Therapists may come to the diagnosis of DID in very different ways. It is important for all therapists to retain a high index of suspicion that includes DID when seeing patients that might be diagnosed with clinical depression, Bipolar Disorder, or Borderline Personality disorder. Why? It is because early childhood trauma that is the etiology of DID is both common and easily hidden.
DID is not rare, that is a straw man argument that has led to misdiagnoses and lost years of ineffective therapy. Being treated for depression with medication will not address or heal depression if it is the result of unprocessed early childhood trauma – even though it may take years to come to that conclusion. Reputable studies from various countries and cultures offer similar data: They all end up with approximately 1% of the general population suffering from DID.
Remember, dissociation ranges from normal to pathological so a therapist must be able to navigate that range. A highly functional surgeon needs to be able to dissociate from temporary personal troubles while he is performing a surgery. This kind of dissociation is beneficial for both patient and doctor. After all, you don’t want a surgeon operating on you who is in the middle of an angry divorce if he cannot keep that rage out of the operating room.
While there are high functioning individuals with DID, it may be characterized as pathological when the individual dissociates out of the present moment overwhelmed by either emotional recollections, conceptual or bodily memories from the past trauma(s). The diagnosis of DID is confirmed on the therapist meeting or being convinced of the presence of an alter or alters.
In the last pages of Oxnam’s book, there are 24 pages by his psychiatrist, Dr. Jeffrey Smith, summarizing his views on treating DID. It is a low-keyed account of the DID condition, far removed from the usual dramatization of dealing with alternate personalities which are usually distracting, which overshadow the trauma, heart ache and struggles in the early childhood period. It is a gem of a summary.
Dr. Smith pointed out 3 kinds of trauma: [1] the shouting, screaming and outright physical violence [2] the lack of support and emotional unavailability of the primary caregiver; and [3] the kind of horror that is so far removed from our ordinary concepts or daily like. This 3rd kind is of unimaginable evil and cruelty, an unthinkable horror that can befall a child in the earliest times of life.
There is a reluctance of society, and within psychiatry in particular, to come to grips with the idea that such evil would ever take place. It seems easier to deny when such horror does happen, than address the causes and consequences. From the very beginning of psychiatry, Freud was aware of early childhood sexual trauma in several of his patients. When he first presented this to his Viennese colleagues, the reception was ice cold. They were not ready to believe that such conduct could ever happen – certainly not within their own social class and environment.
The vitriol forced Freud to change his analysis to call the phenomenon of childhood sexual violence /abuse a “seduction” and forced him away from talking about trauma as the etiology of what was then named “hysteria.” Using the term seduction allowed the medical community of the time to place the blame on the victim of the sexual violence rather than the perpetrator. This was at the end of the 19th Century, in the Germanic scientific era.
But today, well over a hundred years later, we still face strong resistance to acknowledge the reality of early childhood trauma and how it impacts people their whole lives. While the prevalence of incest is now acknowledged to be far greater than previously assumed, early childhood sexual trauma remains a taboo subject that is not willingly acknowledged by many of my colleagues. With my own ears I have heard my colleagues assert that early sexual abuse is overly dramatized! I wonder exactly how “dramatized” they believe early sexual abuse should be before they would acknowledge it.
