Environmental. Interpersonal physical and sexual abuse is associated with an increased risk of dissociative identity disorder. Prevalence of childhood abuse and neglect in the
United States, Canada, and Europe among those with the disorder is about 90%. Other forms of traumatizing experiences, including childhood medical and surgical procedures, war, childhood prostitution, and terrorism, have been reported.
Course modifiers. Ongoing abuse, later-life retraumatization, comorbidity with mental disorders, severe medical illness, and delay in appropriate treatment are associated with poorer prognosis.
Many features of dissociative identity disorder can be inﬂuenced by the individual’s cul- tural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non—epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the characteristics of the other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession- sion states in that the former is involuntary, distressing, uncontrollable, and often recur- rent or persistent; involves conﬂict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion.
Females with dissociative identity disorder predominate in adult clinical settings but not in child clinical settings. Adult males with dissociative identity disorder may deny their symptoms and trauma histories, and this can lead to elevated rates of false negative di- agnosis. Females with dissociative identity disorder present more frequently with acute dissociative states (e.g., ﬂashbacks, amnesia, fugue, functional neurological [conversion] symptoms, hallucinations, self—mutilation). Males commonly exhibit more criminal or vi— olent behavior than females; among males, common triggers of acute dissociative states in- clude combat, prison conditions, and physical or sexual assaults.
Over 70% of outpatients with dissociative identity disorder have attempted suicide; mul- tiple attempts are common, and other self-injurious behavior is frequent. Assessment of suicide risk may be complicated when there is amnesia for past suicidal behavior or when the presenting identity does not feel suicidal and is unaware that other dissociated iden- tities do.
Impairment varies widely, from apparently minimal (e.g., in high-functioning profession- als) to profound. Regardless of level of disability, individuals with dissociative identity disorder commonly minimize the impact of their dissociative and posttraumatic symp- toms. The symptoms of higher-functioning individuals may impair their relational, mar- ital, family, and parenting functions more than their occupational and professional life (although the latter also may be affected). With appropriate treatment, many impaired in- dividuals show marked improvement in occupational and personal functioning. How- ever, some remain highly impaired in most activities of living. These individuals may only respond to treatment very slowly, with gradual reduction in or improved tolerance of their dissociative and posttraumatic symptoms. Long-term supportive treatment may slowly increase these individuals’ ability to manage their symptoms and decrease use of more restrictive levels of care.
Other specified dissociative disorder. The core of dissociative identity disorder is the division of identity, with recurrent disruption of conscious functioning and sense of self.
This central feature is shared with one form of other specified dissociative disorder, which may be distinguished from dissociative identity disorder by the presence of chronic or re- disorder or are not accompanied by recurrent amnesia.
Major depressive disorder. Individuals with dissociative identity disorder are often de- pressed, and their symptoms may appear to meet the criteria for a major depressive episode.