fpsyg-12-637929 May 4, 2021 Time: 14:6 # 1
published: 06 May 2021
Laureate Institute for Brain Research,
Hosein Mohaddes Ardabili,
Mashhad University of Medical
Psychiatry Region Zealand, Denmark
Igor Jacob Pietkiewicz
This article was submitted to
a section of the journal
Frontiers in Psychology
Received: 04 December 2020
Accepted: 14 April 2021
Published: 06 May 2021
Pietkiewicz IJ, Ba ´
Tomalski R and Boon S (2021)
Revisiting False-Positive and Imitated
Dissociative Identity Disorder.
Front. Psychol. 12:637929.
Revisiting False-Positive and
Imitated Dissociative Identity
Igor Jacob Pietkiewicz*, Anna Ba ´
nbura-Nowak, Radosław Tomalski and Suzette Boon
Research Centre for Trauma & Dissociation, SWPS University of Social Sciences and Humanities, Katowice, Poland
ICD-10 and DSM-5 do not provide clear diagnosing guidelines for DID, making it
difﬁcult to distinguish ‘genuine’ DID from imitated or false-positive cases. This study
explores meaning which patients with false-positive or imitated DID attributed to their
diagnosis. 85 people who reported elevated levels of dissociative symptoms in SDQ-
20 participated in clinical assessment using the Trauma and Dissociation Symptoms
Interview, followed by a psychiatric interview. The recordings of six women, whose
earlier DID diagnosis was disconﬁrmed, were transcribed and subjected to interpretative
phenomenological analysis. Five main themes were identiﬁed: (1) endorsement and
identiﬁcation with the diagnosis. (2) The notion of dissociative parts justiﬁes identity
confusion and conﬂicting ego-states. (3) Gaining knowledge about DID affects the
clinical presentation. (4) Fragmented personality becomes an important discussion
topic with others. (5) Ruling out DID leads to disappointment or anger. To avoid
misdiagnoses, clinicians should receive more systematic training in the assessment
of dissociative disorders, enabling them to better understand subtle differences in the
quality of symptoms and how dissociative and non-dissociative patients report them.
This would lead to a better understanding of how patients with and without a dissociative
disorder report core dissociative symptoms. Some guidelines for a differential diagnosis
Keywords: dissociative identity disorder (DID), false-positive cases, personality disorder, dissociation, differential
Multiple Personality Disorder (MPD) was ﬁrst introduced in DSM-III in 1980 and re-named
Dissociative Identity Disorder (DID) in subsequent editions of the diagnostic manual (American
Psychiatric Association, 2013). Table 1 shows diagnostic criteria of this disorder in ICD-10, ICD-
11, and DSM-5. Some healthcare providers perceive it as fairly uncommon or associated with
temporary trends (Brand et al., 2016). Even its description in ICD-10 (World Health Organization,
1993) starts with: “This disorder is rare, and controversy exists about the extent to which it is
iatrogenic or culture-speciﬁc” (p. 160). Yet, according to the guidelines of the International Society
for the Study of Trauma and Dissociation (International Society for the Study of Trauma and
Dissociation, 2011), the prevalence of DID in the general population is estimated between 1 and
3%. The review of global studies on DID in clinical settings by Sar (2011) shows the rate from
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Pietkiewicz et al. Revisiting False-Positive and Imitated DID
TABLE 1 | Diagnostic criteria for dissociative identity disorder.
ICD-10 Multiple personality disorder F44.81
(A) Two or more distinct personalities exist within the individual, only one being evident at a time.
(B) Each personality has its own memories, preferences, and behavior patterns, and at some time (and recurrently) takes full control of the individual’s behavior.
(C) There is inability to recall important personal information which is too extensive to be explained by ordinary forgetfulness.
(D) The symptoms are not due to organic mental disorders (F00–F09) (e.g., in epileptic disorders) or to psychoactive substance-related disorders (F10–F19) (e.g.,
intoxication or withdrawal).
ICD-11 Dissociative identity disorder 6B64
Dissociative identity disorder is characterized by disruption of identity in which there are two or more distinct personality states (dissociative identities) associated with
marked discontinuities in the sense of self and agency. Each personality state includes its own pattern of experiencing, perceiving, conceiving, and relating to self, the
body, and the environment. At least two distinct personality states recurrently take executive control of the individual’s consciousness and functioning in interacting with
others or with the environment, such as in the performance of speciﬁc aspects of daily life such as parenting, or work, or in response to speciﬁc situations (e.g., those
that are perceived as threatening). Changes in personality state are accompanied by related alterations in sensation, perception, affect, cognition, memory, motor
control, and behavior. There are typically episodes of amnesia, which may be severe. The symptoms are not better explained by another mental, behavioral or
neurodevelopmental disorder and are not due to the direct effects of a substance or medication on the central nervous system, including withdrawal effects, and are not
due to a disease of the nervous system or a sleep-wake disorder. The symptoms result in signiﬁcant impairment in personal, family, social, educational, occupational, or
other important areas of functioning.
DSM-5 Dissociative identity disorder 300.14
(A) 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 in identity 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.
(B) Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
(C) The symptoms cause clinically signiﬁcant distress or impairment in social, occupational, or other important areas of functioning.
(D) The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary
playmates or other fantasy play.
(E) 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).
0.4 to 14%. However, in studies using clinical diagnostic
interviews among psychiatric in-patients, and in European
studies these numbers were lower (Friedl et al., 2000). The
discrepancies apparently depend on the sample, the methodology
and diagnostic interviews used by researchers.
Diagnosing complex dissociative disorders (DID or Other
Speciﬁed Dissociative Disorder, OSDD) is challenging for several
reasons. Firstly, patients present a lot of avoidance and rarely
report dissociative symptoms spontaneously without direct
questioning (Boon and Draijer, 1993;International Society for
the Study of Trauma and Dissociation, 2011;Dorahy et al.,
2014). In addition, standard mental state examination does not
include these symptoms and healthcare professionals do not
receive appropriate training in diagnosing dissociative disorders
(Leonard et al., 2005). Secondly, complex dissociative disorders
are polysymptomatic, and specialists would rather diagnose these
patients with disorders more familiar to them from clinical
practice, e.g., anxiety disorders, eating disorders, schizophrenia,
or borderline personality disorder (Boon and Draijer, 1995;Dell,
2006;Brand et al., 2016). For these reasons, complex dissociative
disorders are underdiagnosed and often mis-diagnosed. For
example, 26.5–40.8% of DID patients would already have been
diagnosed and treated for schizophrenia (Putnam et al., 1986;
Ross et al., 1989). On the other hand, because there is so much
information about DID in the media (Hollywood productions,
interviews and testimonies published on YouTube, blogs), people
who are confused about themselves and try to ﬁnd an accurate
diagnosis for themselves may learn about DID symptoms on the
Internet, identify themselves with the disorder, and later (even
unintentionally) report core symptoms in a very convincing
way (Draijer and Boon, 1999). This presents a risk of making
a false positive diagnosis, which is unfavorable for the patient,
because using treatment developed for DID with patients
without autonomous dissociative parts may be ineﬃcient or even
reinforce their pathology.
Authors who wrote about patients inappropriately diagnosed
with this disorder used terms such as ‘malingering’ or ‘factitious’
DID (Coons and Milstein, 1994;Thomas, 2001). According
to Draijer and Boon (1999), both labels imply that patients
intentionally simulate symptoms, either for external gains
(ﬁnancial beneﬁts or justiﬁcation for one’s actions in court) or
for other forms of gratiﬁcation (e.g., interest from others), while
in many cases their motivation is not fully conscious. Getting
a DID diagnosis can also provide structure for inner chaos and
incomprehensible experiences, and be associated with hope and
belief it is real. On the other hand, diagnostic errors often result
in inappropriate treatment plans and procedures.
Already in 1995 Boon and Draijer stressed that a growing
number of people self-diagnosed themselves based on
information from literature and the Internet, and reported
symptoms by the book during psychiatric or psychological
assessment. Based on their observation of 36 patients in whom
DID had been ruled out after applying the structured clinical
interview SCID-D, these clinicians identiﬁed diﬀerences between
genuine and imitated DID. They classiﬁed their participants into
three groups: (1) borderline personality disorder, (2) histrionic
personality disorder, or (3) persons with severe dissociative
symptoms but not DID. Participants in that study reported
symptoms similar to DID patients, including: amnesia (but only
for unacceptable behavior), depersonalisation, derealisation,
identity confusion, and identity alteration. However, they
presented themselves and interacted with the therapist in very
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diﬀerent ways. While DID patients are usually reluctant to
talk about their symptoms and experience their intrusions as
shameful, people who imitated DID were eager to present their
problems, sometimes in an exaggerated way, in an attempt to
convince the clinician that they suﬀered from DID (Boon and
Draijer, 1995;Draijer and Boon, 1999). Similar observations
were expressed by Thomas (2001) saying that people with
imitated DID can present their history chronologically, using
the ﬁrst person even when they are highly distressed or allegedly
presenting an altered personality, and are comfortable with
disclosing information about experiences of abuse. They can
talk about intrusions of dissociative parts, hearing voices or
diﬃculties controlling emotions, without shame.
Unfortunately, ICD-10, ICD-11, and DSM-5 oﬀer no speciﬁc
guidelines on how to diﬀerentiate patients with personality
disorders and dissociative disorders by the manner in which
they report symptoms. There are also limited instruments to
distinguish between false-positive and false-negative DID. From
the clinical perspective, it is also crucial to understand the motives
for being diagnosed with DID, and disappointment when this
diagnosis is disconﬁrmed. Accurate assessment can contribute to
developing appropriate psychotherapeutic procedures (Boon and
Draijer, 1995;Draijer and Boon, 1999). Apart from observations
already referred to earlier in this article, there are no qualitative
analyses of false-positive DID cases in the past 20 years.
Most research was quantitative and compared DID patients
and simulators in terms of cognitive functions (Boysen and
VanBergen, 2014). This interpretative phenomenological analysis
is an idiographic study which explores personal experiences and
meaning attributed to conﬂicting emotions and behaviors in
six women who had previously been diagnosed with DID and
referred to the Research Centre for Trauma and Dissociation for
re-evaluation. It explores how they came to believe they have DID
and what had led clinicians to assume that these patients could be
suﬀering from this disorder.
MATERIALS AND METHODS
This study was carried out in Poland in 2018 and
2019. Rich qualitative material collected during in-depth
clinical assessments was subjected to the interpretative
phenomenological analysis (IPA), a popular methodological
framework in psychology for exploring people’s personal
experiences and interpretations of phenomena (Smith and
Osborn, 2008). IPA was selected to build a deeper understanding
of how patients who endorsed and identiﬁed with dissociative
identity disorder made sense of the diagnosis and what
it meant for them to be classiﬁed as false-positive cases
Interpretative phenomenological analysis uses
phenomenological, hermeneutic, and idiographic principles. It
employs ‘double hermeneutics,’ in which participants share their
experiences and interpretations, followed by researchers trying
to make sense and comment on these interpretations. IPA uses
small, homogenous, purposefully selected samples, and data
are carefully analyzed case-by-case (Smith and Osborn, 2008;
Pietkiewicz and Smith, 2014).
This study is part of a larger project examining alterations
in consciousness and dissociative symptoms in clinical and
non-clinical groups, held at the Research Centre for Trauma
& Dissociation, ﬁnanced by the National Science Centre, and
approved by the Ethical Review Board at the SWPS University
of Social Sciences & Humanities. Potential candidates enrolled
themselves or were registered by healthcare providers via an
application integrated with the website www.e-psyche.eu. They
ﬁlled in demographic information and completed online tests,
including: Somatoform Dissociation Questionnaire (SDQ-20,
Pietkiewicz et al., 2018) and Trauma Experiences Checklist
(Nijenhuis et al., 2002). Those with elevated SDQ-20 scores
(above 28 points) or those referred for diﬀerential diagnosis were
consulted and if dissociative symptoms were conﬁrmed, they
were invited to participate in an in-depth clinical assessment
including a series of interviews, video-recorded and performed at
the researcher’s oﬃce by the ﬁrst author who is a psychotherapist
and supervisor experienced in the dissociation ﬁeld. In Poland,
there are no gold standards for diagnosing dissociative disorders.
The ﬁrst interview was semi-structured, open-ended and
explored the patient’s history, main complaints and motives for
participation. It included questions such as: What made you
participate in this study? What are your main diﬃculties or
symptoms in daily life? What do you think caused them? Further
questions were then asked to explore participants’ experiences
and meaning-making. This was followed by the Trauma and
Dissociation Symptoms Interview (TADS-I, Boon and Matthess,
2017). The TADS-I is a new semi-structured interview intended
to identify DSM-5 and ICD-11 dissociative disorders. The
TADS-I diﬀers in several ways from other semi-structured
interviews for the assessment of dissociative disorders. Firstly,
it includes a signiﬁcant section on somatoform dissociative
symptoms. Secondly, it includes a section addressing other
trauma-related symptoms for several reasons: (1) to obtain a
more comprehensive clinical picture of possible comorbidities,
including symptoms of PTSD and complex PTSD, (2) to gain
a better insight into the (possible) dissociative organization of
the personality: patient’s dissociative parts hold many of these
comorbid symptoms and amnesia, voices or depersonalisation
experiences are often associated with these symptoms; and (3)
to better distinguish between complex dissociative disorders,
personality disorders and other Axis I disorders and false positive
DID. Finally, the TADS-I also aims to distinguish between
symptoms of pathological dissociation indicating a division of
the personality and symptoms which are related to a narrowing
or a lowering of consciousness, and not to the structural
dissociation of the personality. Validation testing of the TADS-I
is currently underway. TADS interviews ranging from 2 to 4 h
were usually held in sessions of 90 min. Interview recordings
were assessed by three healthcare professionals experienced in
the dissociation ﬁeld, who discussed each case and consensually
came up with a diagnosis based on ICD-10. An additional mental
state examination was performed by the third author who is
a psychiatrist, also experienced in the diﬀerential diagnosis of
dissociative disorders. He collected medical data, double-checked
the most important symptoms, communicated the results and
discussed treatment indications. Qualitative data collected from
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six patients out of 85 were selected for this interpretative
phenomenological analysis, based on the following criteria for
inclusion, which could ensure a homogenous sample expected of
IPA studies – (a) female, (b) previously diagnosed or referred to
rule in/out DID, (c) endorsement and identiﬁcation with DID, (d)
dissociative disorder disconﬁrmed in the assessment. Interviews
with every participant in this study ranged from 3 h 15 min to 7 h
20 min (mean: 6 h).
Participants of this IPA were six female patients aged between
22 and 42 years who were selected out of 86 people examined
in a larger study exploring dissociation and alterations in
consciousness in clinical and non-clinical groups. (Participants
in the larger study met criteria of diﬀerent diagnoses and
seven among them had ‘genuine’ DID). These six patients did
not meet DID criteria on the TADS-I interview but believed
themselves that they qualiﬁed for that diagnosis. Four of them
had higher education, two were secondary school graduates.
All of them registered in the study by themselves hoping to
conﬁrm their diagnosis but two (Olga and Katia) were referred
by psychiatrists, and the others by psychotherapists. All of them
traveled from far away, which showed their strong motivation
to participate in the assessment. Four had previously had
psychiatric treatment and ﬁve had been in psychotherapy due
to problems with emotional regulation and relationships. In
the cases of Victoria and Dominique, psychotherapy involved
working with dissociative parts. None of them recalled any
physical or sexual abuse, but three (Dominique, Victoria, and
Mary), following therapists’ suggestions, were trying to seek
such traumatic memories to justify their diagnosis. They all felt
emotionally neglected by carriers in childhood and emotionally
abused by signiﬁcant others. None of them reported symptoms
indicating the existence of autonomous dissociative parts.
None had symptoms indicating amnesia for daily events, but
four declared not remembering single situations associated
with conﬂicting emotions, shame, guilt, or conversations
during which they were more focused on internal experiences
rather than their interlocutors. None experienced PTSD
symptoms (e.g., intrusive traumatic memories and avoidance),
autoscopic phenomena (e.g., out-of-body experiences), or
clinically signiﬁcant somatoform symptoms. None had
auditory verbal hallucinations but four intensely engaged in
daydreaming and experienced imagined conversations as very
real. All of them had been seeking information about DID
in literature and the Internet. For more information about
them see Table 2. Their names have been changed to protect
The principal investigator (IJP) is a psychotherapist, supervisor,
and researcher in the ﬁeld of community health psychology
and clinical psychology. The second co-investigator (RT) is
a psychiatrist, psychotherapist, and supervisor. The third co-
investigator (SB) is a clinical psychologist, psychotherapist,
supervisor, and a consulting expert in forensic psychology,
who also developed the TADS-I. They are all mentors and
trainers of the European Society for Trauma and Dissociation,
with signiﬁcant expertise in the assessment of post-traumatic
conditions. The ﬁrst co-investigator (AB) has a master’s degree in
psychology and is a Ph.D. candidate. She is also a psychotherapist
in training. All authors coded and discussed their understanding
of data. Their understanding and interpretations of symptoms
reported by participants were inﬂuenced by their background
knowledge and experience in diagnosing and treating patients
with personality disorders and dissociative disorders.
Verbatim transcriptions were made of all video recordings, which
were analyzed together with researchers’ notes using qualitative
data-analysis software – NVivo11. Consecutive analytical steps
recommended for IPA were employed in the study (Pietkiewicz
and Smith, 2014). For each interview, researchers watched
the recording and carefully read the transcript several times.
They individually made notes about body language, facial
expressions, the content and language use, and wrote down
their interpretative comments using the ‘annotation’ feature
in NVivo10. Next, they categorized their notes into emergent
themes by allocating descriptive labels (nodes). The team then
compared and discussed their coding and interpretations. They
analyzed connections between themes in each interview and
between cases, and grouped themes according to conceptual
similarities into main themes and sub-themes.
During each interview, participants were encouraged to give
examples illustrating reported symptoms or experiences.
Clariﬁcation questions were asked to negotiate the meaning
participants wanted to convey. At the end of the interview,
they were also asked questions to check that their responses
were thorough. The researchers discussed each case thoroughly
and also compared their interpretative notes to compare
their understanding of the content and its meaning (the
Participants in this study explained how they concluded they
were suﬀering from DID, developed knowledge about the
syndrome and an identity of a DID patient, and how this aﬀected
their everyday life and relationships. Five salient themes appeared
in all interviews, as listed in Table 3. Each theme is discussed
and illustrated with verbatim excerpts from the interviews, in
accordance with IPA principles.
Theme 1: Endorsement and
Identiﬁcation With the Diagnosis
All six participants hoped to conﬁrm they had DID. They
read books and browsed the Internet seeking information about
dissociation, and watched YouTube videos presenting people
describing multiple personalities. Dominique, Victoria, Mary,
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TABLE 2 | Study participants.
Name Participant’s characteristics
Victoria Age 22, single, lives with parents and younger brother. Stopped her studies after 3 years and was hospitalized in a psychiatric facility for a short period
due to problems with emotions and relationships. Reports difﬁculties with recognizing and expressing emotions, emptiness, feels easily hurt and
rejected, afraid of abandonment. Perceives herself as unimportant and worthless, sometimes cuts herself for emotional relief. Maintains superﬁcial
relationships, does not trust people; in childhood was frequently left alone with grandparents because her parents traveed; described her parents as
setting high expectations, mother as getting easily upset and impulsive. No substance use. No history of physical or sexual trauma. Her maternal
grandfather abused alcohol but was not violent; no history of suicides in her family. Scored 38 points in SDQ-20 but no signiﬁcant somatoform
symptoms reported during clinical assessment.
Karina Age 22, single, secondary education. Enrolled in university programs twice but stopped. Acting is a hobby; recently worked as a waitress or hostess,
currently unemployed. Has had psychiatric treatment for 17 years due to anxiety and problems in relationships. Two short hospital admissions; in
psychodynamic psychotherapy in last 2 years. Reports emotional instability, feeling depressed, anxious, and lonely; maintains few relationships;
experiences conﬂicts with expressing anger and needs for dependency, no self-harm. She had periods of using alcohol excessively in the past, currently
once a month, no drugs. No family members used psychiatric help. Reports abandonment, emotional and physical abuse in childhood and eagerly
talks about these experiences. Scored 68 points in SDQ-20 but no signiﬁcant somatoform symptoms reported during clinical assessment.
Dominique Age 33, higher education, married, three children. Works as a playwright, comes from an artistic family. Was given away to her grandparents as a baby
and returned to parents and brothers when she was seven; often felt abandoned and neglected. She had learning difﬁculties and problems in
relationships, mood regulation, auto-aggressive behavior, feelings of emptiness and loneliness. Denies using alcohol or drugs; at secondary school
abused marihuana. Her paternal grandmother had psychosis, her father abused marihuana and mother was treated for depression. Reports poverty at
home. No suicides in family. Often retreated into her fantasy world in which she developed a story about boys kept in a resocialisation center. Has had
psychiatric treatment and counseling for 20 years. Scored 52 points in SDQ-20 but no somatoform symptoms conﬁrmed during clinical assessment.
Mary Age 34, higher education, married. Works in the creative industry and engaged in proselytic activities as an active Jehovah’s Witness (joined the
organization 10 years earlier, encouraged by her mother). Has had EMDR therapy for 2 years due to problems maintaining relationships and managing
anger. When her therapist asked if she felt there were different parts inside her, she started exploring information about DID. She denies smoking or
using any drugs, alcohol. Mother suffered from mild depression. No suicides in family. Scored 48 points in SDQ-20 but no somatoform symptoms
conﬁrmed during clinical assessment.
Olga Age 40, higher education, single. Works in social care. Reports depressive mood, low self-esteem, difﬁculties with concentration, problems with social
contacts. Occasionally uses alcohol in small doses, no drugs. Describes her mother as demanding but also distant and negligent because she was
busy with her medical practice. Father withdrawn and depressed but never used psychiatric treatment. No other trauma history. No suicides in family.
Tried psychotherapy four times but usually terminated treatment after a while. Her psychiatrist referred her for evaluation of memory problems, and
conﬁrming DID. Scored 31 points in SDQ-20; conﬁrms a few somatoform symptoms: headaches, symptoms associated with cystitis, detachment from
Katia Age 42, post-graduate education. Unemployed. On social beneﬁts for 15 years due to neurological and pulmonary symptoms, complications after
urological surgeries. Reports low self-esteem, self-loathing, problems in establishing or maintaining relationships, feeling lonely, rejected and not
understood. Inclinations toward passive-aggressive behavior toward people representing authority, fatigue, insecurity about her ﬁnancial situation.
Reports no alcohol or drug use. Mother treated for depression. No suicides in family. Scored 69 points in SDQ-20; multiple somatic complaints
associated with Lyme disease, describes mother as emotionally and physically abusive, and father as abandoning and unprotecting. Has never used
psychotherapy; was referred for consultation by a psychiatrist after persuading him that she had DID symptoms.
Participants names have been changed to protect their conﬁdentiality.
TABLE 3 | Salient themes identiﬁed during the interpretative
Theme 1: Endorsement and identiﬁcation with the diagnosis
Theme 2: Using the notion of dissociative parts to justify identity confusion
and conﬂicting ego-states
Theme 3: Gaining knowledge about DID affects the clinical presentation
Theme 4: Fragmented personality becomes an important discussion topic
Theme 5: Ruling out DID leads to disappointment or anger.
and Karina said that a mental health professional suggested
this diagnosis to them. Dominique remembers consulting a
psychiatrist when she was 15, because she had problems
controlling anger at home or in public places. She initially
found descriptions of borderline personality captured her
experiences well enough, but a psychiatrist refuted the idea and
recommended further diagnostics toward a dissociative disorder.
However, the girl refused to go to hospital for observation.
During an argument with my mother I felt as if some incredible
force took control and I smashed the glass in the cabinet with my
hand. It was like being under control of an alien force. I started
reading about borderline and I thought I had it. I found a webpage
about that and told my mother I should see a psychiatrist. I went
for a consultation and told her my story. This lady said: “Child,
you don’t have borderline, but multiple personality.” She wanted
to keep me in the psychiatric unit but I did not agree to stay for
This led Dominique to research the new diagnosis. Karina also
said she was encouraged to seek information about DID, when a
doctor suggested she might be suﬀering with it.
When I was 11, I had problems at school and home. Other
children made fun of me. My mom took me to a doctor and he
said I had borderline, but later I was diagnosed with an anxiety
disorder. That doctor also suggested I had DID and told me that I
should read more about this diagnosis. (Karina).
Victoria and Mary shared similar stories about
psychotherapists suggesting the existence of dissociative parts,
having readily accepted this new category as a good explanation
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for aggressive impulses or problems with recalling situations
evoking guilt or shame. Dominique and Victoria stressed,
however, that, apart from feeling emotionally abandoned, they
could not trace any signiﬁcant traumas in their early childhoods,
although therapists maintained that such events must be present
in dissociative patients.
I have no idea why I have this [DID]. My therapist looked for
evidence of childhood trauma, which sounds like the easiest
explanation, but I don’t feel I had any horriﬁc memories which
I threw out of my consciousness. (Victoria).
Katia and Olga had used psychiatric treatment for anxiety
and depression for years. After exploring information about
diﬀerent mental disorders they concluded they had DID.
They thought there was a similarity between their personal
experiences and those of people publishing testimonials about
I tried to understand this battle inside, leading me to stagnation.
I didn’t know how to describe that but I recently bought a book
Healing the fragmented selves of trauma survivors, and everything
was explained there. Some of these things I have discovered myself
and some were new to me. (Olga).
Subsequently, Katia presented to her doctor a review
of literature about DID, trying to persuade him that she
had this disorder.
Theme 2: Using the Notion of
Dissociative Parts to Justify Identity
Confusion and Conﬂicting Ego-States
Once participants had embraced the idea of having multiple
personalities, they seemed to construct inner reality and justify
conﬂicting needs, impulses or behaviors as an expression of
dissociative parts. They referred to being uncertain about who
they were and having diﬃculties recognizing personal emotions,
needs or interests. Some of them felt it was connected to a
negative cognition about themselves as worthless, unimportant,
and not deserving to express what they felt or wanted. Victoria
said she would rather deﬁne herself through the eyes of others:
My therapist asked what I wanted or needed. It turned out that
without other people’s expectations or preferences to which I
normally adjust, I wouldn’t know who I am or what I want. I
usually engage in my friends’ hobbies and do what I think gives
them pleasure. Otherwise, I think they will not like me and reject
me, because I have nothing to oﬀer. (Victoria).
Since a young age, Dominique tended to immerse herself in
a fantasy world, developing elaborated scenarios about people
living in a youth center administered by a vicious boss. Diﬀerent
characters in her ‘Story’ represented speciﬁc features, interests
and plans she had.
Well, there is John who is a teacher and researcher. He teaches
mathematics. I have no skills in maths at all. Tim is a philosopher
and would like to train philosophers, enroll doctoral studies. He
would like me to study philosophy but the rest of the system
wants me to be a worrier. Ralf is a caring nurse and would
like to become a paramedic. It is diﬃcult to reconcile all these
diﬀerent expectations. Whoever comes up front, then I have these
Dominique neither had amnesia nor found evidence for
leading separate lives and engaging herself in activities associated
with her characters. She maintained her job as a playwright, and
merely imagined alternative scenarios of her life, expressed by
her inner heroes. In other parts of the interview, she referred
to them as ‘voices inside,’ but admitted she never heard them
acoustically. They were her own vivid thoughts representing
diﬀerent, conﬂicting opinions or impulses.
Katia said she felt internally fragmented. There were times
when she engaged in certain interests, knowledge and skills, but
she later changed her goals. Fifteen years ago she gave up her
academic career and went on sickness beneﬁt when she became
disabled due to medical problems; she experienced this as a great
loss, a failure, which aﬀected her sense of identity and purpose.
In recent years I have a growing sense of identity fragmentation. I
have problems with deﬁning my identity because it changes. I used
to feel more stable in the past. I had these versions of myself which
were more dominating, so I had a stronger sense of identity. For
example, 20 years ago there was this scientist. I was studying and
felt like a scientist, attending conferences. Now I don’t have that
and I don’t know who I am. [. . .] I also have changing interests and
hobbies because of diﬀerent personalities. Long ago I liked certain
music, played the guitar, sang songs. I don’t do that anymore, I
suddenly lost interest in all that. (Katia).
She described changes in her professional and social lives
in terms of switches between dissociative parts. Although she
maintained the ﬁrst person narrative (“I was studying,” “I played,”
or “I sang”), indicating some sense of continuity, she thought it
proved the existence of two or more distinct personalities.
Participants also reported thoughts, temptations, impulses or
actions which seemed to evoke conﬂicting feelings. Attributing
them to ‘something inside that is not-me’ could free them from
guilt or shame, so they used a metaphor of someone taking over,
logging in, or switching. Dominique thought it was inappropriate
to express disappointment or anger, but she accepted the thought
that her dissociative parts were doing this.
When I’m angry at my therapist, it is not really me but somebody
inside who gets angry easily. Greg often switches on in such
situations and says: “Tell her this and this”. [. . .] I went to a shop
once and discovered that the price on the label was not for a whole
package of batteries but a single one. And suddenly Greg switched
on and had a row with the cashier. I mean, I did it, but wound up
by his anger. This is so weird, I wouldn’t react like that. They just
charged incorrectly and I would normally ignore that but Greg
said: “I give a shit about their mistakes. I won’t accept that.” What
a failure! (Dominique).
Mary said she had parts that expressed anger, sadness,
and needs associated with attachment. She observed them and
allowed them to step in, when situations required.
There were situations in my life when the teenager must have been
active. She protected me. She is ready to ﬁght; I am not like that
at all. I hate violence, and that teenager likes using force to protect
me. [. . .] My therapist suggested I call her after this interview if I
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do not feel well. I didn’t accept that but the [inner] girls got upset
and told me I needed her help. They made me comply, so I agreed
to call her if I do not feel well. It has always been like this. (Mary).
During assessment, no participant provided evidence for the
existence of autonomous dissociative parts. It seems that the
inner characters described by them personiﬁed unintegrated ego-
states which used to evoke conﬂicting feelings.
Theme 3: Exploring Personal
Experiences via the Lens of Dissociation
Reading books, websites and watching videos of people who
claimed to have DID, encouraged them to compare themselves,
talk about and express ‘multiple personalities.’ The participants
became familiar with specialist terms and learned about core
symptoms mentioned in psychiatric manuals.
I read First person plural which helped me understand what this
is all about. The drama of the gifted child and The body keeps the
score. More and more girls started to appear. There is a 6-month
old baby which showed up only 2 months ago, a sad 11-year
old teenager, and a 16-year old who thinks I am a loser. I was
a teenager like that. Now she is having problems and becoming
withdrawn there are fewer switches, because she knows we need
to help the little one ﬁrst. (Mary).
Olga was also inspired by books. Not only did she ﬁnd
similarities to trauma survivors but she made new discoveries
and thought there were other experiences she had been unaware
of earlier. Victoria started using techniques which literature
recommended for stabilization in dissociative disorders. She
said these books helped her understand intense emotions and
This explains everything that happens to me, why I get so angry.
I also found anchors helpful. I focus on certain objects, sounds or
smells which remind me where I am, instead of drifting away into
my thoughts. (Victoria).
It seemed that exploring information about DID encouraged
changes in participants’ clinical presentation. At ﬁrst, they
merely struggled with emotional liability or detachment, internal
conﬂicts, and concentration problems. Later, they started
reporting intrusions of dissociative parts or using clinical terms
(e.g., ﬂashback) for experiences which were not necessarily
clinical symptoms. Dominique said that the characters of her
story would often ‘log in’ and take control. She demonstrated
that during the interview by changing her voice and going
into a ‘trance.’ She created her own metaphors, explaining
these experiences and comparing them with those described in
literature. She stressed that she never had amnesia and remained
aware of what was happening during her ‘trance.’
I think it is a form of dissociation on the emotional level. I read a
lot. . . The minds of Billy Milligan or First person plural. For sure, I
do not have an alteration of personality. I have co-consciousness.
My theory is, we are like a glove, we all stem from one trunk, but
we are like separate ﬁngers. (Dominique).
While participants maintained they had ﬂashbacks, they
understood them as sudden recollections of past memories
but not necessarily related to trauma. Katia said she recently
remembered the picture of the house and garden where she
played as a child and associated these experiences with moments
of joy. Karina also exempliﬁed her ﬂashbacks with ‘intrusions of
happy memories’ which belonged to other personalities:
Sometimes I begin to laugh but this is not my laughter, but the
laughter of sheer joy. Someone inside me is very happy and wants
to talk about happy childhood memories, make jokes. (Karina).
Mary said a child part of her was responsible for ﬂashbacks and
making comments about current situations. However, she later
denied hearing voices or having any other Schneider’s symptoms.
I can hear her comments, that she does not like something. I can
be ﬂooded by emotions and have ﬂashbacks associated with that
child. For example, there is a trigger and I can see things that
this child has seen. She is showing me what was happening in
her life. (Mary).
Participants discussed their dissociative parts, their names and
features, exhibiting neither avoidance nor fear or shame. On
the contrary, they seemed to draw pleasure by smiling, showing
excitement and eagerness to produce more examples of their
unusual experiences. At the beginning of the interview, Karina
was very enthusiastic and said, “My heart is beating so fast, as if I
were in ﬁght-or-ﬂight mode.”
Theme 4: Talking About DID Attracts
Not only were multiple personalities a helpful metaphor for
expressing conﬂicting feelings or needs (already mentioned
in Theme 2), but they also became an important topic of
conversations with family or friends.
My husband says sometimes: “I would like to talk to the little girl.”
He then says that I start behaving diﬀerently. I also talk to my
therapist using diﬀerent voices. Sometimes, she addresses them
asking questions. If questions are asked directly, they respond, but
there are times I do not allow them to speak, because the teenager
part can be very mean and attacks people. (Mary).
It may have been easier for Mary to express her needs for
dependency and care by ascribing them to a little girl and,
because she felt awkward about feeling angry with the therapist,
attributing hostile impulses to a teenager could give her a sense
of control and reduce guilt. Karina decided to create a video-
blog for documenting dissociative parts, and shared her videos
with people interested in DID. She said she was surprised to ﬁnd
clips in which she looked dreadful, having her make-up smeared
all over the face, because she had no memory of doing that.
However, she showed no signs that it bothered her. She discussed
the videos with her best friend, a DID fan who had encouraged
her to enroll in the study in order to conﬁrm her diagnosis.
They were collecting evidence to support the idea that she had
a dissociative disorder, which she presented one by one, before
being asked about details.
Mark [her friend] reads a lot about DID. He says I sometimes talk
in a high voice which is not the way I usually talk. He refers to
us as plural. [. . .] In some of these videos I do not move or blink
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for a minute. I look at some point and there is no expression on
my face. I can remember things until this moment, and later I
discover myself looking like something from Creepypastas. I am
so sorry for people who have to see this. . . and I found my diary.
I have been writing diaries since I was seven. I sometimes have no
memory for having written something. I need to ﬁnd these notes
because I would like to write a book about a fantasy world and
inner conﬂicts. (Karina).
Dominique and Katia also wrote journals to record
dissociative experiences. Katia hoped to be recognized as
an expert-by-experience and develop her career in relation
to that. She brought with her a script of a book she hoped
to publish 1 day.
Theme 5: Ruling Out DID Leads to
Disappointment or Anger
Four participants were openly disappointed that their DID
diagnosis was not conﬁrmed. They doubted if their descriptions
were accurate enough, or they challenged the interviewer’s
understanding of the symptoms. Katia also suggested that she
was incapable of providing appropriate answers supporting her
diagnosis due to amnesia and personality alterations.
Do you even consider that I might give diﬀerent answers if
you had asked these questions 2 or 5 years ago? I must have
erased some examples from my memory and not all experiences
belong to me. I know that people can unconsciously modify their
narratives and that is why I wanted an objective assessment.
[. . .] Nobody believed I was resistant to anesthetics until I was
diagnosed with some abnormalities. It was once written in my
medical report that I was a hypochondriac. One signature and
things become clear to everyone. Sometimes it is better to have
the worst diagnosis, but have it. (Katia).
She expected that the diagnosis would legitimize her
inability to establish satisfactory relationships, work, and become
ﬁnancially independent. For this reason, she also insisted that the
ﬁnal report produced for her should contain information about
how she felt maltreated by family or doctors, and revealed her
hopes to claim damages for health injury. Mary and Karina were
also upset that the interviewers did not believe they had DID.
Can you try to imagine how hard it is? I am not making things
up? You don’t believe me. I am telling you things and you must
be thinking, from the adult perspective: “You are making this up.”
Nothing pisses me oﬀ more than someone who is trying to prove
to others that they have just imagined things. They [dissociative
parts] feel neglected again, as always! (Mary).
Karina tried to hide her disappointment and claimed she was
glad she didn’t have a severe mental illness. However, she thought
she would need to build another theory explaining her symptoms.
After the interview, she sent more videos trying to prove the
assessment results were not accurate.
What about my problems then? I am unable to set boundaries,
I have anxiety, I fear that a war might break out. If this
is not dissociation, then what? I had tests and they ruled
out any neurological problems. I came here and ruled out
another possibility. It is some information but I have not heard
anything new. (Karina).
Only Victoria seemed relieved that her DID diagnosis was not
conﬁrmed. She was happy to discuss how attachment problems or
conﬂicts with expressing emotions and needs aﬀected her social
life and career, and receive guidelines for future treatment. She
felt liberated from having to uncover childhood traumas that her
therapist expected her to have as a dissociative patient.
I was hoping that you would ﬁnd another explanation for my
problems. . . for what is wrong with me, why I feel so sensitive
or spaced out, because it is annoying. I would like to know what is
going on. I don’t think I’ve had any severe trauma but everybody
wants to talk about trauma all the time. (Victoria).
ICD-10 and DSM-5 provide inadequate criteria for diagnosing
DID, basically limited to patients having distinct dissociative
identities with their own memories, preferences and behavioral
patterns, and episodes of amnesia (American Psychiatric
Association, 2013;World Health Organization, 1993). Clinicians
without experience of DID may therefore expect patients
to present disruptions of identity during a consultation and
spontaneously report memory problems. However, trauma
specialists view DID as a ‘disorder of hiddenness’ because patients
often ﬁnd their dissociative symptoms bizarre and confusing and
do not disclose them readily due to their shame and the phobia
of inner experiences (Steele et al., 2005, 2016;Van der Hart et al.,
2006). Instead, they tend to undermine their signiﬁcance, hide
them and not report them during consultations unless asked
about them directly. Dissociative patients can also be unaware
of their amnesia and ignore evidence for having done things
they cannot remember because realizing that is too upsetting.
Contrary to that, this study and the one conducted in 1999 in
the Netherlands by Draijer and Boon, show that some people
with personality disorders enthusiastically report DID symptoms
by the book, and use the notion of multiple personalities to
justify problems with emotional regulation, inner conﬂicts, or
to seek attention. As with Dutch patients, Polish participants
were preoccupied with their alternate personalities and two
tried to present a ‘switch’ between parts. Their presentations
were naïve and often mixed with lay information on DID.
However, what they reported could be misleading for clinicians
inexperienced in the dissociation ﬁeld or those lacking the
appropriate tools to distinguish a genuine dissociative disorder
from an imitated one.
Therefore, understanding the subtleties about DID clinical
presentation, especially those which are not thoroughly described
in psychiatric manuals, is important to come up with a correct
diagnosis and treatment plan. Various clinicians stress the
importance of understanding the quality of symptoms and
the mechanisms behind them in order to distinguish on the
phenomenological level between borderline and DID patients
(Boon and Draijer, 1993;Laddis et al., 2017). Participants in
this study reported problems with identity, aﬀect regulation
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and internal conﬂicts about expressing their impulses. Some
of them also had somatic complaints. These symptoms are
common in personality disorders and also in dissociative
disorders, which are polysymptomatic by nature. However,
the quality of these symptoms and psychological mechanisms
behind them may be diﬀerent. For a diﬀerential diagnosis,
clinicians need to become familiar with the unique internal
dynamics in people who have developed a structural dissociation
of personality as a result of trauma. These patients try to
cope with everyday life and avoid actively thinking about
and discussing traumatic memories, or experiencing symptoms
associated with them. Because of that avoidance, they ﬁnd
it challenging to talk about dissociative symptoms with a
clinician. Besides experiencing fear of being labeled as insane
and sent to hospital, there may be internal conﬂicts associated
with disclosing information. For example, dissociative parts
may forbid them to talk about symptoms or past experiences.
This conﬂict can sometimes be indicated by facial expression,
involuntary movements, spasms, and also felt by the clinician
in his or her countertransference. In other words, it is not
only what patients say about their experiences, but how they
do this. Therapists’ observations and countertransference may
help in assessing the quality of avoidance: How openly or easily
do patients report symptoms or adverse life experiences? Is
that associated with strong depersonalisation (detachment from
feelings and sensations, being absent)? Is there evidence for
internal conﬂicts, shame, fear or feeling blocked when talking
about symptoms (often observed in facial expression, tone of
voice)? Participants in this study were eager to talk about how
others mistreated them and wanted to have that documented
on paper. Diﬃcult experiences in the past sometimes triggered
intense emotions in them (anger, resentment, and deep sadness)
but they did not avoid exploring and communicating these
states. On the contrary, they eagerly shared an elaborate
narrative of their sorrows and about their inner characters –
the multiple personalities they were convinced they had.
They became keen on DID and used a variety of resources
to familiarize themselves with core symptoms. They also
spontaneously reported them, as if they wanted to provide
sound evidence about having DID and were ready to defend
their diagnosis. Some planned their future based on it (an
academic career, writing a book, or a ﬁlm). During the
interviews, it became clear that some perceived having an
exotic diagnosis as an opportunity for seeking attention and
feeling unique, exhibiting the drama of an ‘unseen child’ (see
section “Theme 4”).
Understanding a few of the symptoms identiﬁed in this
study can be useful for diﬀerential diagnosis: intrusions,
voices, switches, amnesia, use of language, depersonalisation.
How they are presented by patients and interpreted by
clinicians is important.
Triggered by external or internal factors (memories or anything
associated with trauma) dissociative patients tend to relive
traumatic experiences. In other words, they have intrusive
memories, emotions or sensorimotor sensations contained by
dissociative parts which are stuck in trauma. In addition
to avoidance, this is another characteristic PTSD feature
observed in the clinical presentation of DID patients (Van
der Hart et al., 2010). Interestingly, participants in this
study showed no evidence for intrusions (images, emotions
or somatosensory experiences directly related to trauma),
but rather problems with emotional regulation (illustrated in
sections “Themes 1 and 2”). Asked about intrusive images,
emotions or thoughts, some gave examples of distressing
thoughts attacking self-image and blaming for their behavior.
This, however, was related to attachment problems and
diﬃculties with self-soothing. They also revealed a tendency
to indulge themselves in these auto-critical thoughts instead of
actively avoiding them, which is often a case in dissociative
patients. Some intrusions reported by DID patients are
somatoform in nature and connected with dissociative parts
stuck in trauma time (Pietkiewicz et al., 2018). Although
three participants in this study had very high scores in
SDQ-20 indicating that they may have a dissociative disorder
(scores of 50–60 are common in DID), further interviews
revealed that they aggravated their symptoms and, in fact,
had low levels of somatoform dissociation. This shows that
tests results should be interpreted with caution and clinicians
should always ask patients for speciﬁc examples of the
symptoms they report.
It is common for DID patients to experience auditory
hallucinations (Dorahy et al., 2009;Longden et al., 2019).
The voices usually belong to dissociative parts and comment
on actions, express needs, likes and dislikes, and encourage
self-mutilation. Subsequently, there may be conﬂicts between
‘voices,’ and the relationship with them is quite complex.
Dorahy et al., 2009 observe that auditory hallucinations
are more common in DID than in schizophrenia. In
dissociative patients they are more complex and responsive,
and already appear in childhood. Speciﬁcally, child voices
are also to be expected in DID (97% in comparison to 6%
in psychosis). None of our participants reported auditory
hallucinations although one (Dominique) said she had
imaginary friends from childhood. While this could sound
like a dissociative experience, exploring their experiences
showed she had a tendency to absorb herself in her fantasy
world and vividly imagine characters in her story (see
section “Theme 2”).
Literature also shows that it is uncommon for avoidant
dissociative patients to present autonomous dissociative parts
to a therapist before a good relationship has been established
and the phobia for inner experiences reduced (Steele et al.,
2005). Sudden switches between dissociative personalities may
occur only when the patient is triggered and cannot exercise
enough control to hide his or her symptoms. Two participants
in this study (Dominique and Karina) tried to present ‘alternate
personalities’ and they actually announced this would happen,
so that the interviewer did not miss them. Later on, they could
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relate to what happened during the alleged switch (no amnesia),
maintaining the ﬁrst-person perspective (I was saying/doing).
Contrary to that, dissociative patients experience much shame
and fear of disclosing their internal parts (Draijer and Boon,
1999). If they become aware that switches had occurred, they try
to make reasonable explanations for the intrusions of parts and
unusual behavior (e.g., I must have been very tired and aﬀected
by the new medicine I am taking).
Dell (2006) mentions various indicators of amnesia in patients
with DID. However, losing memory for unpleasant experiences
may occur in diﬀerent disorders, usually for behaviors evoking
shame or guilt, or for actions under extreme stress (Laddis
et al., 2017). All patients in this study had problems with
emotional regulation and some said they could not remember
what they said or did when they became very upset. With
some priming, they could recall and describe events. For this
reason, it is recommended to explore evidence for amnesia for
pleasant or neutral activities (e.g., doing shopping or cleaning,
socializing). According to Laddis et al. (2017) there are diﬀerent
mechanisms underlying memory problems in personality and
Use of Language
Participants in this study often used clinical jargon (e.g.,
ﬂashbacks, switches, and feeling depersonalized) which indicates
they had read about dissociative psychopathology or received
psycho-education. However, they often had lay understanding
of clinical terms. A good example in this study was having
‘ﬂashbacks’ of neutral or pleasant situations which had once been
forgotten. Examples of nightmares did not necessarily indicate
reliving traumatic events during sleep (as in PTSD) but expressed
conﬂicts and agitation through symbolic, unrealistic, sometimes
upsetting dreams. When talking about behavior of other parts
and their preferences, they often maintained a ﬁrst-person
perspective. Requesting patients to provide speciﬁc examples
is thus crucial.
Detachment from feelings and emotions, bodily sensations
and external reality is often present in various disorders
(Simeon and Abugel, 2006). While these phenomena have
been commonly associated with dissociation, Holmes et al.
(2005) stress the diﬀerences between detachment (which can
be experienced by both dissociative and non-dissociative
patients) and compartmentalisation, associated with the
existence of dissociative parts. Allen et al. (1999) also stress
that extreme absorptive detachment can interfere with noticing
feelings and bodily sensations, and also memory. Some
participants in this study tended to enter trance-like states
or get absorbed in their inner reality, subsequently getting
detached from bodily sensations. They also described their
feeling of emptiness in terms of detachment from feelings.
Nevertheless, none of them disclosed evidence for having
distinct dissociative parts. Some of their statements might
have been misleading; for example, when they attributed anger
attacks to other parts, not-me (see: Dominique in section
“Theme 2”). One might suspect it could be evidence for
autonomous dissociative parts. However, these participants seem
to have had unintegrated, unaccepted self-states and used the
concept of DID to make meaning of their internal conﬂicts.
In their narrative they maintained the ﬁrst-person narrative.
None of them provided sound evidence for extreme forms of
depersonalisation, such as not feeling the body altogether or
There can be many reasons why people develop symptoms
which resemble those typical of DID. Suggestions about a
dissociative disorder made by healthcare providers can help
people justify and explain inner conﬂicts or interpersonal
problems. In this study several clinicians had suggested a
dissociative disorder or DID to the patient. Literature on
multiple personalities and therapy focused on them, and
using expressions such as ‘parts’, ‘dissociating’, ‘switches,’ can
also encourage demonstrating such symptoms. There are also
secondary gains explained in this study, such as receiving
attention and care. Draijer and Boon (1999) observe that
people with borderline features justiﬁed shameful behavior
and avoided responsibility by attributing their actions to
‘alter personalities.’ Such people can declare amnesia for
their outbursts of anger, or hitting partners. Others explained
their identity confusion and extreme emptiness using the
DID model. All their participants reported emotional neglect
and felt unseen in their childhood, so they adopted a
new DID-patient identity to ﬁll up inner emptiness (Draijer
and Boon, 1999). Just like the participants in this study,
they were angry when that diagnosis was disconﬁrmed
during the assessment, as if the clinician had taken away
something precious from them. This shows that communicating
the results should be done with understanding, empathy
and care. Patients and clinicians need to understand and
discuss reasons for developing a DID-patient identity, its
advantages and pitfalls.
In countries where clinicians are less familiar with the
dissociative pathology, there may be a greater risk for both false-
negative and false-positive DID diagnoses. The latter is caused
by the growing popularity of that disorder in media and social
networks. People who try to make meaning of their emotional
conﬂicts, attachment problems and diﬃculties in establishing
satisfactory relationships, may ﬁnd the DID concept attractive.
It is important that clinicians who rule out or disconﬁrm DID,
also provide patients with friendly feedback that encourages
using treatment for their actual problems. Nevertheless, this
may still evoke strong reactions in patients whose feelings
and needs have been neglected, rejected or invalidated by
signiﬁcant others. Disconﬁrming DID may be experienced by
them as an attack, taking something away from them, or an
indication that they lie.
Limitations and Further Directions
Among the 85 people who participated in a thorough diagnostic
assessment, there were six false-positive DID cases, and this study
focused on their personal experiences and meaning attributed
to the diagnosis. Because IPA studies are highly idiographic,
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TABLE 4 | Red ﬂags for identifying false-positive or imitated DID.
This table enumerates suggestive features of false positive or imitated DID cases identiﬁed in this study, which should be taken into consideration during diagnostic
1. Directly or indirectly expects to conﬁrm self-diagnosed DID.
2. DID previously suggested by someone (friend, psychologist, and doctor) without thorough clinical assessment.
3. Keen on DID diagnosis and familiarized with symptoms: read books, watched videos, talked to other patients, participated in a support group for dissociative
4. Uses clinical jargon: parts, alters, dissociating, switch, depersonalisation, etc.
5. Reveals little avoidance: eagerly talks about painful experiences and dissociation, no indicators for genuine shame or inner conﬂicts associated with disclosing
symptoms or parts.
6. Readily justiﬁes losing control of emotions and unacceptable or shameful behavior in terms of not being oneself or being inﬂuenced by an alternative personality.
7. No evidence for the intrusions of unwanted and avoided traumatic memories or re-experiencing them in the present.
8. Denies having ego-dystonic thoughts or voices, especially starting in early childhood and child-like voices.
Note: Dissociative patients may be afraid, ashamed, or feel it is forbidden to talk about the voices.
9. No evidence of amnesia for neutral or pleasant everyday activities, e.g., working, doing shopping, socializing, playing with children.
10. Tries to control the interview and provide evidence for having DID, e.g., eagerly reports dissociative symptoms without being asked about them.
11. Announces and performs a switch between personalities during clinical assessment, especially before a good relationship with the clinician and trust has been
12. Finds apparent gains associated with having DID: receives special interest from family and friends with whom symptoms and personalities are eagerly discussed,
runs support groups, blogs or video channels for people with dissociative disorders.
13. Gets upset or disappointed when DID is not conﬁrmed, e.g., demands re-evaluation, excuses oneself for not being accurate enough in giving right answers, wants
to provide more evidence.
they are by nature limited to a small number of participants.
There were two important limitations in this research. Firstly,
information about the level of psychoform symptoms has not
been given, because the validation of the Polish instrument
used for that purpose is not complete. Secondly, TADS-I used
for collecting clinical data about trauma-related symptoms and
dissociation has not been validated, either. Because there are no
gold standards in Poland for diagnosing dissociative disorders,
video-recordings of diagnostic interviews were carefully analyzed
and discussed by all authors to agree upon the diagnosis. Taking
this into consideration, further qualitative and quantitative
research is recommended to formulate and validate more
speciﬁc diagnostic criteria for DID and guidelines for the
Clinicians need to understand the complexity of DID
symptoms and psychological mechanisms responsible
for them in order to diﬀerentiate between genuine and
imitated post-traumatic conditions. There are several features
identiﬁed in this study which may indicate false-positive or
imitated DID shown in Table 4, which should be taken into
consideration during diagnostic assessment. In Poland, as
in many countries, this requires more systematic training
in diagnosis for psychiatrists and clinical psychologists in
order to prevent under- and over-diagnosis of dissociative
disorders, DID in particular. It is not uncommon that
patients exaggerate on self-report questionnaires when
they are invested in certain symptoms. In this study, all
participants had scores above the cut-oﬀ score of 28 on
the SDQ-20, a measure to assess somatoform dissociation,
which suggested it was probable they had a dissociative
disorder. However, during a clinical diagnostic interview
they did not report a cluster of somatoform or psychoform
dissociative symptoms and did not meet criteria for any
dissociative disorder diagnosis. Clinicians also need to go
beyond the face value of a patient’s responses, ask for speciﬁc
examples, and notice one’s own countertransference. Draijer
and Boon (1999) observed that DID patients were often
experienced by clinicians as very fragile, and exploring
symptoms with people with personality disorders (who try
to aggravate them and control the interview) can evoke
tiredness or even irritability. It is important that clinicians
understand their own responses and use them in the
While psycho-education is considered a crucial element in
the initial treatment of dissociative disorders (Van der Hart
et al., 2006;Howell, 2011;Steele et al., 2016), patients whose
diagnosis has not been conﬁrmed by a thorough diagnostic
assessment should not be encouraged to develop knowledge
about DID symptomatology, because this may aﬀect their clinical
presentation and how they make meaning of their problems.
Subsequently, this may lead to a wrong diagnosis and treatment,
which can become iatrogenic.
DATA AVAILABILITY STATEMENT
The datasets generated for this study are not readily available
because data contain highly sensitive clinical material,
including medical data which cannot be shared according
to local regulations. Requests to access the datasets should
be directed to IP, email@example.com.
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Pietkiewicz et al. Revisiting False-Positive and Imitated DID
The studies involving human participants were reviewed
and approved by Ethical Review Board at the SWPS
University of Social Sciences and Humanities. The
patients/participants provided their written informed consent
to participate in this study.
IP collected qualitative data, performed the analysis, and
prepared the manuscript. AB-N transcribed and analyzed the
interviews and helped in literature review and manuscript
preparation. RT performed psychiatric assessment and
helped in data analysis and manuscript preparation. SB
helped in data analysis and manuscript preparation. All
authors contributed to the article and approved the
Grant number 2016/22/E/HS6/00306 was obtained for the study
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Conﬂict of Interest: The authors declare that the research was conducted in the
absence of any commercial or ﬁnancial relationships that could be construed as a
potential conﬂict of interest.
Copyright © 2021 Pietkiewicz, Ba´
nbura-Nowak, Tomalski and Boon. This is an
open-access article distributed under the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
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Frontiers in Psychology | www.frontiersin.org 13 May 2021 | Volume 12 | Article 637929