Editing Dissociative identity disorder (section)

==Diagnosis==
===General===
The fifth, revised edition of the [[American Psychiatric Association]]'s [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM-5-TR) diagnoses DID according to the diagnostic criteria found under [[DSM-5 codes#Dissociative disorders|code 300.14 (dissociative disorders)]]. DID is often initially misdiagnosed because clinicians receive little training about [[dissociative disorders]] or DID, and often use standard diagnostic interviews that do not include questions about trauma, dissociation, or post-traumatic symptoms.<ref name=Guidelines2011 />{{rp|style=ama|p= 118}} This contributes to difficulties diagnosing the disorder, and to clinician bias.<ref name=Guidelines2011 />

DID is rarely diagnosed in children.<ref name="pmid15560314"/> The criteria require that an individual be recurrently controlled by two or more discrete [[identity (social science)|identities]] or [[Personality psychology|personality]] states, accompanied by [[amnesia|memory lapses]] for important information that is not caused by alcohol, drugs or medications and other medical conditions such as [[complex partial seizure]]s.<ref name="DSM5" /> In children, the symptoms must not be better explained by "imaginary playmates or other fantasy play".<ref name="DSM5" /> Diagnosis is normally performed by a clinically trained mental health professional such as a [[psychiatrist]] or [[psychologist]] through clinical evaluation, interviews with family and friends, and consideration of other ancillary material. Specially designed interviews (such as the [[SCID-D]]) and personality assessment tools may be used in the evaluation as well.<ref name="webmd"/> Since most of the symptoms depend on self-report and are not concrete and observable, there is a degree of subjectivity in making the diagnosis.<ref name = Kihlstrom/> People are often disinclined to seek treatment, especially since their symptoms may not be taken seriously; thus dissociative disorders have been referred to as "diseases of hiddenness".<ref name="MacDonald"/><ref name="Recognizing Traumatic Dissociation">{{cite journal |author=Spiegel D |title=Recognizing Traumatic Dissociation |journal=American Journal of Psychiatry |volume=163 |issue=4 |pages=566–568 |year=2006 |pmid=16585425 |doi=10.1176/appi.ajp.163.4.566}}</ref>

The diagnosis has been criticized by supporters of ''therapy as a cause'' or the sociocognitive hypothesis as they believe it is a [[culture-bound syndrome|culture-bound]] and often health care induced condition.<ref name = Hersen2012/><ref name="pmid15560314">{{cite journal |vauthors=Piper A, Merskey H |year=2004 |title=The persistence of folly: Critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder |url=https://journals.sagepub.com/doi/epdf/10.1177/070674370404901005 |journal=Canadian Journal of Psychiatry |volume=49 |issue=10 |pages=678–683 |doi=10.1177/070674370404901005 |pmid=15560314 |s2cid=8304723 |doi-access=free}}</ref><ref name="pmid15503730" /> The social cues involved in diagnosis may be instrumental in shaping patient behavior or attribution, such that symptoms within one context may be linked to DID, while in another time or place the diagnosis could have been something other than DID.<ref name = Paris2012/> Other researchers disagree and argue that the existence of the condition and its inclusion in the DSM is supported by multiple lines of reliable evidence, with diagnostic criteria allowing it to be clearly discriminated from conditions it is often mistaken for (schizophrenia, borderline personality disorder, and seizure disorder).<ref name = Cardena/> That a large proportion of cases are diagnosed by specific health care providers, and that symptoms have been created in nonclinical research subjects given appropriate cueing has been suggested as evidence that a small number of clinicians who specialize in DID are responsible for the creation of alters through therapy.<ref name = Hersen2012/>

===Differential diagnoses===
Patients with DID are diagnosed with 5-7 comorbid disorders on average – higher than other mental conditions. Misdiagnoses (e.g. schizophrenia, bipolar disorder) are very common among patients with DID.<ref name=Gillig/>

Due to overlapping symptoms, the differential diagnosis includes [[schizophrenia]], normal and rapid-cycling [[bipolar disorder]], [[epilepsy]], [[borderline personality disorder]], and [[autism spectrum disorder]].<ref name=Shibayama>{{cite journal | author = Shibayama M | title = Differential diagnosis between dissociative disorders and schizophrenia | journal = Seishin Shinkeigaku Zasshi = Psychiatria et Neurologia Japonica | volume = 113 | issue = 9 | pages = 906–911 | year = 2011 | pmid = 22117396 }}</ref> Delusions or auditory hallucinations can be mistaken for speech by other personalities.<ref name=Spiegel/> Persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotizability and reports from family members or other associates indicating a history of such changes can help distinguish DID from other conditions. A diagnosis of DID takes precedence over any other dissociative disorders. Distinguishing DID from [[malingering]] is a concern when financial or legal gains are an issue, and [[factitious disorder]] may also be considered if the person has a history of help or attention-seeking. Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with [[dissociative disorder not otherwise specified]] rather than DID due to the lack of identities or personality states.<ref name = dsm>{{cite book | last = American Psychiatric Association| author-link = American Psychiatric Association | title = Diagnostic and Statistical Manual of Mental Disorders-IV (Text Revision) | volume = 1 | pages = [https://books.google.com/books?id=3SQrtpnHb9MC&pg=PA526 526–529]| date = June 2000 | publisher = American Psychiatric Publishing, Inc. | location = Arlington, VA, US | isbn = 978-0-89042-024-9 | doi = 10.1176/appi.books.9780890423349 | title-link = Diagnostic and Statistical Manual of Mental Disorders | doi-broken-date = 16 December 2024 }}</ref> Most individuals who enter an [[emergency department]] and are unaware of their names are generally in a psychotic state. Although auditory hallucinations are common in DID, complex visual hallucinations may also occur.<ref name=Gillig>{{cite journal |author=Gillig PM |title=Dissociative Identity Disorder: A Controversial Diagnosis |journal=Psychiatry |volume=6 |issue=3 |pages=24–29 |year=2009 |pmid=19724751 |pmc=2719457}}</ref> Those with DID generally have adequate reality testing. People with DID may have more positive and less negative Schneiderian symptoms of schizophrenia.<ref name=Cardena2/> The DID persona perceives any voices heard as coming from inside their heads whereas the schizophrenia persona perceives voices as external.<ref name=Hersen2012/> In addition, individuals with psychosis are much less susceptible to hypnosis than those with DID.<ref name=Spiegel/> Difficulties in differential diagnosis are increased in children.<ref name=Boysen/>

DID must be distinguished from, or determined if comorbid with, a variety of disorders including [[mood disorder]]s, [[psychosis]], [[anxiety disorder]]s, PTSD, [[personality disorders]], [[cognitive disorder]]s, [[neurological disorder]]s, [[epilepsy]], [[somatoform disorder]], [[factitious disorder]], [[malingering]], other dissociative disorders, and [[trance]] states.<ref name=Sad2007>{{cite book | last = Sadock | first = B.J. |author2=Sadock, V.A. | title = Kaplan & Sadock's Synopsis of Psychiatry |series=Behavioral sciences / clinical psychiatry | year = 2007 | publisher = [[Lippincott Williams & Wilkins]] | location = Philadelphia, PA | isbn = 978-0-7817-7327-0 | pages = 671–6 |chapter = Dissociative disorders – Dissociative identity disorder | chapter-url=https://books.google.com/books?id=u-ohbTtxCeYC&pg=PA671 | edition = 10th}}</ref> An additional aspect of the controversy of diagnosis is that there are many forms of dissociation and memory lapses, which can be common in both stressful and nonstressful situations and can be attributed to much less controversial diagnoses.<ref name = Paris2012/> 

A relationship between DID and borderline personality disorder has been posited, with various clinicians noting overlap between symptoms and behaviors and it has been suggested that some cases of DID may arise "from a substrate of borderline traits". Reviews of DID patients and their [[medical record]]s concluded that 30-70% of those diagnosed with DID have comorbid [[borderline personality disorder]].<ref name=Gillig/>

The DSM-5 elaborates on cultural background as an influence for some presentations of DID.<ref name=DSM5/>{{rp|style=ama|p= 295}}

{{blockquote|Many features of dissociative identity disorder can be influenced by the individual's cultural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the characteristics of other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion.|sign=|source=}}