David Yeung's Blog

Dissociative Identity Disorder (“DID”) is a condition found all over the world with a prevalence rate of around 1%. It is often denigrated by being characterized as a North American Disorder, out of ignorance and prejudice but rate at which it exists is irrespective of culture and exposure to North American influence. 

I am a retired psychiatrist, having practiced psychiatry in three continents. I have written a four volume series on DID.   Since my retirement, I have formed the habit of asking all newly graduated psychiatrists I meet of their experience with this disorder. As it is statistically more common than schizophrenia, the answers always shock me. That these newly qualified doctors have usually only seen one or two cases of these patients, if any, in their entire medical training!   The only possible explanations I can think of are:

[1] These cases are indeed extremely rare, and that the medical statistic of more than 1% is wrong; or

[2] These cases are generally missed by the medical profession in the initial diagnostic stages.

The most common misunderstanding about dissociative identity disorders is the belief of some that people fake DID symptoms to avoid the consequences of illegal actions, e.g., “I am not responsible for shoplifting because it was my other personality.”

In my own experience, I have missed a lot of such cases and misdiagnosed them as patients suffering from depression.   Only when I have given them time and patience listening, I can come to the correct diagnosis.  In most cases, they resist coming to accept such a diagnosis because it is an unpleasant diagnosis, when instead of having one unitary personality, there are fractured selves, mostly hidden inside, who feel strongly that they are also occupying the same body.   Just imagine how unpalatable it would be to find out that there is another “self” sharing this body of yours and may take over the time, such as going out to spend the night when what you want is to go to bed and rest. 

Yes, one must pay attention to the context.  When a patient sees a psychiatrist, it is usually when they need some help in figuring out why they are feeling a certain way that they find unpleasant or painful.    Under very rare conditions, a patient goes to a psychiatrist looking for an excuse, faking symptoms to avoid the consequences of illegal actions, to get off being punished. 

In my 40 years of clinical experience I have never encountered such a case. Granted I am not working as a forensic psychiatrist but I have seen many cases and written forensic reports which patients could have faked symptoms to escape consequences of wrong doing.  

[3]   Actually in most cases, when a doctor sees a patient for the first time, usually within an hour, the diagnosis will be apparent.  In their board examinations, as in oral examinations, a candidate usually is given an hour to see a patient. The candidate is then expected to write a report including a diagnosis, and differential diagnosis (other potential diagnoses) pending on blood work and/ or other laboratory findings such as X-rays to confirm the diagnosis.  In other words, usually within the first visit, a doctor should have some idea what is wrong with the patient. 

However, in the case of some suffering from DID, most of the symptoms can be hidden. The patient may not be able to talk about or expose those hidden symptoms before a trusting therapeutic alliance is established.   Or some alters may have a deep suspicion and prevent the host from divulging any telltale symptoms to the doctor.  In other words, the patient may be resisting telling the truth because of a dissociative part acting in a self-protecting way. DID patients usually have a highly traumatized background.

Usually, the patient has some strongly mistrustful alter safeguarding what that alter considers secrets too important to expose.   Why would such an alter prevent exposure of those secrets? Consider that early childhood trauma usually includes betrayal by the abuser, denial by the abuser and others of the trauma itself, and misuse of the abuse disclosure that leads to further abuse. It is critically important to always remember that when seeing a patient for assessment, the patient also has parts inside assessing the therapist, to determine whether such person would be safe enough to be entrusted with that vital information’s. In meeting a DID patient, the therapist is meeting a group instead of meeting a single individual, even if only one personality appears to be present.

Dr. Frank Putnam, a notable psychiatrist who authored significant works on Dissociative Identity Disorder (DID) identified the long diagnostic delays (often 5-12 years) associated with the disorder. Using questionnaires is well known to expedite the diagnosis.   However, this method has not been universally adopted to arrive at a more rapid and more correct diagnosis by doctors and psychiatrists.  Many psychiatrists may be less familiar with these specialized assessment tools. 

There is a serious communication problem between psychiatrists and psychologists.  But that is another story outside the scope of this article.   

My conclusion, therefore, is that the real reason for such low cases of dissociative identity disorder encountered by medical students and medical doctors, including psychiatrists, is due to such cases being missed, misdiagnosed for depression, bipolar depression and personality disorder (mostly borderline personality disorder)

The follow is a clear information sheet that most front line doctors should read to remind themselves: 

https://journals.lww.com/hrpjournal/fulltext/2016/07000/separating_fact_from_fiction__an_empirical.2.aspx

The post Why Psychiatrists Miss (and Misdiagnose) DID appeared first on Engaging Multiple Personalities.

Panic attacks are always accompanied by intense fear.  Intense fear is appropriate if you come upon a cougar on your jogging route. But if your heart pounds with fear with no obvious explanation, it is most likely a panic attack. 

Where does such an unexplained fear come from?  For those who have experienced trauma, it comes from some past experience that involved both a loss of control and the feeling of intense fear in your body. 

Essentially, a panic attack is being out of sync with your here and now bodily reality.  Grounding is the best way to redirect your body to reconnect to the reality of the here and now.  For example, if you are sitting in the quiet environment of my office, in a temperature and humidity controlled building, when all is peaceful in the city, then why are you responding as if you are facing a life threatening cougar?   

This response to past trauma does not mean you are crazy. You are simply re-experiencing a physiological memory of past traumas that have not been processed and healed. It is important to realize re-traumatizing triggers generate panic that engenders a self-perpetuating feedback loop that sustains, reinforces, and maintains itself.  Efforts made to calm down often make it worse. “Try to relax” is the most ineffective instruction one can make to a person in a panic!  Yet I am sure we all have heard that, from friends as well as therapists with good intentions.   Fighting to calm down is a contradiction. One cannot calm down through struggle. 

One heals by practicing how to step beyond the panic by learning to redirect and return yourself to the reality of the here and now. Redirect your attention by focusing on what you see, hear, taste, smell and touch rather than struggling within yourself to relax.  

In past posts, I have focused on physical techniques to step beyond the panic. They are based on using your own body to reclaim the present.

At https://www.youtube.com/watch?v=30VMIEmA114, there is a guided approach to grounding. It is similar to what I often used with patients in my office psychiatric practice. It is not something I was always confident that my DID patients could do on their own at home – hence the physical exercises I recommended to them and included in earlier posts.

Nevertheless, for many people, this additional grounding approach may be of benefit. It uses attention to the five senses. Name out loud:

1.  What you see—a wall, a lamp, a few pictures, a vase of flowers…

2.  What you hear—-the humming of the traffic outside the building, the clock tickling…

3.  What you taste—-the sweetness of your iced tea or the aftertaste of your coffee…

4.  What you smell— whether it is unpleasant or pleasant…

5.  What you feel through touch—-The gentle pressure of your bottom on the chair seat or the weight of your hands resting on the arm rest…

With this exercise, you establish your capacity to return yourself to the experience of the here and now. This grounding is accomplished by reconnecting with each of your sense perceptions at this very moment.

This sequence does not include a question of emotion, like “What do you feel?” Why? You already know that you are feeling panic. Panic is an emotion, not a sense perception. It is not a sensation your body experiences directly when you interact with the physical world. Make sure to ground yourself through the power of to your bodily experience of seeing, hearing smelling, tasting and touching.

What is most precious about this is that you are doing it all by yourself. It is a foundation for establishing the confidence that you already have the capacity to move beyond the panic. You have the power to do this without relying on hypnosis by a therapist, a medication, or any other external source.  The only input is your own sense perception, one by one. 

This is empowerment — the best therapy. 

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Part 5: Recommendations

Diagnosis of DID is very rarely made on the first encounter between the clinician and the patient. Remember that depression is found in almost every patient walking into a psychiatrist’s office seeking help! We must distinguish between depression as a complaint/symptom and depression that is a disorder responsive to antidepressants.  The distinction is not easy and is often left to the psychiatrist’s own discretion or bias. 

Because of this, I cannot overemphasize ensuring that you maintain an appropriate diagnostic index of suspicion when meeting with patients.

Popular books and movies such as the three faces of Eve, Sybil, and the United States of Tara have given the public the wrong impression of DID.  Further, DID has suffered a great deal of negative publicity which negative publicity was promoted through litigation involving the now defunct False Memory Foundation. While I am happy that such Foundation is no longer operating, the negativity and doubt it sought to promote continues to impact acknowledgment of DID. The inclusion of the word “controversial” in news reports about DID is a most unfortunate artifact of those efforts.

For example, the incidence of incest was grossly under-estimated for decades until a study reported in a 1988 study in Finland about incest.   Girls reported incest experiences with their biological father at a rate of 0.2% and while girls living with a stepfather reported a rate of 3.7%. This is much more realistic than the extremely low figure often quoted for generations in psychiatry before. Bessel Van der Kolk and Judith Herman have written on childhood trauma in ways that opened the eyes of society to the impact of trauma which has been grossly neglected for years.   It is time for psychiatrists to wake up and reconsider the role of childhood trauma in every patient we encounter. 

We must continue to push back against the notion that DID is a controversy because it isn’t. DID is a condition that results in much dysfunction, pain and suffering. But because we are drawn to the dramatic, in movies and books, we have forgotten the tragic aspect of the human suffering in living breathing people who have experienced or are experiencing DID. 

Therapeutic training must include understanding both the incidence and the etiology of trauma and dissociation. In other words, pay attention to the symptoms of early childhood trauma. No fancy drama details are needed to assess the condition. Just pay attention.

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Part 4 The Error of the Medical Model in Diagnosis

Severe early childhood trauma is the etiology of DID. This does not fit in well with the traditional medical model of disease, particularly as ossified in the pharmacological approach to mental health. 

In the medical model, one follows the procedure of eliciting symptoms and signs. For most illnesses, one is aided by laboratory findings such as blood work, x-rays, MRI, CT scan. Using those tools, one comes to a diagnosis, usually within a definite period of time starting from the same day of consultation to a week or so of waiting for the results of investigations. Using that medical model, coupled with the pharmacological and sometimes surgical views of treating illness, is important when dealing with physical illnesses.

Unfortunately, based on the pervasiveness of that model coupled with the promotion of pharmacological interventions for treating mental health issues, the clinician isolates and focuses in on symptoms that are treatable with medication. The result is that anxiety, depression and so on are identified as the illness without further exploration. As noted above, these symptoms are descriptive only. The medication is applied to the description, not necessarily to the illness.

In DID, the diagnostician is faced with a chaotic fractured mind, with a one part generally presenting as the patient, usually identified as the “front” or “host.”  There is likely varying degrees of amnestic barriers between the separated parts. In most cases, the host has no awareness of the presence of “alters” and comes for therapy to deal with symptoms like depression and anxiety. Sometimes, they will also identify “time loss” as a confusing aspect of their life.

It is in the nature of the pathology that the host, as well as the individual alters, just think of themselves. The host is oblivious to the presence of the others. While the others, the alters, are often aware of the host but just as often dismissive of the host and the other alters.  It is also in the nature of the pathology that there will likely be some protective ones who are concerned about the therapist or even engaging in therapy.

Why would this happen? The concern is quite rationale. It is because therapy grants the therapist a position of power in the situation. The concern of the protective alters is that the therapist has the potential to use that power in a way hostile to the alters. After all, the therapist may be just another one of the serial abusers the system has encountered in life. Therefore, protective alters often regard the therapist as an unwelcome potential enemy.  They will be the very first to resist the probing nature of the therapist’s “interference” and test the therapist before, during, and even after allowing any genuine communication.

To approach a potential DID patient for a diagnostic assessment interview, one must be aware of all these different sets of conditions.   It is no wonder that a novice clinician will often be at a loss in proceeding. The novice may seize upon the first symptom of depression, feeling relieved that they have found a diagnosis. They are satisfied with that initial diagnosis and are now – rightly or wrongly – able to prescribe medication. 

This is a very common bias in the psychiatric field. In fact, most of the missed cases of DID referred to me by colleagues were individuals misdiagnosed who were labeled as suffering from “Treatment Resistant Depression.”  This misnomer, Treatment Resistant Depression, should have been seen as a giant red flag that the underlying problem that kept provoking the depression was not being treated by the medication. It wasn’t that the depression was resistant to treatment, it was that the treatment was medication prescribed based on a misdiagnosis.

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Part 3 Healing Past Trauma. 

Just knowing that trauma is frequently the real issue underlying their individual issues does not mean that there are easy solutions for trauma survivors.   Trauma is not something that one can easily elicit and heal.  The first step is to avoid quick solutions that seek temporary symptomatic relief and allows one to confuse symptomatic relief with actual healing.

[1]   Do not jump to a quick diagnosis of anxiety and depression as the reason why many are dysfunctional and disabled. This drive to immediately diagnose a patient is a mistake and dangerous.

Why? It cuts off considering other potential causes that should be on your index of suspicion. Your training should have included the fact that anxiety and depression are not necessarily the disorder. Rather, they can be mere manifestations of the underlying pain and suffering from past trauma.  

As therapists, we cannot simply ask, “Did you experience trauma when you were little?” and expect an accurate response. But this question is something for therapists to keep in mind. The answer requires patience and human contact to elicit. But no clarifying answer will be put forward unless and until a genuine therapeutic alliance is established. 

Without the time and effort needed to establish a genuine therapeutic alliance, it is no wonder that a person suffering from unresolved early childhood trauma gets diagnosed with an anxiety disorder, panic and/or depression.  Diagnosing those symptoms as a disorder is not appropriate without exploring whether they are a disorder or merely symptoms of a different disorder – such as DID. Do not confuse symptoms which are mere descriptions of how the patient feels because while descriptive, they do not clarify the etiology. Giving the patient pills to relieve these symptoms without confirming the etiology is like giving aspirin to lower a fever without checking to see if there is an underlying infection in need of antibiotic treatment.

[2]    The mind, confronted with something uncontrollable, terrifying, and overwhelming, seeks escape from the experience. When one cannot escape the situation, the mind can fracture so that while part of it remains trapped with the body in the experience, part continues as if the experience is happening elsewhere, to someone else.  It is why the natural (and likely solely available) defense of dissociation kicks in. 

Repeated psychological trauma results in this becoming a habit to cope with the ongoing trauma pattern.  Typically, the split off part says, “This is not happening to me. It is only happening to someone else so it is no concern of mine.”  This should be understood to be an uncontrollable response that encourages, if not solidifies, the creation of alters as well as the amnestic barriers that are the hallmarks of DID.

[3]   Very often the clinician compares their own life experiences with those they hear from the client. While understandable in some contexts, there is an enormous therapeutic danger in concluding that what the client experienced was “no big deal.” It is made easier then the therapist believes that the description they have been given by their patient is accurate both as to content and depth. With that, they fall prey to their own misguided assumptions.

No trauma patient would describe their original trauma(s) in the kind of detail that would overcome such an assumption without a firm and deep therapeutic alliance. It may simply too terrifying to describe. The risk of re-traumatization is too great to try to demand such a thing from a patient.

I will point out from my own experience. Having treated one particular patient for many months, details of an early traumatic experience exploded out of the patient one session. The details still leave me overwhelmed and speechless when I think about that patient. When you are so privileged, through the trust of a genuine deep therapeutic alliance such that your patient is able to share their experience with such immediacy, it jolts you to get a true glimpse of the depth of their trauma experience. It is also why I warn therapists of the very real impact of vicarious trauma, of the need to care for oneself when treating individuals with such intense childhood trauma.

[4]   No two experiences are the same.   

Different people react to distress differently.  Some are remarkably resilient and are able to bounce back. Others are crushed under its weight. Sometimes having a sympathetic bystander helps to ease the pain of feeling hopelessly alone.  At the same time, two soldiers pinned down in a fox hole by gun fire may result in only one having severe PTSD decades later, while the other is able to move on.

This is particularly noteworthy as it is sometimes the case that a victim who feels supported and loved by a caretaker can recover from almost any psychological trauma. With a loving caretaker, many of them can survive the trauma without permanent damage.  When an infant, toddler or small child is abused by the caretaker, without support he/she will feel utterly vulnerable and alone – because they are!  It is both simplistic and callous to say that what a patient experienced as trauma is commonplace and should not produce irreparable damage.  The extent of damage depends on many other factors, including the repetition of the trauma itself or of a like trauma.   

[5]   Clinicians often have the outmoded belief that the past should be forgotten. They say that it is only with one’s eyes facing forward to the future, can one start taking the next step forward.    This is a very common belief, and I have come across well qualified teachers and people of responsible position who utter this view.   While it may be helpful for people moving past ordinary setbacks, it ignores the fact that trauma, particularly repeated trauma, often leaves the victim with symptoms, without accessible explicit memory, and no understanding of how to work with the trauma and its effects.   

Dissociation is a hallmark of many trauma victims. They may have hazy memories or even complete amnesia. This is why it is said that trauma leaves us with symptoms rather than memories.  When trauma survivors are triggered, regardless of the clarity or accessibility of their memory, their nervous system literally re-experiences the trauma. This re-traumatization that further undermines even a tentative feeling of safety.

[6]   Dissociation is a phenomenon that stretches on a spectrum from normality to abnormality.   Dr. David Spiegel, author of Dissociation: Culture, Mind, and Body, once said, “I certainly hope my surgeon can dissociate when he operates on me.”  Why would he say that? Well, one hopes one’s surgeon will concentrate on the operation rather than being distracted by some unpleasant domestic upheaval at home. Concentration itself often involves dissociation.  

This mixing of normal and abnormal dissociation has confused many clinicians who have a simplistic black and white view of dissociation.   Dissociation in the DID patient is the creation of amnestic barriers between parts of the fractured self. It arises to wall off unacceptable and immensely painful past experiences of trauma and abuse.   Dissociation is an effective response to trauma that is embedded in the human mind. It should be clear that DID is not controversial.   The only thing controversial is why therapists hold on to a mistaken view of the dissociative pathology in DID.  

[7]   For therapists, particularly psychiatrists, who say that they have never seen a case of DID, I suggest that they are wrong. According to studies, schizophrenia has about the same incidence in the population as DID. In my own practice, looking back at my early years as a psychiatrist, there were most certainly DID cases that I missed. I believe I missed them at the time because my training included the guidance that DID was so rare I would likely never see it in my practice. So, for many years, DID was not included in my index of suspicion despite the presentation of dissociative symptoms in patients.

Putnam, author of the first text book on MPD wrote, “We (Putnam et al., 1986) found the median length of time in treatment with the therapist who made the diagnosis of MPD was 6 months after initial presentation, with a number of cases continuing for several years before a diagnosis was made.”  These psychiatrists with a special interest in MPD (now termed DID) and who still took an average of 6 months to come to their diagnosis. 

It is no wonder so many psychiatrists say that they have never seen a case of DID. They have likely indeed seen DID but simply didn’t recognize what they were seeing!

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Part 2: Characteristics of Trauma

Van der Kolk describes the characteristics of psychological trauma as damage from uncontrollable, terrifying, and overwhelming life events. 

Uncontrollable means that it is outside of one’s power even to confront.  The prevailing feeling is one of helplessness, a hallmark of anxiety.

Terrifying means that there is nowhere to run, no escape. Therefore, when a memory of the experience is triggered, the terror returns in a re-traumatizing flashback occurs, a re-experiencing of the physiological and psychological state of the original trauma. 

Overwhelming means that it sweeps over one’s ego and emotional defenses like a tsunami, irresistible; undermining the very foundational experience of feeling safe. 

Those dealing with trauma victims are frequently pressured into a simplistic analysis in trying to triage these individuals.  This happens due to the constraints of limited financial and emotional support both for victims and for those working on the front lines. This is true for working with individuals are trapped in their family enclave. It is also true in large scale social enclaves, such the victims of past trauma found en masse in the Skid row areas of every major city.   They include the disenfranchised sleeping on the streets as well as alcoholics, drug addicts and prostitutes selling their bodies to maintain their drug dependency. 

Substance abuse, moral degeneration and social breakdown of cpmmunities of marginalized people, and chronic mental disorder is usually blamed for the groups of street people in the cities.  This is a simplistic and convenient explanation which is neither helpful nor all that accurate.  Paying even a little attention to the individuals in these groups, one sees that many share a common background: They have been traumatized from early childhood. What they need is treatment for their trauma. Without that, attempts made to cure their depression, or treat their violence, alcohol and drug addiction issues, will likely fail.  

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PART 1 – Introduction

It has taken a long tortuous path for the therapeutic community to recognize the true impact of psychological trauma on mental health.  For centuries, psychological trauma has received some attention but that attention has always been capricious rather than sustained.  Despite its documented history – extensively in wartime – it was not until 1980 that the American Psychological Association included PTSD in its Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) for mental health practitioners

A naturally resilient child who is loved and supported by at least one primary caregiver, can often recover from an individual traumatic experience. Permanent damage is the likely result of ongoing domestic violence, corporal punishment, sibling tormentors, teasing, humiliation, and physical threats.  While emotional deprivation and humiliation are frequently ignored as issues, but these may constitute serious trauma.

Sexual violation can be perpetuated by immediate as well as extended family members like uncles and grandparents. People close to the family or child, such as so-called friends, ministers, teachers and others may be abusers.   We cannot afford to be so naive as to overlook such possibilities. 

But given the depth of its impact, why is trauma so often overlooked? 

Simply speaking, we often close our eyes to ugly facts of life. We keep them closed until we are absolutely unable to do so anymore.   Whether the result of natural occurrences or from human evil acts, trauma inflicted on children is a topic most people wish to ignore, forget, or deny that it ever happens – certain that it would never happen in their family or community.  

There remains the tendency to ignore, leave out of our consciousness or deny even sweeping acts of atrocity such as the Holocaust, the Nanjing massacres, or the Pol Pot’s Cambodian massacre.  While we sometimes can include our shock at the torturing of children or at domestic violence, the practice of genital mutilation in certain culture and incest, this is usually limited to the generalities of the topic rather than the horror of individual cases. This enables us to insulate ourselves from the reflected pain of such an experience, to limit our empathy to the conceptual rather than experiential.

When such topics are avoided or minimized individually as well as by society, they are more easily excluded from our index of suspicion in clinical diagnostic settings.

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As I have repeatedly pointed out in my blog and books, DID is a severe disorder affecting between 1 to 1.5% of the general population. According to a 2023 summary article concerning French psychiatrists’ views of DID, https://www.medscape.com/viewarticle/988814#vp_2, about 50% of psychiatrists in France have strong doubts about whether DID exists or not, despite their awareness that it is included in DSM-5.

According to this article, even though ½ of the psychiatrists have strong doubts about DID, 80% of them do not believe that patients are pretending or faking symptoms. This is at least one step in the right direction. It means that at among group participating in this French study, the odds are in favor of someone with DID meeting a psychiatrist who will not automatically deny their symptoms. Given that the initial barrier to any therapeutic alliance arises when a patient feels that the psychiatrist does not believe them, this is positive news.

The more that DID individuals engage with psychiatrists who are take their symptoms seriously, the more quickly DID will become acknowledged to be as common as schizophrenia rather than be seen as a rare disorder. If 50% of the psychiatrists in a country understand that DID is a legitimate diagnosis per DSM-5, the odds are so much better than in the past that a patient will find a psychiatrist that at least has DID in his/her index of suspicion for diagnoses. Again, positive news.

It is instructive that over 60% of those psychiatrists stated that they had not been trained regarding dissociative disorders. Of those that were, 37% said that they had educated themselves. This is another step in the right direction. It implies that a fair percentage of psychiatrists are 1) paying attention to their patients that present with dissociative symptoms; and 2) taking it seriously enough to educate themselves for the benefit of those patients.

It seems that the idea of multiple personalities is a distraction for many psychiatrists. Those who deny DID as a proper diagnostic entry in the DSM-5 often see it as good material for movies but not part of a patient profile that they would ever see or engage. For those psychiatrists, I would urge them to forget what they see as drama, and deal with the underlying trauma. Trauma is the issue. Perhaps we should consider changing the diagnostic, Dissociative Identity Disorder, to Complex PTSD with dissociation in the next DSM. Maybe something as simple as changing the name of the diagnosis would bypass the issue of psychiatrists being distracted and/or unwilling to acknowledge the dissociation that presents as alters or parts. With a name change like this, psychiatrists can treat the trauma and related dissociation in patients without having to worry about being seen by other psychiatrists as having committed a belief in the reality of alters before treating dissociative patients.

DID is basically a complex PTSD problem. When viewed through that lens, it is possible that psychiatrists, even those uncomfortable with the idea of DID, will be open to treating the trauma. And treating the trauma leads to healing. So maybe for those psychiatrists, it would be easier for them to treat DID if they see and identify it as Complex PTSD with dissociation! A label like that would not trigger the confusion that movies have caused in some psychiatrists, giving them license to see it is a scriptwriter’s (or patient’s) fantasy.

As an explanation for why so many in psychiatry continue to dismiss DID, the author of the study quotes Goethe: “You only see what you know.” Bluntly speaking, most DID patients present initially with depression – a known mental health issue with several readily available pharmaceutical treatment protocols. Because of this, many DID cases are missed. They are dismissed as depression and treated with pharmaceuticals. Remember the Goethe quote as to why this happens. The psychiatrists “know” depression; they do not know DID. Even better from their point of view, it is quick and easy to write a prescription.

One red flag that this mistaken approach raises is when the pharmaceutical treatment fails. Instead of acknowledging that the pharmaceutical treatment failure might indicate that the simplistic diagnosis of depression is incorrect, patients are given a different prescription medication. This can happen repeatedly, on and on, until the diagnosis is “refined” to be labeled “treatment resistant depression.”

Once the patient is diagnosed as having treatment resistant depression, the psychiatrist fails to examine the initial diagnostic assumption because this new diagnosis, as it says in the name, acknowledges the depression and identifies it as immovable. In short, such a psychiatrist has abdicated his responsibility to re-examine his diagnostic assumptions. With that abdication, etiology of DID – early childhood trauma – may never be identified. In that event, treatment will lack the key reference point of the need to address the early childhood trauma.

As I have noted before, this ignorance of DID generates a massive loss to individuals, families and society, in addition to major financial losses. Think of pain and suffering that continues for everyone whose lives are touched by DID as well as the money wasted on misdiagnosing a disorder that affects 1% to 1.5% of the population.

But let’s end on a positive note. The study indicates that 50% of the psychiatrists in the French study acknowledge DID, 37% of those have taken it upon themselves to learn about DID. These are beginning milestones that hopefully will spread to the psychiatrists in other countries.

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Once the extraordinary difficulties of veterans who returned from the Viet Nam war could no longer be denied, PTSD was formally included in the DSM classification. Although trauma was still not fully defined, awareness of trauma entered the public consciousness. However, generally speaking, early childhood trauma was neither clearly recognized nor on most psychiatrist’s index of suspicion with patients in difficulty.

Before 1980, trauma-induced disability was generally limited to obvious trauma inflicted on the battlefield. It was labeled as “effort syndrome,” “soldier’s heart,” “shell shock,” and “war neurosis.” Subsequently, significant trauma in civilian life arising from natural disasters was seen as an acceptable use of the PTSD label. However, most therapists’ index of suspicion in considering diagnoses failed to include early childhood trauma related to family violence, parental/caretakers’ abuse and neglect, failure of attachment, and other overwhelming life- threatening experiences.

There is no doubt that we are affected by our past. Sunny optimistic personalities usually can be traced to an early life of love and nurture, like a seedling growing in a protective and nurturing environment. Sour and mistrustful personalities carrying behaviors that sabotage both intimate and other social relationships can often be traced to active abuse or a severe absence of love and care by the individual’s primary caretakers.

In these ways, people can be primed to become warm and happy individuals or cold, angry or depressed individuals. This happens in varying degrees across the spectrum throughout the general population. But, some individuals may be traumatized so early and so deeply as to end up with the extreme consequence of Dissociative Identity Disorder. They present as different identities depending on the which triggers they encounter as they move through their life situations.

Adverse childhood experiences that have not healed continue to impact individuals well into their adulthood. Trauma is not something that one just “grows out of.” Rather, it continues throughout and even to the end of one’s life journey. The result of such intensely negative experiences, left un-countered by nurturing warmth, is that individuals develop protective armor. This armor develops in order to potential recurrences of negativity from getting too close.

Protective armor is not always bad. It is the basis for the ordinary vigilance one needs to navigate one’s world – like looking both ways before crossing a street. But, when that protective armor hypervigilantly raised up all the time and cannot ever be relaxed, it keeps one isolated from others. This hypervigilance undermines the ability to perceive and correctly analyze potential threats, or lack thereof, from another person. It often cuts off the healing qualities of a supportive nurturing relationship by preventing anyone from ever getting close enough to cause harm in that same intimately familiar way.

Many traumatized individuals spend a large part of their life unhappy, prevented from achieving their full potential because of unprocessed past trauma. Many continue causing pain and suffering to their significant others, their next generations, and to people at large that they encounter. Many such people operate camouflaged under the cover of financial success and/or professional status. Reading news reports and interviews with celebrated successful people, we are often surprised to find that the external appearance of success masks their private burden, and sometimes hell, of unprocessed trauma.

While most people presume that the majority of people are not operating out of the impact of trauma, statistics betray the prevalence of debilitating results arising from negative life experiences. I suggest that these numbers may be directly and/or indirectly related to unprocessed early trauma.

Look at the number of adult individuals in developed countries who are prescribed pharmaceuticals for anxiety and depression, plus the almost normalized alcohol drinking social “norm” in those countries. Then, examine the incidence of family violence, or the figures on the use of comfort foods, with their consequence of gross obesity and/or Type 2 diabetes. These highlight how much time, energy, and money are spent on toxic self-soothing activities.

One might reasonably conclude that most people are engaged in that kind of self-soothing rather than actually enjoying life. Look at how advertising works. All of those smiling actors with 6 pack abs downing in the ads beer or eating chips infer that you too could be happy just like those smiling actors if only you were drinking and eating high salt/high sugar snacks. It is a mass market deception.

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It is my experience, personally and with patients, that time does not necessarily heal trauma. Even after I retired as a psychiatrist, I continue to encounter elderly individuals still struggling to free themselves from the ravages of their past. Granted that my encounters are, effectively, an extremely limited anecdotal study, but I do not see another explanation for people in their 80s and 90s still tormented by nightmares linked to their memories.

A friend’s 95 year-old mother, on her deathbed, was terrified that there were people just outside her door trying to break in to harm her. One might see this as a case of psychotic delusion commonly found in confused patients with a failing brain. That could well be the first diagnostic impression based on a therapist’s customary index of suspicion. Most doctors would think she was paranoid or trapped in dementia.

But, within the family it was known that she went through traumatic war-time experiences in the 1940s, few therapists would consider this fear as a flashback given that it happened 70s years before. Rather than being given anti-psychotic medication and sedatives as part of her dying process, she needed reassurance that she was safe now – not that she was crazy. Speaking to her softly, reassuring her that she was not alone, that she was safe and protected right now. Simply holding her hand for a while would probably work better at relieving her anxiety than giving her a chemical cocktail.

Past trauma lingers in our neuro-circuitry for decades, and continues to affect our present well-being. This is something people dealing with DID, PTSD and other trauma disorders are experiencing all the time. It is important for all therapists, family members, and caring individuals to keep this in mind.

Trauma has to be properly processed to eliminate its malignant effects. Without that, neither a successful career nor financial security guarantees that one will be free from a private hell of anxiety or depression. The goal in therapy is not to deny, suppress or ignore the past but rather to be able to live without experiencing life as solely a terrible ongoing struggle.

So, is it possible to have some relatively simple and practical guidelines for the majority of the populace to improve their life by processing and overcoming early childhood negative experiences? There are a myriad of books and articles promoting hundreds of methods promising to rectify the impacts of negative childhood experiences. It is easy to become confused in the jungle of information, misinformation, and the latest highly promoted miracle cures. First, there is no miracle cure. Second, there is certainly no “one size fits all” cure. Third, processing trauma is difficult long-term work.

Addressing the impact of early childhood negative experiences is not easy, because the root causes are so personal. Depending on how early they occur, how often they are repeated, the relationship with the perpetrator, and how long abuse continues will determine how closely bound the trauma is into our psyche, into our sense of who we are.

Some people may find answers they need solely through their own life experience. Some may find solace in their spiritual experience. Yet many remain stuck in their pain. For many, what seems an unwillingness to pursue healing, is actually the impact of the powerful inertia to continue in the same ways with familiar pain, rather than do the hard work to heal that often provokes fears that these is unknown pain waiting in ambush for anyone daring to try to heal from their trauma.

I know people who have reached full adulthood, including those who are objectively old such as my peers in retirement, who have yet to find any sense of safety or peace because of early childhood trauma. Do not be fooled: You are not alone in your experience. It is not that you have failed and everyone else you see is filled with joy. Have confidence that while people display their brand name clothes, their expensive cars, and their elegant cruises, many remaining trapped on the inside – unable to escape the impact of the early trauma.

I find the following 3 books to be helpful reference sources for therapists who wish to deepen their understanding of trauma. Much of this article comes from insights found in these books.

[1] Dr. Judith Herman, in her seminal work Trauma and Recovery (1992), presented treatment in a phase oriented way. Herman (1992) emphasized that the treatment of complex trauma has to take place in predictable stages.

[2] Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society (1996) by Bessel A. Van der Kolk , Alexander McFarlane & Lars Weisaeth.

[3] Trauma Model Therapy (2009) by Colin Ross and Naomi Halpern — mainly involving treatment of DID.

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