Psychiatry & Psychotherapy Podcast - Dissociative Identity Disorder (DID) Explained: Trauma, Neuroscience, Controversies & Recovery

Episode Date: March 21, 2026

In this episode of the Psychiatry Podcast, Harvard experts from McLean Hospital: Dr. Melissa Kaufman, Dr. Matthew Robinson, and cognitive neuroscientist Dr. Lauren Lebois. Join Dr. David Puder to deliver the clearest, most evidence-based explanation of Dissociative Identity Disorder (DID) available today. Discover how DID is a developmental post-traumatic adaptation rooted in repeated childhood maltreatment, explore the neuroscience behind hyperarousal versus shutdown states (including groundbreaking Reinders studies), debunk persistent media myths like Sybil, and navigate long-standing controversies around validity, Freud versus Janet, false memories, and DID versus BPD. Dr. Kaufman shares her own courageous personal journey from living with DID and PTSD to full integration and recovery, offering real hope that this condition is treatable. Whether you're a clinician, someone with lived experience, or simply seeking the truth about dissociation, trauma, and identity fragmentation, this conversation will transform how you understand one of the most misunderstood psychiatric disorders. Presenters' conflicts of interest: Dr. Lauren Lebois reports unpaid membership on the Scientific Committee for the International Society for the Study of Trauma and Dissociation (ISSTD), spousal IP payments from Vanderbilt University for technology licensed to Acadia Pharmaceuticals and spousal private equity in Violet Therapeutics unrelated to the present work. Dr. Melissa Kaufman reports Member, DSM Review Committee, Internalizing Disorders (unpaid); Primary Investigator, National Institute of Mental Health; Board of Directors (unpaid), International Society for the Study of Trauma and Dissociation. Dr. Matthew Robinson and Dr. David Puder do not have any conflicts to report By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to Blog  Link to YouTube video

All right, welcome back. I am joined today with three guests. We have Melissa Kaufman, a trauma psychiatrist and researcher at McLean Hospital. She is the, she serves as the co-director of the dissociative disorders and trauma research program and the medical director of the trauma continuum of care, an associate professor at Harvard Medical School. I also have Matthew Allen Robinson. He is the program director at McLean's Trauma Continuum of Care at the Hill Center specializing in the partial hospitalization and outpatient services for trauma-related disorders. And also Lauren Lebois, she is a cognitive neuroscientist and assistant professor of psychiatry at Harvard Medical School, Director of the Dissociative Disorders and Trauma

Research Group at McLean Hospital with a focus on post-trauma adaptations. Hopefully I got that all right. Welcome to the show. Thank you. Thanks so much for having us. Yeah, so I'm excited today. We're going to be talking about dissociative identity disorder. We're going to be talking about dissociation, trauma. How about we begin with a basic definition of DID, dissociative identity disorder?

I think that's a great place to start. And thank you again for having us on your program. DID is, I think, very misunderstood psychiatric condition. but I think that we are at a place in our scientific understanding and clinical understanding where we can easily describe it. DID is really a developmental post-traumatic adaptation. It begins in childhood and without treatment, children will go on to exhibit symptoms into adulthood. And basically it is an adaptation for kids who have two sort of both the biology and the environment.

I think a lot of people who know about DID think that it is caused by childhood trauma. I would say that that is necessary but not sufficient. Children need to have the biological capacity to dissociate, which is really mostly normally distributed quality in the population, but it has a long tail at the end. And so if a child is sort of in that, you know, highly dissociative just by biological nature, and that is combined with long-term childhood maltreatment, typically at the hands of caretakers, then they may have a propensity to develop a dissociative identity disorder.

And I would say diagnostically, people with DID universally have post-traumatic stress disorder due to the, the childhood maltreatment. In addition to all of the symptoms of PTSD, they also have very severe symptoms of dissociation, including depersonalization, which is kind of feelings of detachment from one's sense of self or body, and then de-realization,

which is symptoms of detachment from or towards one's surroundings. And then two other things. There are gaps in memory, often for traumatic episodes during childhood as well as gaps in awareness during everyday life. And then there is this identity fragmentation. And we can talk a lot more about what that is. Yeah. Thank you for that. You know, I think there's probably some people who are listening who immediately think, like, is this the thing?

it's in the DSM, you know, what are some of the main controversies around it? And how have you guys made sense of those controversies? So, I mean, first and foremost, yes, DID is a DSM-5 diagnostic diagnosis, and it's been highly validated in clinical observation and research, and more recently more rigorous neurobiological research that Lauren and Melissa can say more about. Some of the misconceptions, the most common ones, are that DID is like what is portrayed in the media,

which is people drastically changing their appearance or mannerisms as if they are completely different people in very big ways. That's not the typical presentation that we see. And again, we can say more about that. But also, people think that it's not its own diagnosis and that maybe it's a personality disorder or some other disorder

and that it doesn't hold up on its own. Again, Lauren Melissa can say more about the long list of studies and research that shows in various ways that DID is a real disorder. And certainly, for anyone who's worked with highly trauma, patients and has seen DID, we all know that it's a real thing. Yeah, and just to add that a little bit, I think there's also just a fascinating history to DID and how it's been documented. It's one of the earliest documented psychiatric conditions, and there's, yeah, just a really fascinating historical controversy between, for example, Pierre

Jeannet, who was originally documenting what, he would have called hysteria and that we would now understand as some forms of dissociation and DID and showing that it really was in some ways caused by difficult events in childhood, childhood maltreatment, and then initially Freud agreeing with and finding some similar, documenting some similar cases and agreeing with Jeannes' findings. And then a lot of controversy surrounding Freud backing up from those conclusions and then deciding that actually these weren't actual traumas that children had experienced, but rather fantasies that they had instead about what had happened to them. And it seems like, again, a lot of controversy around this,

but we have kind of followed Freud and his conclusions in the field for a very long time. and part of his shift going towards more of the fantasy model, he has this letter to Wilhelm Flaes, a friend of his, where he kind of describes that it's kind of improbable that this would happen, this extreme maltreatment would happen to so many people. And so that in part explains perhaps some of the shift in this direction that it's difficult to imagine that this happens to so many people. and it's uncomfortable to think about as well.

So I think that can explain part of the controversy. And after the second wave of feminism and Vietnam War veterans returning to the U.S., and we started to see what we would now call PTSD, and we started to understand more about childhood maltreatment and domestic violence, and a lot of research started around that time. there's more an acceptance of these, that these things happen to people. And that sort of started to change the tide and lead to a lot more dissociation and DID-related research as well. I agree with that. I think right around that time of real science starting in the study of post-traumatic stress disorder and the men and women who returned from Vietnam, that was a time of second wave feminism.

And people started to understand domestic violence just prior to that. battered child syndrome was, you know, really documented while in the clinical literature. And so there was more of an openness to really thinking about that this is real, that child abuse does happen. And I think over the past 10, 20 years, even more so, I think that there's been a societal shift in understanding that there's certainly documentation in definitely documentation of severe, you know, child maltreatment, Department of Human Services has done that. So I think we're in an error where that is more accepted. And that has helped to bring some clarity to an understanding to dissociation and what that means. Excellent. I appreciate you going through the history. I've thought about Freud's departure from Pierre Genet, right? I'm saying that right.

and how, you know, he could not hold, right? This thought of the horrific nature of the trauma, it takes a while for a mental health professional to be able to hold it as well. And I hope that conversations like this allow us as mental health professionals to have an increased capacity to hold that, right? It's like we don't want to believe

something so awful could take, place, right? So we don't want to believe. And yet now I feel like with a lot of my patients, it's staring right in our face with the Epstein file release. We don't need to go a lot into that, but people are talking about it. And then you talked about Vietnam War and I was thinking about the videos I've seen of World War I and two. It's like shell shock. Their bodies were moving abnormal. They had a lot of functional movement disorder type symptoms. After Vietnam, you get more of the classic PTSD symptoms, because it was so stigmatized to have PTSD, I think, prior to Vietnam. And then, yeah, I think I really appreciate how you bring up the awareness of domestic violence,

the push against that, right? And how that's, you know, it was like the family secret. It was the thing no one talked about, right? People suffered in silence for decades. Unfortunately, Sometimes they still do. So, okay, yeah, so that brings us all the way up to the 80s when it seemed like multiple personality disorder kind of came on to the radar of people. And then how do you feel like it went off? You talked a little bit about how it almost like,

there's kind of like a histrionic version of it maybe of kind of people that want to be, gardener attention maybe, and then there's the people that are really suffering, right? And so how do you differentiate those two groups of people? I think that's a valid point. And just prior to the 80s, I think it was 1975, 74 is when Flora Rita Schreiber wrote the book, Sybil. And it was a national bestseller. And then a year or two after that, you know, Sally Field won an Emmy for her portrayal of civil. And I wasn't there. I don't know exactly what happened, but

sort of piecing it together, you know, that was a there's enough in the book that rings true in some way, but what I think happened was that the author didn't know how to portray what really is for the most part an internalized disorder, and so she showed it on paper what the patient herself was feeling, but, you know, both in the book and in the movie, you know, especially in the movie you see Sally Field, she won an Emmy, but she's literally talking with different accents. She, you know,

her clothes change, her style changes, and it's just right out there in this very externalized way. I mean, I can tell you clinically, I've never met someone that, I mean, it looks as if there's different people, right? It's not one person. It's not one person. It's multiple, not just personalities, it's multiple people. Well, it's not. And I think that's where it sort of went off the rails a little bit. People with DID, it tends to be a fairly, a hidden disorder. Someone once famously called it a disorder of hiddenness. And the, you know, it's just different aspects of self that have been disowned by a child and personified internally. But it is just not this big dramatic

full bike production. I mean, that just has like very little to do with what DID is. DID is someone who grew up with intolerable circumstances and really conflicts. How can I, you know, get up the next day

and function? And so, you know, difficult thoughts and feelings and memories are compartmentalized so you can just get up and move forward. So the way that it is depicted in popular media movies, books. I think therapists got the wrong, you know, mental health professionals

had the wrong idea. People had the wrong idea. And so I think that that was very problematic, but we've come a long way in our understanding and public awareness, I think, professional awareness, to some extent, but we still need to educate people. It's just, it's not what it looks like in the popular media. And were there people, you know, who, who probably didn't have D-I-D, may have been traumatized, but we're sort of acting out in these ways of therapists that may have pushed too hard for this type of scenario. There may, in fact, happen,

but there's also been a lot of folks that have had this disorder and did not recognize themselves in these popular portrayals, therapists who for many years have been doing good work, good research and understanding what is the typical manifestation, which is, again, very different than what popular and fictional media portrayals present. Maybe we can go back a little bit. You mentioned that there's a certain personality type that is more maybe prone to dissociation, maybe.

Like, what do we know about that? Even before the trauma exists, right? I think I wouldn't so much call it a personality type. It's sort of a capacity to dissociate. And really what is meant by that is sort of born with a capacity to become highly, it's absorption. So many people have this, you know, the typical sort of portrayal of this is like highway hypnosis where you're like driving home, you got the radio on and you miss your exit. You don't even realize for, you know, like, four stops or you become incredibly absorbed in a movie and you're like surprised when the lights you know go back on that you weren't like fully in the movie that's just incredible that's that's absorption and people are born again with this different capacities some some people don't become absorbed at all some people become highly absorbed and i think in order to be someone that is highly dissociative, you have to have this capacity to become very internally absorbed. And that's why it is

sort of an internal disorder. It's a way of being able to absorb internally, which also is an ability to not attend emotionally or, you know, think in a thinking way to sort of compartmentalize that away. So it's both being able to absorb internally inside and sort of shut out what's going on. And that's, again, just normally distributed except for this high tail at the end. I was just going to add that part of the reason that diagnosis was changed from multiple personality disorder to DID is to recognize that this really isn't about personality or having multiple personalities. It's about not developing a cohesive sensitive. of self at a certain developmental time because the child's creative capacity was able to have

this adaptation that made the abuse that was happening, not me. It was happening to someone else. Or, you know, it was that other boy or girl, not me. And as Melissa mentioned earlier, that allows them to leave what happened the night before with that boy or that girl, and the school boy or girl can go to school and listen and pay attention and be social without being bedraggled by the reality of what went on the able for. So it's not a personality disorder, it's not multiple personalities. It's not enough of one because of early life experiences. Right.

And it feels like, so, you know, there's not different people inside. There's not really a different little person that goes to school. There's not really a different little person who, is, you know, dealing with whatever's happening at home, but it feels very much like that to the person, and that's how they cope. It's not, it's not conscious. This is just something that they sort of arrive at because, you know, during early childhood, there's this, this time, and you may remember this yourself, when you personified things, where your stuffed, you know, if you don't want to go to school, but your mom's saying you have to go to school,

You say, well, I'll go, but my stuffed animal, you know, is mad at you. He doesn't want to go to school. It's just an natural developmental way that kids have of just kind of disavowing feelings or thoughts and then personifying them. And if you have that ability to do that as kid and lots of little children do, and again, really difficult things are happening, you're going to make use of that ability to disavow. and personify externally. And that becomes the not-me adaptation. So instead of a little child who says, oh, my stuck animal's mad at you,

not me, I love you, but he's mad at you, as a way to figure out how to deal with conflicting feelings that are hard to manage. And at that age, you don't know that your stuffed animal isn't real, right? Santa Claus is real, Superman is real. So that's sort of the developmental ground that children are walking on that age. And again, if they're being, you know, have really tremendous challenges, relational trauma, they're going to use that ability.

And again, it's not really conscious. Children don't think to the cells, oh, I'm going to pretend that I'm mad, that my stuffed animals mad. I'm going to just say that because I don't want my mom to be mad at me. They don't know that. They really feel that that's happening. So that's when DID develops, and that's the sort of disavowal and personification that happens and then just continues because it's because, you know, the child is highly dissociative and they just keep doing this and doing this. And so it feels internally as if these things are real. I'm curious kind of going to early childhood development, like, for example, something like disorganized attachment style.

There's research on kids with disorganized attachment style later have higher degrees of dissociation. Is that part of this pathway in your mind or is this something different? I think it hasn't been shown. They haven't done, you're thinking of Ruth. I can't remember last name, Lyons. She was like. Lines Ruth, yep. Yeah, thank you.

And Beatrice Beebe as well. Yes. Really impressive research from them showed Beatrice Beebe at four months was able to predict based off of the video of a mother infant died if a kid would develop disorganized attachment style at the age of one and half years of age. And what Lyonsmooth did was to use the adult attachment inventory, right, that was developed and then follow it along and look at the kids who were predicted using the adult attachment inventory of. who may go on to have disorganized detachments later, followed them longitudinally, and saw that they had higher scores of dissociation. What I don't think has been done yet,

but there's a lot of theory about it, is there hasn't been the longitudinal study that goes on to show that people actually develop DID, but theoretically it makes a lot of sense. And I think there's been some really elegant conceptual papers hypothesizing that, you know, children who grew up to have DID have disorganized attachments. It's something that we would actually love to do in the lab is to do an adult attachment inventory on folks with DID and C.

But very hard to do those longitudinal studies for long enough to see if someone ends up developing DID, but I think it makes a lot of sense. One thing I've seen when I've looked at DID in the past is the trauma and the horrific nature of the trauma seems so much higher than PTSD or like it's not a singular event. Can you speak to this? Can you speak to the extent,

what research you've seen? I know you have a lot of, in your group, you follow some lived experienced patients as well. And I know IOP partial kind of attracts, right? A lot of the most horrific trauma. So I imagine you've seen a lot of this stuff. Yeah, I think the type of trauma that we're talking about that most often results in someone later developing DID are situations that are really inescapable and repeated. That's where we get the repeated nature because if it happens once and it's, you know, the coping doesn't require the same level of dissociation that it does if it's happening repeatedly.

and, you know, it doesn't mean that it has to be, you know, I hate to categorize like rank trauma. It doesn't have to be the worst things ever. I think for some people, it's the combination of this prolonged persistent experience that's confusing and harmful in some way, neglectful. You know, that can be, quote unquote, enough because the child needs to escape to survive. And so really I think it's about that need, that need for escapability as opposed to the specific type of trauma. I think correlationally you probably, I've seen in my work at least people that experienced, you know, repeated childhood sexual or physical abuse will often develop DID with all the other criteria that we've already discussed. But that's not the only, doesn't have to be those, those things per se. I think another interesting piece is thinking about like a gene by environment interaction as well,

which would be true of any psychiatric condition of you could, someone who has a very high genetic loading for, like Melissa is saying, the capacity just to dissociate and for that to turn into DID would need less severe. Again, it's weird like you're saying back to rank traumas, but would need less of a stress to push them down. the path of coping using DID versus someone else who had a genetic loading for, I don't know, bipolar disorder would that stress would push them down that road. Someone who had less of a genetic loading for DID but had a lot more trauma that would

get them down the DID road. So I think it's all interacting in that way. That makes it kind of complex. Yeah. I think we're thinking about it in more sophisticated ways as time goes on. There were a number of quite a few early studies in the 80s, 90s that did show that patients with DID reported more severe childhood maltreatment across, you know, it typically wasn't one form, right? If you're being sexually abused, odds are you're probably being emotionally abused as well. you may be being neglected, but people with DID in these early studies are reporting more severe

levels of childhood trauma across different types of traumatic events at the hands of caretakers. But I also agree with what you're saying, Lauren and Matt, that I think there's also, there's more complexity there as well. I've certainly met people who have DID and, you know, certainly were raised in very challenging environment. but, you know, only had this or only had that, but it was over a long course of time. And if you think about it, if someone's being sexually abused over a long course of time or physically abused or emotionally abused, coping skills are probably going to be pretty scarce because that's where we learn how to cope is from our parents. So that's part of it as well.

It's not just the abuse or just the biological capacity. It's that there's no other way to cope. the child is left to their own defenses because they're not learning from their parents how to cope well. I know that like it could present a number of ways, but what are some of the typical presentations that make you think this is more DID versus other things like borderline precise order or like, yeah, what are the things, like, how are you actually diagnosing this? in your clinics in the IOP partial. Yeah.

You know, it's not, it's typically not that someone comes in and says, I think I have DID, you know, can you do an hour-long assessment and that's it? More typically, but, you know, let's say it's someone that's presenting in outpatient treatment. It may be, you know, someone who comes in for treatment and they may be complaining of, you know, long-standing depression or long-standing anxiety. and you start to take a history and what you may notice is a couple of things.

One is that it's hard for people with DID to really create a linear narrative. They can be very high functioning, for example, in their lives and, you know, be very sophisticated thinkers. But when you start to ask them about their childhood, suddenly their narrative becomes difficult to follow. And you may notice that they, you know,

may say, you know, I'm kind of getting fobby, This is hard to talk about, and there are some subtle physical types of manifestation that makes it look like people are really, like, suddenly, really focused internally, blinking of the eye, you know, sort of blinking, closing their eyes, just having kind of a glazed expression on their face or their eyes, and they're just suddenly way more focused internally than they were. and that is something a person who can say yeah I had a tough time growing up but really can't give me details and when they start to give details

they start to look like they're dissociative that can be a sign people with DID always have post-traumatic symptoms so you're looking at someone who's having nightmares or you know

clearly avoid of certain kinds of situations as a startle response. And then, you know, they're telling you that, you know, yeah, things were tough when I was growing up. You know, I wouldn't know at that point if they have DID or not, but I would want to start to inquire and ask them about symptoms of dissociation. And often what we find is, you know, someone comes in and maybe they have a past diagnosis of PTSD. But when we start to ask them about dissociation, symptoms of depersonalization, de-realization, symptoms that don't make a lot of sense, that sometimes thoughts and feelings

don't feel so much like they belong to them, even though they know that that's not possible, because this is not psychosis. And they say, no one's ever asked me that before. Like, how do you know this? And we're simply inquiring about symptoms of dissociation. And again, a lot of times people don't ask. Walk me through that. Like, give me the actual questions that you would ask for dissociation? What are the, what, rattle off the ones that you normally? Well, I mean, there's certainly, you know, reliable and validated self-report measures and, you know, clinical interviews, but if I, you know, not doing that at, you know, meeting with someone for the first time, I start to notice these things. I might ask, you know, do you ever have periods of time,

you know, do you ever feel that you're a little bit detached from your own thoughts or feelings? Do you feel detached from your body sometimes? Do you ever have the experiences where things start to feel dreamlike around you? I mean, there's many, many different ways to ask about dissociation. Maybe you guys can pop in with some other ones. Yeah, one of the most common is the experience of feeling like you're watching yourself from another perspective or that you're on autopilot, sort of like you're riding around in your body and going about your daily life, but watching, not really feeling that you're controlling,

you know, you're washing the dishes, you're doing this with that, but not really thinking about it. A lot of people will report that sounds or sites feel louder or quieter than they actually are, or further away or closer than they actually are. That dream-like thing that Melissa mentioned, where it's like, you know, kind of cloudy and fuzzy and... Do you guys start to feel it?

Because I, like, I know when I'm with someone who's starting to discerting, They don't have to say anything. Like, I'm just starting, I can start to feel it. And sometimes I'm like, okay, is this me? Is this them? I didn't want to say that because that's not, I mean, unless you've experienced it, it sounds a little weird. But yeah, sometimes you may, your own understanding of it is because you start to feel a little fuzzy or foggy and you become aware that you're sort of thinking about something else and then

you're sort of, yeah, you can. can, things can start to feel a little dreamlike, a little foggy. But again, I didn't want to say that because if you haven't really experienced it, it sounds odd. It's like our mirror neurons, right? We see it happening or we kind of perceive it, and we start to experience it too. I think if you're an empathic human being, you can't not feel that. Or just like any time you're with someone when they're talking about something traumatic, you may feel a little bit like that. you may feel a little bit more numb, a little bit more disconnected. You may feel like this sleepy haze come upon you.

Absolutely. I find myself sometimes like needing to feel my focus on the sensation of my butt in the chair. Ground yourself. Ground myself, right, yeah. I think you're exactly right. If you've ever seen someone have a trauma-related flashback, you also, you know, what this, it is a, you know, the hair on the back of your nut goes up and it feels very much like you're watching something terrible happen in the moment.

Yeah. Yep. I remember. I haven't felt that. If you haven't seen that before, it's hard to understand. Yeah. I mean,

I don't want to, like, dissociate everyone that's listening to this podcast, but I remember this one story, this horrific trauma that one of my patients was delivered by their mother, that involved, like, a near-drowning type of situation. and it was very purposeful, very like sadistic from the mother too.

It wasn't like an accident, right? And when the patient described this for me, it was like the room just like started like jerking. And I was like, I had to like, I was like, what is? It kind of reminded me of when I used to play, I used to do sport. And during a wrestling match, like when you're, when it's like I was about to lose or I was almost about to get pissed. pinned, you know, and had to like, like, there was this moment where I would start to go hazy and then I would like have to try to fight out of it to win.

Yeah. Or, so yeah, I think this is kind of like that experience, right? But when you're with, you're with a patient like this, it could be kind of like a chronic. Like you could go, every session feels like this slightly, right, for for months. I had one patient who was very dissociative that it was like two years of like trying to come out of the dissociation varying degrees, right? I'm glad we're talking about how this manifests

in a treatment room. I would say though for your audience and a lot of mental health providers who are really encountering people for one or two times in an emergency room setting or you know that you may not get that sense from people because it is, I mean, they are often more guarded.

And some of the other maybe not clinical things in the room things that I would look for are multiple past diagnoses, often bipolar disorder, borderline personality disorder, mood-related psychotic disorder. And sort of you have all three of those, and none of them really fit or hold water fully because they didn't have a Fult Mantic episode and they never really lost reality testing. and maybe they have some somatic symptoms. And you see this sort of concoction of diagnoses that follow people

and no one's been able to make sense of it. That's always sort of a ding, ding, ding for me. And, you know, remembering that DID's prevalence is on par with schizophrenia. So you are seeing these people all the time, whether you know it or not, probably. So looking for multiple past diagnoses that don't stick is another common sign. And you asked about distinguishing between something like BPD and DID, and there's lots we could say about that. But Melissa Lauren and I will often share.

I think others in the field would agree that people with DID have a very full, like overly full, overly loud internal experience when you get to know them. Whereas people with BD will often describe feeling empty or having a lack of sense of self, not having enough of a self to really ground themselves or, attached to. And that's, you can kind of feel that too when you're working with someone.

When you meet someone with BPD versus DID. Say that again, I didn't hear which one was, so the BPD is a lack of internal self, like an emptiness? Is that what you said? Yes. Like difficulty with identity,

fragmentation, sense of self, but in an empty way. Whereas people with DID are often conflicted and confused and overwhelmed with how much they have internally to grapple with and make sense of, and that's kind of what keeps them quiet, hidden, and confused because

it's too much to make sense of. I completely agree with that. I think the way that I understand personality is like, okay, I think that BPD has been stigmatized. I'm more of the psychodynamic where we have neurotic level of functioning, borderline level of functioning, psychotic level of functioning, we have defense mechanisms, everyone has a personality style, whether the highest functioning person of the world

could be a narcissistic personality style and like enjoy the acclaim and very focused on image protection, right? But very high functioning, you know, maybe some world leaders may have that. Or you could have like, you know, a schizoid level where it's like, you know, there's a rich fantasy life and you have this fear of being consumed

So I'm wondering, like, is it more one personality style or another? Like, could they just as easily be a little bit maybe narcissistic or a little bit schizoid or a little bit histriotic or a little bit dependent personality, depressive personality, hypomanic personality? Or do you guys not think in those categories in your sort of day-to-day? I do, mostly. And I'm thinking about Nancy McWilliams book that... Love it. exactly what I'm talking about, and I was trained somewhat dynamically. And certainly in that book, she describes the dissociative identity as its own, right? It's a chapter at the end of that

great book that she described. So I definitely hear you. I think a lot of people aren't trained that way anymore, which is too bad. It's a very interesting way to think about it. But I think it's its own, I think there's a dissociative structuring of the mind that happens, that involves compartmentalization of thoughts, feelings, affects, memories. And if we're going along, you know, that sort of line in what you're thinking, there's, you know, there's like horizontal splitting versus vertical splitting. And I think that's an interesting way of thinking about it. So it's not repression.

It's not, you know, sort of this horizontal divide. It's a vertical divide. And where any of these thoughts and memories and feelings can be accessed at any time, but they're shut off by these vertical walls until, you know, they're triggered or there's some unconscious motivation that happens. And so there's the change. But I hear what you're saying. I think it's a rich and fascinating way of describing things. It's just not the way we tend to think about things in the clinic, but I do like that. Well, and now that you're saying that, Melissa, it makes me think that, you know, people with DID who are out in the world do have,

a character style and kind of adult defenses. Like they might have a more narcissistic or whatever way of dealing with their world around them and DID. The DID tends to be more hidden in operating the background. And they have this other sort of style of way of being in the world that's, you know, allows them just like all of us to function. They're organized in a certain way. And it's actually can be quite adaptive because if you think about it by compartmental

you know, these very difficult, keep saying the same thing, but thoughts and feelings and memories, by compartmentalizing that, there's still then the chance to feel humor, feel connection, feel empathy, as opposed to someone that doesn't sort of compartmentalize away. It's so overwhelming.

And I've seen people with, you know, PTSD who are in the moment, their symptoms are so much worse because they don't have the capacity to compartmentalize away. It's not easy to live with, you know, rampant dissociation and DID in no way

and people with DID have terrible PTSD at times, but they have this ability to compartmentalize things away. So they can be feeling horrible and then get up and go to work, get up, you know, take care of their children. There is this capacity that is defensive and structure, but is quite adaptive.

And just to say one more thing, we're talking about all of these ways of seeing DID. DID is as, there's a diverse presentation and experience of VID. So, right, so there are people who really struggle with the symptoms and have a hard time functioning all the way up to people who you would never know, and they may never tell you have DID, but they've had it all along. and everything in between. So it's not like there is a prototypical, you know, D-I-D person, person with D-I-D, obviously.

Maybe I can get Lauren to weigh in on some of the brain findings, some of the scans, this kind of lowering of the heart rate that can sometimes happen when someone gets under this kind of stress, but it's not like they're, you know, normally we'd expect their heart rate to go up, but their heart rate actually drops. So what are some of those different findings? means and yeah. Yeah. Thanks, David. I think the neuroscience of DID has been evolving in exciting ways,

but you're right, it kind of lays on the foundation of some of those early PTSD studies. And so I think that's a great place to start in the neuroscience to help understand what's going on in DID as well. But to go back to what you're saying, there's some really great They're called symptom provocation studies in PTSD. And how they work is that they ask folks with PTSD to come into the lab and they narrate a traumatic experience that's happened to them personally in the past. They record that, play it back to them while they're in a neuroimaging scan. That idea being that they can capture what's happening in the brain while someone is feeling

triggered and actively symptomatic with their PTSD symptoms because they're back in that traumatic memory. And what they find in classic PTSD with more that kind of dominance of hyper-arousal symptoms, feeling emotionally flooded, is that you have rapid activation of the amygdala and what would,

which is involved in orienting you to potential salient information in your environment, for an example, it would be potential threats. And so in someone without PTSD, that would happen. But then very quickly, the ventrometrial prefrontal cortex would come online to help regulate that bodily stress response that the amygdala is helping to mount. And they found in classic PTSD that fails to occur. So the ventrometrial prefrontal cortex is not coming online to help regulate the amygdala.

And a metaphor we can use to think about that is if the ventrometrial. medial prefrontal cortex, kind of like the breaks, the breaking mechanism isn't there. And so you're getting this continuous stress response being mounted, even though that threat is no longer there. They're just listening to a recording of what's happening to them in the past. What Ruth Lannius and her team have done, they've built on these findings, looking at folks who have the dissociative subtype of PTSD. So all the regular PTSD symptoms, but in addition, symptoms,

depersonalization or derealization, feeling detached from your sense of self in your environment. And she's found that the opposite thing actually occurs in the dissociative subtype of PTSD, where it's like the brakes are on too tightly. There's actually less amygdala activation and more activation in regions like the ventrometrial prefrontal cortex. And then Simone Rinder's and her team have also done symptom provocation studies in folks with DID, and she finds that depending on what the jargon in the field we use for this is dissociative self-states. So depending on what state someone is in experiencing at any moment,

they'll either show the classic PTSD pattern or the dissociative subtype PTSD pattern. So an example of a prototypical self-state that someone with DID mind experience is one that feels kind of more hyper aroused and activated. They have a sense when they're listening to that trauma and memory that it did happen to them personally. And that's where we see the breaks are off in the brain. There's more amygdala activation, less ventromedial preformal cortex activation. But when someone with DID is in another prototypical state, which is one that's more numb and detached, has lost a sense of agency and ownership over that trauma memory. So it kind of feels like it happened to somebody else. It's not them. That's where we see that the breaks are on too

tightly. There's increased ventramedal prefrontal cortex activation and less activity in regions like the amygdala. So I think that's a key set of findings in D.I.D. that help place it on a continuum as a post-traumatic adaptation. We're seeing these different types of PTSD brain patterns in the patterns of activation in DID. Yeah, I don't know if you guys saw recently the polyvagal theory. There was a big paper that came out with like 50 or so

people that co-signed it saying, this thing is not a thing. And I've always seen it as like the three stages, you know, rest and relaxation, fight and flight, and more of that dissociation. And I think a lot of the stuff kind of makes sense in that context, right? Where it's like there's, it's not just one nerve in the body, like the, you know, the dorsal vagal, as the polyvigal theory says, but it's like this whole like brain system that is dissociation, right? Do you guys have any comments on that?

I haven't seen the paper. I think it's an eloquent or elegant theory. I agree it's not one single nerve. in that way, it seems, it always seemed a bit simplistic. But I think theoretically, in thinking about the symptom cascades in that way, that there is a, you know, hyper aroused, there is a more shut down kind of a response that some patients have. So, I mean, that makes sense to me clinically. I will look up that paper.

What journal was it in? I don't recall. off the top of my head. The other thing I was thinking was, what do you guys think of false memory syndrome or this idea? Because, you know, like 20 or 10 years ago, if someone said like, oh, you know,

I was sexually assaulted by this congressman and this president and this billionaire, you know, we'd be like, oh, is this person crazy? You know, but now post-Eptstein files, we'd be like, oh, wait, like some of this stuff matches up, you know, like this might have happened, right? so but then there's also like this this whole like genre of you know there are false memories right and there are people that don't remember things maybe or they're off they're all false

there's the capacity for people to create memories that didn't exist so how do you differentiate this in your mind like what are your thoughts i mean i think you just summed it up pretty well um that there are all sorts of studies on both camps. And we could sort of debate, you know, is dissociation false memories? Are there false memories? Do sometimes people have false memories? I suspect so. Are some memories true? Yep. You know, is it possible to dissociate childhood maltreatment? It is. are people who, you know, grew up to have post-traumatic symptoms and dissociation. Have there been documented cases where they go back and look through the records and, in fact, they were abused? Yes.

Were there therapists at times who may have pushed too hard or, you know, had their own agenda or whatever? And there were, you know, people ended up having symptoms that perhaps they didn't walk in with, Probably. I tend not to be black and white about it, but if someone comes in and reports a history of childhood abuse and they have all the symptoms of it, I'm not a detective and I'm not going to go back and make sure that the records are documented. I know enough that it does happen. I know that PTSD is a real thing. I know that DID is a real thing. I know that child abuse does have. happen. At the same time, you want to be really careful as a treater, not to, it's your, it's your patient's story. And, you know, there's nothing, you don't get any points for, you know, having this, you know, diagnosing someone with this or that, that you have an ethical obligation, right, to practice according to standards of care. As that happened, as, if that not happened at times, yes. do I believe my patients when they tell me things and the symptoms are there and, you know, I go with what I'm shown.

Have I had also? I mean, people can malinger. People can have factitious disorders. I mean, there's all, it's just so gray. There's no polite about any of this. But I think that maybe an important thing to hold on to is just because there may be one person who was factitious or malingering or something. something doesn't mean that the majority of you can sort of that. Yeah. There's a great paper 2012 by Dollenberg and colleagues. And I would just, if you haven't read it, it's great. I would suggest that anyone who's interested who's listening to the podcast, read that article where it goes through very, very carefully and addresses these types of issues

about false memory syndrome. and it's really a classic in the field. Yeah, one thing, there's a couple of patients that come to mind that could not remember the abuse until the parent that committed the abuse passed away. And I'm curious if you've seen this at all, what do you think might be going on there? I have seen that.

And I've even seen a couple times very dramatic, like they literally had no memory of it. However, most, you know, most often there are, it's just sort of a central memory maybe missing, but as you, you know, the patient talks to you more, there are symptoms that they're expressing, that are, you know, post-traumatic, and they're, it may not remember, like, one thing in particular,

but, you know, their siblings have talked about other things. It's usually not just like a complete, I didn't remember one thing about it, and I'm shocked that this happened. Sorry, your question was about when a parent dies. So, yes, I have seen that because I think the sort of motivation to not remember or to not know really has, it's eased in that kind of situation. Similarly, I think when a parent's adult children move out of the house, we might see someone's symptoms get worse, or when, you know, kind of a major life event that changes their need to stay hidden or stay to keep things so compartmentalized goes away that we see people often start to become symptomatic, you know, later in life, whatever that point is. The kids have gone off to college, and so they're less, you know, distracted, if you will, by child rearing or, you know, going to school or going out and becoming the, you know, excellent at your job.

those things, I've seen a lot of people in retirement age who are slowing down and all of a sudden, you know, that's what they're left with. I've also seen people when they stop drinking alcohol heavily. That's when they start to remember or, yeah, you're all nodding your heads. I mean, in a way, it's just another way to, I don't want to say distract, but the way of, you know, someone who has been busy, their whole raising children or going to school. I mean, all of this stuff has been probably a wonderful distraction in the same way that drinking sort of is

you cope by overworking or taking care of others, you cope by drinking. So I think it's sort of similar in that way. They stop drinking, that way of coping with the traumatic thoughts and feelings

has gone. So, yeah, I agree. Speak a little bit about, like, it seems like people with DID have, like, a part of themselves that's more of the protector, more, you know, could be more maybe even angry or violent, if necessary. Is this common? Is this something you look for? Yeah. I would say it's not, like, in my clinical work, I don't go looking for anything in particular when having a, you know, a self-states, if you will. I appreciate that. I appreciate that. And you're right that I think

if you think about what a kid would need to survive or the different ways a kid would need to be in the world to stay hidden, having someone who can be protective and bold or set boundaries might be a state. Having someone who holds anger or fear or like really overwhelming emotion, whatever that is, could be a state. Someone who is, someone who is, soothing and reassuring could be a state. Having a critical, sort of, you know, overly critical voice or, yeah, anger towards the self-voice could be a state, Lauren, yeah. Great.

And those are, I think those are, not everyone has those, but those are commonly reported in a person's own words in way. Yeah, it's, you know, yeah, lots of people with DID, are pretty allergic to anger. And right when you're a little kid and you, you know, you're being harmed, it would be very natural to become angry, but it's not very adaptive when you're very small to show anger. So that's, you know, a huge conflict for a kid. What do they do with it? So it becomes dissociated. So I would say that, yeah, having, you know, an angry self-state, I often see that. You'd said, you know, able to become violent. I would say that folks with DID, I would not say that they, I mean, there have been, I would say that the people that I have treated that have DID were not violent people. If anything, they were allergic to violence. Despite, you know, there have been some cases that have been quite sensationalized in the media about, you know, folks who had, you know, committed murder and then said, you know, it wasn't me, it was him.

and I think a lot of those aren't DID, but some of them are. But on the whole, I would say that folks with DID are probably less outwardly violent because there's an internal solution. And it just, it wasn't, it wouldn't, it's not adaptable to be violent if you're a young child or, you know, a woman in many ways.

So, yeah. Lauren, I know you have to do some child care stuff coming up here, are there other big areas that we haven't even started to talk about that you could maybe take us through? Yeah, that's a great question. I feel like, I mean, just kind of sticking with the neuroscience a little bit, there are some other key findings there that might be helpful to hold in mind as a clinician or when you're talking to insurance companies or when you're encountering kind of folks who are giving you a little bit of pushback about what DID is or does it really exist or something?

So another big line of work that Simone Reinders has taken on is comparing folks with DID to people who stimulate having DID and comparing their brain activity. The idea

being that, okay, so maybe the fantasy model of people are making this up or role playing in some way or they're, it's iatrogenic or something, that's that's captured by this control condition of someone asked and trained to simulate the symptoms of DID. And they go through pretty elaborate trainings and lots of manipulation checks to make sure someone really gets this.

And they ask them, for example, to do the symptom provocation study of remembering their own past dramatic, re-immersing in their own past traumatic memories in one state versus another. And then they compare that to someone who's genuinely done. diagnosed with DID, what does it look like for them in one state versus another in these different memory conditions. And they, in all studies that have done that to date, they've never been able to, the simulating control has never been able to replicate the brain activation that we see in folks with DID. So that helps to, um, kind of dispel that particular theory about genuinely the ID. I think that's really important. There's also a lot of the neuroscience of DID has focused on

comparing one dissociative self-date to another. And they, I think that's helpful in that it shows that these are, while it's not, as we've been talking about this caricature of actual different people, they are internally experiencing very, what feels like very distinct states. And we see that in the brain activation across paradigms, across different neuroimaging modalities, there's different activity in the brain when someone's in one dissociative self-state versus another, and what that specific brain activation is just kind of depends on what you're asking them to do in the scanner. So I think that's helpful to hold on to that these are real states that people are experiencing. And then I think this takes us a little bit out of the neuroscience, but I think another important thing to talk about is that you can, DID is treatable, you can recover from DID.

And yeah, I think that's an important point to hold on to hope-wise for people who are experiencing this or have loved ones who have this condition that it is treatable. Yeah. And Melissa Kaufman, I know you shared publicly that this is something. that you have struggled with historically. Maybe you could mention a little bit about like your road to recovery or what you would like to mention about this, I guess, yeah. Yeah. I'm happy to do that. I have spoken publicly about the fact that I, you know, grew up having DID. I did receive treatment, you know, luckily enough to find a really excellent treatment. when I was actually a resident, a psychiatry resident, and fully recovered, I no longer have PTSD or DID, and it's very important to me. That's one of the big reasons that I chose to self-disclose

later in life. I really wanted to get the message out that these things, you can feel much better, and it is treatable. I was treated by a psychiatrist who, did have some background in treating people that had been dealt with, you know, childhood abuse and neglect. She actually was a psychodynamic psychotherapist. And I think broadly speaking, it was sort of phasic in the way she treated it. It took me a long time to feel comfortable with her. I think a large part of, you know, my treatment was sort of building trust and being able to feel like

I could talk about these things that had been hitting. for so long. I would say she never, she didn't do any sort of trauma focused treatment like prolonged exposure or cognitive processing. Really because in DID, the trauma is always sort of there. And really what she taught me was more so how to become less symptomatic and how to, if I were starting to feel a dissociative or starting to feel like I was having a flashback, how to manage it. she would help me manage it, and then I began to be able to manage it myself. And the more that I could do that, the more it felt, I felt very gradually able to go from a sense of, you know, that didn't happen to me. I know that's, you know, I always felt like that sounded crazy. I never wanted to say that

because, but I did have this internal sense of having different, you know, people inside me, even though I knew that, you know, intellectually, that's not what. possible. It was, I was so conflicted about it. But over time, as she taught me and then I was able to take it in myself, that I had control, I could stop flashbacks, I could stop dissociating. I didn't have to talk about anything I didn't want to, but if I felt like I could tolerate it, it would talk about it, and gradually over time, there was just this diminishment of sense that it's not me and then it's like oh my god that was me no it couldn't have been well my god it was me and then eventually it's like oh my gosh it was me all along there's this sort of gradual

dawning of awareness if you will and that was it it wasn't super dramatic um and it's like you know it you know in i'm thinking about in the movie sybil there was this one i mean it was like an amazing uh it was an amazing sort of piece of art in terms of drama, but, you know, she, I can't remember exactly what it was, but she remembered something and collapsed, and then it seemed like she didn't have DID anymore. It's just like that. It's just a gradual, more and more able to integrate within oneself the huge conflicts about being dependent, huge conflicts about saying things about your, you know, about people in your life that you don't want to say bad things about, you know, those kinds of conflicts that people

have when they've grown up in challenging situations. So that was my treatment and I feel very fortunate and I very much want people to understand. I mean, not everyone wants that either. I mean, not everyone wants to be integrated that some people with DID don't like that word. And there's some people that it may not make sense to sort of reach that point. It may make more sense to arrive at a place where the sort of internal, not-me states get along better. There's not so much conflict anymore. And some people are okay reaching that state, and that's okay. Do you still find it's

There are moments where you can dissociate maybe more than the average person or is that Mostly resolved as well Yeah, it's interesting I suspect I you know I'm still Like an absent-minded professor I can get very Immersed in books and movies and But not like I could not like I used to But not like spacing out for Not as much as I used to. I'm way more in the outside world than I was before. And in some ways, I miss it. But, you know, I say that. But, you know, it's not easy having DID. It's not easy, you know, having post-traumatic symptoms. But I've changed a little bit. Yeah, I'm just not as internally focused as I used to. Thank you for sharing.

Thanks for asking. Thank you for sharing. Matthew, do you have any like treatment pearls? Yeah, well, I mean, first I want to say that treatment and access to treatment for DID is woefully under, there's a huge access problem. And so the more people that can learn about DID, the better, as Melissa described, I think, the biggest focus of treatment is relationship building and development and helping a person develop the language to understand their mind. So it is a very relational, I think, psychodynamic approach in many cases. And treatments like finding solid brown, which is a

new treatment by Bethany Brand, Ruth Lannius and colleagues that can help teach people skills for grounding and managing the sort of active symptoms of dissociation, it's a great adjunct to the work that goes on to help a person feel more whole and in control. But I would say a lot of people want to find a DID specialist, and I often have to tell people, find a good therapist. Yeah. Find a good therapist who wants to build a strong relationship, and a lot of the work will happen that needs to happen because they know how to do therapy.

And they know how to be therapy. And one thing that's really important is to find a therapist that's really boundary. That was actually something, you know, I learned as a psychiatrist. I also learned in my own treatment how important that is. I think it can sometimes with folks that have, you know, been through very difficult circumstances, there may be, you know, a wish to, you know, help more or show more or be more. to a person. And I think having a very boundary therapist for many, many reasons, that's one of the most important things. That's actually the pearl. So Melissa is one of the people that

trained and mentored me as a person who feels moderately comfortable treating DID. I've learned a lot from her. And I have a voice in my head about just be consistent. Be consistent. Be be consistent, be bound read, and paste. And so I've held that in the background as I'm trying to work with someone with the ID. That and also, I always remember that it's one person. The person I'm working with can describe their experience in lots of ways. And whether or not, I don't always challenge that or ask about that, but I'm always holding on to the notion, the reality that this is one whole person who experiences themselves

in the world in this way. And so my job is to hold that frame and help them to find the ability to hold that frame for themselves over time. Yeah, you definitely can empathize and you're not going to challenge and say, that's not possible to have, you know,

I mean, that's just, you absolutely can empathize with the fact that subjectively, that is absolutely how it feels. And as Matt is saying, you also hold on, you hold on to both. That is subjectively how people, feel and you may in treatment speak to them in a way that they can subjectively understand but also keep reminding yourself this is one person this is one person that's good kind of wrapping up

our time i have to go to my own child care adventures here coaching my son's basketball team so yeah i'm curious if there's anything else kind of floating around in your mind that you really wanted to say. I want to give you the chance to do it. Maybe Lauren, you go first. Or sorry, Lauren's not here. Melissa, you go first. I guess I just want to thank you for having this opportunity. It's really, I think, important for people to understand that, you know, this is what I want to say. I do get tired of saying, you know, DID is real. We don't have to really do that with other psychiatric conditions. So I hope, you know, educational forms like, you know, this, we can keep doing this and thank you for allowing us to do this because at some point

we're going to have to, we can just stop saying that and people can just get on with what needs to be done and that is getting access and care for folks that have dissociative disorders. Yeah. And I hope you don't feel like me putting out the conflicts too early was, because I think, because I think I even mentalize that when I'm thinking about how people think about it. So I think it's good to put out that conflict that is in our space, right? Still there.

We have to talk about it. Yeah, we don't, like Freud, we don't want to think that horrific traumas happen to children. We don't want to think, you know, it would be a nice fantasy to believe it's all fantasy, right? Absolutely.

And also dissociation is alive and well. It's very adaptive. It's absolutely adaptive. Yeah. I'll probably go play some Minecraft tonight with my kids and dissociate from all of the worries of work for half an hour. I appreciate you bringing up the controversies because if you didn't, people would wonder why.

That would be like pretending as if there are, is still no controversy. There's still controversy, but we pay great strides. And again, exactly what you're doing, allowing this space to speak about these things, I could not be more grateful. Matthew, any final thoughts? Just reference me back to a couple of things you actually said.

Thank you. Yes, I agree. It's very glad to have this space. Even though we're talking more about childhood abuse and maltreatment of people and human rights violations, it's in the news more. I still think there's this collective willfulness around action and taking it seriously. And so I would implore kind of anyone listening to when you notice yourself or people around you're doing that, you know, it's not happening to me. It's somewhere else. You know, it can't be as bad as it sounds. A lot of my patients right now are horrified about what's in the news

and the lack of accountability. And they say to me, this is why I didn't talk about it for so long. It's, I mean, there's evidence. There's millions of pages of evidence of something and nothing's happening. So I think as mental health providers, and, you know, we are here to provide treatment, but we're also here to be advocates and a voice for people who can't voice things from themselves. I, um, I, all of a sudden, I have this patient who really likes Punisher comic books, and I decided to get a series of Punisher comic books, which are, about the child sex trade and the punisher going after the abusers.

And then I was like, I became conscious all of a sudden, like, oh, I bought this for a reason at this point in history, at this point in time, right? And we do want justice, right? It's like, I'm not going to become a vigilante, but we do want justice, right? And we do need to speak out. And, you know, we can go back through the early survivors that did speak out about it. Epstein and how they were publicly shunned. I was just talking to a therapist today. She said there was a person that she treated that had been horrifically abused by someone in the, you know, in the film industry

early on in her career. And she never spoke out about it because she knew it would be the end of her career. It would be the absolute end of her career. You know, so we, we collectively need to start to believe, you know, yes, this could happen. It can absolutely happen. And if there's good documentation that it has happened, then these people should be brought to some sense of justice, right? Yeah, absolutely. Agreed.

Thank you. Yeah. All right, guys, we'll leave it there for today, okay? Be care. Part two will probably be like focus on treatment because I feel like we could really go into like I mean you run an IOP partial there's so much collective wisdom that you guys have for this. So we'll we'll do that at other time. Thank you. That's good. Thanks David.