At what age did you (or someone you know) have an imaginary friend as a child? Were you able to “see” this imaginary friend and hear his or her voice? At what age did this imaginary world begin and end? For many adults, a child’s imaginary friends and world are the epitome of a great early childhood experience. It’s a normalized part of childhood development. In fact, it’s a normal part of development throughout the lifespan. Most parents become greatly concerned if their child doesn’t have a fantasy world at some point during the early years. Even more, many of us adults enjoy the fantasy world of Walt Disney World and Disney Land fictional characters. Some of us would spend our entire paycheck just to see Mickey and Minnie Mouse! But we know that these fictional characters are just that, they’re fictional. For children who are showing signs and symptoms of something more severe such as a psychotic disorder, the fantasy world is not a fantasy, but a very real part of their lives. This article will explore and discuss dissociative symptoms and psychotic symptoms that could eventually become “multiple personality disorder” (or as it is referred to today Dissociative Identity Disorder – DID). In the questions and answers section, I would love to hear your thoughts on whether or not you believe the disorder of multiple personality disorder or DID actually exists. It continues to be very controversial.
It is important to mention at the start of this article that multiple personality disorder is not a common diagnosis in children. In fact, there is very little to no literature that explores the diagnosis of multiple personality disorder in children or teens. Most clinical studies have involved adults who had very traumatizing childhoods. However, there are research studies focusing on childhood symptoms such as dissociation that can eventually become a multiple personality disorder in adulthood. Multiple personality disorder is a very controversial diagnosis and it has been since its birth in the 3rd edition of the DSM which was around 1980. It wasn’t until 1994 that multiple personality disorder was changed to DID – Dissociative Identity Disorder. This title change not only de-stigmatizes the so-called illness but also captures the essence of the disorder’s main characteristic, which is the dissociative symptoms that removes the person from reality. Dissociation has been defined as a separation from reality or an unconsciousness that disrupts memory, identity, or sense of self for a temporary period of time. It is a more severe and complicated form of daydreaming and tends to occur under stress, fear, a history of severe abuse and trauma, or anxiety. For many people, dissociation occurs on a spectrum in which there are mild forms and severe forms requiring medication and therapy. In some severe and rare cases, hospitalization or placement is required. As I have explained in previous articles on this topic, some cultures refer to dissociation as a “possession” or a “possession trance.” Possession trance is a term more frequently used in Asia and India and refers to a transient alteration whereby one’s normal identification is replaced by a spirit, ghost, or other similar entity. This view of dissociation is culture-bound but can offer a great deal of insight into what some people feel they actually experience.
For the purposes of keeping this subject simple and to the point, I will use the former term multiple personality disorder throughout this article. It is very difficult for many of us to imagine what a multiple personality disorder could look like. We don’t typically see examples of this in daily life and many psychiatrists and other mental health professionals stray away from discussing this topic, diagnosing the disorder, or educating the public about it. It’s highly controversial, research is lacking for certain populations such as children and teens, and many mental health professionals have not been trained to treat it or provide education on it. Sadly, society has been left to learn about the diagnosis through television or movies which tend to sensationalize the illness. However, some professionals have had the rare experience of having a client who exhibits traits of multiple personality disorder (or DID) which makes identification of similar clients a bit easier. Such an experience occurred in my agency some years ago. I was assigned a case of a child who had experienced a significant amount of trauma while growing up in an orphanage in Russia. The child was brought to my agency for behavioral problems in the home, school, and community. Behavioral problems were severe and often included extreme outbursts toward family and friends, refusal to complete schoolwork, and oppositional behaviors. Tantrums were severe, behaviors were threatening, and verbal aggression became increasingly more difficult over time. But what really stood out about this client was that his so called “bad self” was named “Billy.” “Billy” was the child who would grab knives from the kitchen at night to kill his mother, he was the child who would refuse to do schoolwork because he was powerful enough not to receive consequences, and who would hurl so many insults and curse words that one bar of soap wouldn’t stop it. “Billy” would mysteriously appear during restraints in the agency, during moments where this child would not listen to staff or comply with rules or routine. “Billy” was also the child who would refuse to have individual and family sessions because ‘ “Billy” only had so many hours he would be here with me.’ My client identified himself so much with this other person that other therapists in the agency began to refer to “Billy” as an alter ego, a different version of the child or the opposite side of his personality. But the truth was that this “Billy” person did not appear to be an alter ego of some kind but rather a a highly entwined component of my client’s overall identity. An alter ego is basically a personality that might reflect opposite behaviors, desires, or emotions than your true personality. Sometimes we will dress according to the way in which we believe our alter ego would have us dress. For example, you might dress very conservatively during the workweek and dress very down during the weekend. Your work attire might reflect a clam, laid back business person. But your weekend attire might reflect a 90s pop style or very much like me, you might enjoy wearing your converse shoes, curly hair, and hip jeans to the grocery story. An alter ego is another aspect of your steady personality. It is not psychotic, it is not abnormal.
An individual with a multiple personality disorder can be difficult to understand because the “different personality” causes noticeable changes in attitude, dressing style, language, writing style, memory, and even tone of voice. The above client would sometimes report to therapy with a very confident and arrogant attitude one week and return the next week very irritable and self-conscious. This child did not exhibit a different tone of voice, accent, or attitude, but called on “Billy” when he felt trapped, unsafe, challenged, or afraid. Once “Billy” would appear, my client would appear extremely intuitive, calm, and in control. At times, staff would have to restrain him as “Billy” would become violent and challenging. Once the incident of being restrained was over, the child would “forget” everything and report that he was “gone for a little bit so Billy could take over and protect me.” His adoptive parents thought that he had an imaginary friend that he fantasized as his rescuer. But when this idea fell to the ground, they then began to think that perhaps Billy was an excuse for negative behaviors and a way to control others. After 90 days of observing this child, I began to suspect that “Billy” was actually a component of the client’s self that is stronger and less afraid than he himself. During the extreme trauma of his early childhood years, he had no way of escape but to dissociate from the fear, the pain, the trauma. His “dissociation” created a “stronger self” that exited at opportune times to protect his fragile inner-self. Whether this was a true “DID” remains to be seen, but he certainly created “two selves” to cope with his trauma.
For many people, including mental health professionals, the idea of multiple personality disorder is not only complicated but hard to believe. Even as a professional, I wrestle with questions of my own such as “why doesn’t most people who experience severe trauma exhibit this pattern of behavior? or “why do we see this pattern of behavior in adults and not children as much?” or “why have we stayed away from diagnosing children with DID (even when they exhibit symptoms that are very similar) if we believe the disorder truly exists? Of course, I am not the only professional in this field who asks these questions. You must understand that mental health professionals are always in search of answers to life’s most complicated situations. But reality is that we don’t always have the answers and if we do find what appears to be the answer, we can guarantee that there are more questions to be answered. It’s a very complex dichotomy. Even clergymen and theologians struggles to find answers to this “diagnosis.” For many laypeople, the diagnosis does not exist. There are so many opinions and views on this single diagnosis.
After having worked with a few children who exhibit very similar behaviors to DID, I found specific ways to challenge myself to identify what could possibly be going on. There are 4 signs that a child could possibly be exhibiting signs of severe dissociation. You want to remember that:
- It is not schizophrenia: Dissociative symptoms can look very much like schizophrenia or some kind of psychotic disorder. Some parents have asked me what the differences are due to the behavior appearing “psychotic” and very similar. I agree. But the difference is that dissociation is a split-off from reality into another realm of existence that can often be accompanied by a change in appearance, tone of voice, writing style, or attitude and behavior. A hallucination is a perception of something that is not present such as a figure or voice. For example, a visual hallucination is the perception of a figure or person or “ghost” that others cannot see. An auditory hallucination is hearing things others cannot see. Dissociation is a splitting off from reality (a severe form of daydreaming or zoning out).
- It is not a delusion: A delusion is a false belief held to be true despite evidence to the contrary. It is a belief that something is truly happening that is not happening. For example, a delusional belief could be that you will one day marry your favorite celebrity and that he/she has been sending you signals through their movies or music that you are their chosen one. You might go so far as to try to track this celebrity down or send he/she letters. Despite being arrested, having a PFA put on you, or being told by family and friends that you need psychiatric treatment, you believe you will one day be married. Severe dissociation can result in false beliefs but again, a delusion is not dissociation.
- It is not a state that someone can “snap out of”: For those of us who don’t fully understand dissociative symptoms, it can be very frustrating to live with this person or even provide therapy. It’s as if you are trying to provide therapy to or live with a totally different person. Some parents, like the parents above in the example case, yell “snap out of it would you?” to their children on a daily basis. But the reality is that this state of existence is not one that someone can just snap out of. It is a part of who they are. It’s their reality.
- It could be a good excuse for negative behaviors: Some kids, primarily those who are developing sociopathic or antisocial traits, are very good at manipulating situations for their benefit. Manipulation might include trying to convince others that they are “crazy” or not able to function appropriately or understand expectations. Some highly resistant children come to therapy and sit there, staring at everyone. Some kids are asked questions about their severe behaviors and kids often respond “what?” “What did you say, I didn’t hear you.” These kids often have a noticeable “blank stare” on their faces or you often feel as if you are not being listened to. This is not dissociation. It’s resistance.
It’s important to understand that self-diagnosis will never help you understand symptoms, but seeking professional input will. Because diagnosing someone can take weeks to months to years and require multiple tests, it’s truly difficult to compare symptoms online or take online tests to get answers. It’s best to seek out someone who has experience with DID or dissociation and ask for a consultation or meeting to discuss concerns. In many cases, you will have to do your own research and search for people who understand the specific symptoms you are observing (in yourself or someone else). Self-knowledge is extremely important and I encourage you to educate yourself, your family, and even the sufferer.
Do you know someone, possibly a child, who could have symptoms of multiple personality disorder? Why do you think multiple personality could be the diagnosis? Do you even believe this is a true diagnosis?
As always, I wish you well