Dissociative identity disorder: Neurobiology research offers hope for improved treatment and cultural acceptance - New findings push us past old barriers

By: Tom Cloyd - 7 minute read

(Published: 2025-06-12; reviewed: 2025-06-12:1020 Pacific Time (USA)

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Dissociative identity disorder (DID), an outcast diagnosis in psychopathology for far too long, deserves a wholesale reconsideration, say a group of world-class experts.

Needless historical controversy and misunderstanding have blocked the appropriate education of clinicians, and thus treatment for those who need and want it. This must change, and we may soon see that happen.

Critical research that led to the DSM-5 formalization of the dissociative subtype of PTSD has made possible a newly grounded understanding of severe trauma and dissociative symptoms - especially those seen in DID.

A recently published narrative review by leading experts provides a detailed and highly technical survey of critical symptoms of DID, research-supported treatment interventions, medications for symptom management, and neurobiological findings suggesting the possibility of a clear neurological characterization of the DID diagnosis.

We offer here a summary of this important review to assist non-professionals in understanding the key ideas detailed by these experts.

Page contents…

 

SUMMARY OF: Purcell, J. B., Brand, B., Browne, H. A., Chefetz, R. A., Shanahan, M., Bair, Z. A., Baranowski, K. A., Davis, V., Mangones, P., Modell, R. L., Palermo, C. A., Robertson, E. C., Robinson, M. A., Ward, L., Winternitz, S., Kaufman, M., & Lebois, L. A. M. (2024). Treatment of Dissociative Identity Disorder: Leveraging neurobiology to optimize success. Expert Review of Neurotherapeutics, 24(3), 273–289. https://doi.org/10.1080/14737175.2024.2316153

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DID appears in childhood, as a consequence of abuse and neglect, usually by caregivers. While normal childhood promotes the slow emergence of a sense of “self” that is stable relative to varying emotional states and environmental situations, chronic childhood abuse, probably assisted by an inherent ability to dissociate not seen in all children, can lead to DID.

Individuals with DID experience discontinuous “self-states” (variously termed personality parts or states, ego-states, alters, etc.). Normal individuals experience shifts in self-states that are accompanied by a continuous identity - an uninterrupted subjective sense of who they are. In DID, such shifts create a discontinuous experience and sense of self, leading to experiences of alienation and confusion (but not psychosis). But, because self-states are stored in memory, the self-state system that is personality can be modified.1

This compartmentalization and discontinuity of self (and memory) in DID has adaptive and survival value, but often leads to disruptions in human relationships and activities. This, in turn, can lead to considerable psychological distress, typically including a core experience of shame and unworthiness.

The DID concept and diagnosis, as well as the idea that childhood maltreatment is its cause, have historically been challenged by laypersons and some professionals. It has been suggested that the disorder is imagined, faked, or simply absurd. This has resulted in underdiagnosis, misdiagnosis, lack of treatment, and maltreatment.

It has also resulted in cultural misunderstandings, prejudice, and abuse throughout history and continuing into the present. But there is no empirical support for these rejections of DID and its causes, and significant verified reports and trustworthy data of various sorts clearly legitimizing the DID concept and diagnosis and its causes.

Long-duration significant clinical experience has validated the effectiveness of well-organized and delivered psychotherapy for DID. As is often said in various ways, what was injured in relationship can be repaired in relationship.

A three-phase model, first proposed over a hundred years ago, has proven both durable and successful. The first two phases establish personal and relational safety and emotional tolerance adequate to then allow approaching and processing traumatic memories and overwhelming feelings. Cycling between the two phases as needed allows continuity of therapy and management of the adaptive responses historically used - dissociation, self-harm, and suicide (attempts at which are common with DID).

As therapy progresses, phase 3 work becomes more important: connecting and reconnecting with parts of self and with other people. As this work continues, dissociation as a core characteristic and adaptive mode recedes.

Empirical studies of outpatient treatment for DID have provided clear evidence of “significant decreases in PTSD, dissociative symptoms, other psychiatric symptoms, and suicidal behaviors, as well as improved global functioning”. Both mid-term and long-term improvements have been documented. Individuals with the most severe symptoms have been seen to benefit the most.

A significant aspect of these studies has been the focused improvement of the treatment model, using active involvement of “people with lived experience of DID”.

Due in part to the fact that a significant minority of people in treatment continue to have serious symptoms, innovation and research in treatments are ongoing and expected to continue.

People with DID exhibit a wide range of distress and distressing symptoms. Use of medication to moderate these symptoms is common, with varying success. Placebo-controlled studies of medication for DID do not yet exist, and no medication has been proposed or used to treat the fragmentation of identity that is central to DID.

There are some clear indications that medications used to treat opioid misuse can moderate dissociation, but systematic studies of this effect have led to conflicting findings. Lack of quantity and standardized experimental designs makes an overall interpretation of findings impossible at this point.

The serotonin neurotransmitter system in the brain is clearly implicated in dissociation, yet studies of selective serotonin reuptake inhibitor (SSRI) medication have produced conflicting results, so as yet no medication protocol for this system exists.

The glutamate neurotransmitter system appears connected to dissociation in the brain, but studies of this are even less conclusive than those of the opioid and serotonin systems.

At this point, research in all these systems is ongoing, and outcomes can only be speculated about.

Psychotherapeutic treatment of DID is clearly successful, but not equally for everyone. Improvement in psychotherapy effectiveness and in medication support for such therapy may well come from improved understanding of the neurological foundations of dissociation.

Study of two brain regions normally active and well integrated in the management of emotion and arousal (level of activity in the brain) has suggested that dissociation may arise from overly reduced levels of activity in either or both regions. These reduced levels can occur for various reasons, and both have been found in PTSD and DID.

A different body of research suggests that increased activity in brain regions involved in thinking and decision-making are significant in dissociation, with such activity leading to an over-internalization of stress responses that, while adaptive in childhood, are dysfunctional in adult life.

DID. as a consequence for vulnerable children subjected to childhood maltreatment, is more than adequately documented. This view has no empirically supported competitors.

Validation of phased outpatient treatment of DID is similarly well-documented, and research focused both on treatment process and outcome is active and ongoing.

The expert authors of this review believe that societal acceptance of dissociative identity disorder stems from reluctance to accept the reality of its cause: severe chronic child abuse.

This has led to neglect of the gravely affected children and adults, and neglect of the diagnosis, both in research in clinical training and treatment.

With the reality of DID now firmly established, the focus has shifted to emerging and ongoing research and clinical work on dissociation and its management and treatment. New intervention procedures involving somatic awareness and using hypnosis to affect neural network communications are promising new avenues for improved treatment outcomes.

Another promising approach to improving treatment outcomes is the explicit inclusion of those “…with lived experience in the design, planning, and interpretation of research investigations.” Empowering these individuals invigorates all concerned, providing new feedback and essential information for research and application.

One major outcome of this involvement of those with “lived experience” has been validation of the usefulness of knowledge of the neurobiological aspects of DID: “Knowing DID has robust neurobiological correlates validated and normalized their experience in a landscape of doubt from family, friends, and health care professionals.”

This is an exciting and hope-filled time for all participants in the DID-treatment community. DID today is where PTSD was in the 1970s: emerging from a period of denial, doubt, and confusion to establish a solidly grounded view of the etiology, dynamics, and best-practices treatment that can be used to improve the lives of millions of people.

Notes ^

  1. This is what makes psychotherapy for DID possible! ^

 

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