DID in the DSM-5

As almost everyone vaguely interested in psychiatry knows, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is about to enter its fifth edition. The changes in many areas have come under some scrutiny (most recently the decision to slash some personality disorders), so I thought it might be interesting to take a look at the proposed revisions to dissociative identity disorder.

The current criteria for diagnosis of DID in the DSM-IV are;

A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

B. At least two of these identities or personality states recurrently take control of the person's behavior.

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

The slightly lengthier revised criteria are;

A. Disruption of identity characterized by two or more distinct personality states or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others or reported by the patient.

B. Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.

C. Causes 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 and is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol intoxication) or a general medical condition (e.g., complex partial seizures). NOTE: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

Specify if:**

a) With non-epileptic seizures or other conversion symptoms

b) With somatic symptoms that vary across identities (excluding those in specifier a)

* The workgroup will further consider whether Criterion C is necessary

** These specifiers are under consideration.

There are a few things to comment on here, I think. Apparently dissociative trance disorder, a diagnosis present in the DSM-IV, has been merged with DID for the DSM-V; this merger explains some of the additional diagnostic criteria - primarily the feeling of possession in the revised criteria A. That merge may be broadening the definition of DID to a potentially unhelpful degree, particularly when DID is already a relatively heterogenous disorder.

The cultural/religious caveat in the revised D seems odd to me, primarily because if C remains as it is listed above then D is almost superfluous; if the experience of DID is a normal part of a cultural practice, then it will almost surely not cause clinically significant distress - but if it does cause that distress, why should it matter whether it's part of an accepted tradition?

The revised C is also interesting because, in its current state, it appears to give credence to the concept of "healthy multiplicity"; roughly the idea that, well, if you have all the symptoms of DID, but don't actually suffer from it, then you're okay - and that this can even be quite a beneficial situation to find oneself in.

If C is eventually deemed unnecessary, then that would be a fairly significant alteration of the proposed criteria - it's difficult to judge quite what to make of the proposed revision until the question of C's inclusion has been decided. Interesting developments, though.