:  DSM-5 notes that symptoms of Dissociative Identity Disorder may either be reported by the individual or observed by others. DSM-IV Criterion B (at least two of the person’s identity states routinely take control) has been removed. DSM-5 Criterion C is new (distress or impairment). DSM-5 Criterion D is new (distinction from cultural or religious practices).
Diagnostic Criterion	DSM-5	Highlights of changes from DSM-IV to DSM-5
Criterion A Preoccupation with somatic symptoms	Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption of marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.	Changed wording. Added note that the disturbance may be described as an experience of possession. This change was made to make the criteria more broadly applicable across cultures. Expanded upon the ways in which individual personality states differ from each other. Added note that symptoms may be either reported by the patient or observed by others.
Criterion BForgetting	Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.	Previously listed under DSM-IV Criterion C.   Noted that forgetting may occur for everyday events or traumatic events in addition to personal information.   Changed wording.
Criterion C Distress or Impairment	The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.	This is a new criterion in DSM-5.
Criterion DDistinction from cultural or religious practices	The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.	This is a new criterion of DSM-5.   The distinction from imaginary play was  previously listed in DSM-IV Criterion D.
Criterion E Distinction from other conditions	The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).	Previously listed under DSM-IV Criterion D.   Changed wording.