What is the treatment for Dissociative Identity Disorder (DID)?

Treatment of Dissociative Identity Disorder

Trauma-focused psychotherapy is the primary treatment for Dissociative Identity Disorder (DID), with phase-oriented approaches being the established standard of care, though emerging evidence suggests brief intensive trauma-focused cognitive-behavioral therapy may be effective and should be considered to avoid unnecessarily prolonged treatment.

Primary Treatment Approach: Phase-Oriented Psychotherapy

The cornerstone of DID treatment is stage-oriented psychotherapy that mirrors treatment of other trauma-related disorders, beginning with stabilization before progressing to trauma processing. 1

Three-Phase Treatment Structure

The treatment follows a sequential approach 1, 2:

• Phase 1 (Stabilization): Focus on safety, symptom management, and strengthening coping skills before addressing traumatic material 1, 2
• Phase 2 (Trauma Processing): Direct work with traumatic memories once adequate stability is achieved 1, 2
• Phase 3 (Integration and Rehabilitation): Identity integration and functional rehabilitation 2

Important caveat: Traditional phase-oriented treatment has limitations—relatively few patients reach Phase 3, treatment duration is long, and effects on core DID symptoms can be small or absent 2. Additionally, unnecessarily prolonged stabilization phases may communicate to patients that they are incapable of dealing with traumatic memories, potentially reducing motivation for trauma processing 3.

Emerging Alternative: Brief Intensive Trauma-Focused CBT

A promising alternative approach treats dissociation as maladaptive avoidant coping and directly challenges both avoidance behaviors and dysfunctional beliefs about dissociation through brief, intensive trauma-focused treatment. 4

This approach demonstrated complete remission of both PTSD and DID diagnostic criteria in 2 weeks with maintained results at 6-month follow-up, though this is based on a single case report 4. After PTSD symptoms decrease, patients are offered a farewell ritual to say goodbye to their identities 4.

Schema Therapy Adaptation

Schema Therapy (ST) represents another integrative approach currently under investigation 2:

• Incorporates direct trauma processing through Imagery Rescripting 2
• Has shown reduction in PTSD symptoms, dissociative symptoms, and structural changes in beliefs about self 2
• Treatment involved 220 sessions in the reported case, demonstrating effectiveness but still requiring substantial duration 2

Dialectical Behavior Therapy (DBT) Adaptation

DBT can be adapted for DID treatment, particularly for patients with comorbid borderline personality disorder or high suicidality. 5

• DBT Stage 1 focuses on creating a safe therapeutic frame and addressing behavioral/safety issues before trauma work 5
• DID and BPD share high comorbidity, trauma histories, and suicidality, making DBT techniques particularly relevant 5, 6
• DBT's staged approach aligns with DID treatment principles of stabilization before trauma processing 5

Specific Treatment Considerations

Working with Alter Identities

Treatment must address the unique phenomenology of multiple identity states 1:

• Establish therapeutic relationships with different alter states as clinically indicated 1
• Use hypnosis judiciously when appropriate and with proper training 1
• Consider the heterogeneity of DID patients—high, intermediate, and low functioning groups require different treatment intensities 1

Matching Treatment to Patient Function

Treatment selection should be based on patient functioning and prognosis 1:

• High-functioning patients: More exploratory, integration-focused approaches 1
• Low-functioning patients: More supportive, stabilization-focused approaches 1
• Intermediate-functioning patients: Flexible combination based on clinical presentation 1

Pharmacotherapy Role

There is no specific pharmacological treatment for DID itself; medications target comorbid conditions only 7:

• Use psychotropic medications for comorbid psychiatric conditions such as depression, anxiety, or PTSD symptoms 7
• SSRIs for comorbid depression/anxiety 7
• Medications should target specific comorbid diagnoses rather than dissociative symptoms themselves 7

Critical Pitfalls to Avoid

Do not delay trauma-focused treatment indefinitely by insisting on prolonged stabilization phases, as this may have iatrogenic effects by suggesting the patient cannot handle trauma work 3. The assumption that patients with complex dissociative presentations are not sufficiently stable to tolerate trauma-focused interventions may not be evidence-based 3.

Do not assume affect dysregulation or dissociative symptoms require extensive pre-treatment stabilization—these symptoms can improve with trauma-focused treatment 3.

Do not confuse dissociative flashbacks with psychotic symptoms—flashbacks are intrusive PTSD symptoms where the patient acts as if trauma is reoccurring, not psychotic phenomena 3.

Practical Treatment Arrangements

Establish clear therapeutic boundaries and informed consent processes at treatment outset 1:

• Discuss pragmatic arrangements including session frequency, emergency contact procedures, and treatment duration expectations 1
• Obtain informed consent that addresses the unique aspects of DID treatment, including work with alter states 1
• Consider ancillary therapies and therapeutic modalities as adjuncts to primary psychotherapy 1