Dissociative identity disorder (DID) is characterized by the existence of dissociative identities, disruption of identity and identity alteration, amnesia, depersonalization, and derealization . Over 80% of patients with DID experience auditory hallucinations, and identity alteration is sometimes similar to the symptoms of other mental illnesses, such as delusional thoughts of being controlled. Since DID shares many of its symptoms with schizophrenia, there are difficulties associated with differential diagnosis, with errors in diagnosis leading to inappropriate treatment . The patient in this case study had been diagnosed with schizophrenia and depression at a different hospital, with symptoms of auditory hallucinations and suicide attempts and a medical history that included pharmacotherapy and an inpatient treatment program. Afterwards, he was diagnosed with DID with nine alternate personality states (alternate identities, “alter/alters”) at our clinic, underwent two hospitalization at the department of psychiatry’s closed ward, and has significantly improved symptoms through continuous outpatient treatment. This case study is the first reported case of adolescent DID in Korea and is being introduced to emphasize the importance of differential diagnosis between DID and other mental disorders, such as schizophrenia, and to share the specific treatment approach of ego state therapy that had been applied to this case.
A 16-year-old male patient visited our outpatient clinic for the evaluation of auditory hallucinations and impulsive behavior of stabbing his mother’s forehead with a knife. The patient was born from a planned pregnancy with no reported medical history during the perinatal or postnatal period. The patient experienced numerous traumatic events starting from his childhood, with both parents engaging in severe conflicts that resulted in a two-way domestic assault over the course of their marriage. The patient recalls his parents fighting before his eyes when he was approximately 5 years old, when his father threw an electric fan at his mother, which knocked her unconscious as it struck her head. He remembers heading to the hospital with his mother in an ambulance, trembling with fear of the possibility of his mother dying from the injury. His parents had divorced when he was about 8 years of age; for a few months following the divorce, the patient kept his eyes closed at all times, except when he was walking on the road or eating his meals. He has been bullied at school since the 1st grade, with most of his school life being spent in solitude. When he was approximately 11 years of age, the patient had witnessed his alcohol-intoxicated mother stabbing herself in the abdomen with a knife in their house. When he was about 13 years of age, the patient spent most of his time playing mobile games at home, excluding the time when he was at school. He had gotten into conflict with his mother regarding this issue, with verbal arguments escalating to the point of his mother throwing and breaking his phone repeatedly on multiple occasions. As the patient quarreled with his mother over his phone, the situation sometimes escalated to the point of his mother strangling the patient’s throat or beating his mother until she had black eyes. When he was about 15 years of age (1 year prior to visiting our clinic), the patient started experiencing auditory hallucinations of three beings talking to him: someone who tells the patient to kill, another who tells the patient to kill himself, and a third one who tries to stop these two beings. The patient killed his pet turtle by chopping it with a knife, and he also caught wild pigeons from the roadside to stab them to death. Reacting to the auditory hallucinations, the patient engaged in self-harm by injuring his thighs with a knife and attempted to commit suicide by jumping from the roof of his school. Subsequently, he visited a different psychiatric clinic and started pharmacotherapy with antipsychotics and antidepressants, from the impressions of schizophrenia and depression. Although the patient faithfully followed the medication regimen, the symptoms of auditory hallucinations did not improve. Six months prior to visiting our clinic, he reacted to a voice that told him to kill a person and tried to stab his friend—who was next to him at the time—with a pen. Due to this incident, he was admitted to a closed ward of a different psychiatric clinic to receive a 2-week inpatient treatment. While the auditory hallucinations seemed to have improved since hospitalization, the patient started hearing auditory hallucinations again, starting from 3 months prior to visiting our clinic. The auditory hallucinations tended to occur when the patient was at crowded places, where the three beings—one male, one female, and one unidentified being—would start talking to him with words such as “Kill. If you do not want to, die.” Despite having increased the dosage of his medication, his auditory hallucinations did not improve to the point where the patient started to leave early from school on more frequent occasions, being unable to eat even a single bite of his school lunch. Two weeks prior to visiting our clinic, the patient’s mother handed the patient a knife as she said, “If you are going to make me suffer so, why don’t you rather just kill me,” while she was intoxicated with alcohol. As they were quarreling with each other, the patient stabbed his mother’s forehead by accident. The patient was given recommendations for receiving treatment at an advanced hospital. The patient visited our outpatient clinic for evaluation and treatment and he was admitted to our inpatient psychiatric unit.
Written informed consent was obtained from the patient and his mother for the publication of data and images included in this article. This case study was reviewed and approved by the Institutional Review Board of the Jeju National University Hospital (IRB no. 2022-03-006).
At the time of hospitalization at our inpatient psychiatric unit, the patient was a 174 cm-tall male adolescent weighing 88 kg, with greasy hair and poor hygiene, and had no facial expressions and spoke with a dry and monotonous voice. He said that there were three beings inside himself, and that those voices sometimes command him to stab his mother. He also reported that it was not him who stabbed his mother, but the ‘crow monster’ inside himself. He continued by saying that he was a child who could not feel any emotions. For a thorough evaluation of the patient, a psychiatric interview regarding the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), mental status examination, laboratory tests, brain imaging studies, electroencephalography, and full psychological test for adolescents were administered. Other than hyperprolactinemia (prolactin 67.08 μg/L), there were no noteworthy medical opinions from the laboratory test results. There were also no noteworthy medical opinions based on the brain imaging studies and electroencephalography. Results of the full psychological test for adolescents indicated a Full Scale Intelligence Quotient of 92, and the results of the projective tests suggested no cognitive distortions. In addition, there were no indications of noteworthy aspects from the results of the Minnesota Multiphasic Personality Inventory.
Regarding the ‘three beings within himself’ reported by the patient, it was necessary to have a differential diagnosis for DID. To evaluate for dissociations, the Adolescent Dissociative Experiences Scale (A-DES), which is the adolescent version of the most commonly used measure of dissociation in clinical settings called the Dissociative Experiences Scale (DES), was administered. The DES consists of 28 items measured on the scale of 0–100, each of which is categorized into one of the following four subdimensions: identity confusion/ alteration, absorption, depersonalization/derealization, and amnesia [3,4]. The A-DES consists of 30 items, each measured on a 10-point Likert-type scale; a mean total score of 3.7 in the A-DES was previously found as the standard for ‘significant dissociation’ . In a study of the A-DES of Turkish adolescents, the mean total score of the A-DES was reported to be 6.2 points for the ‘dissociative disorder’ group, 3.9 points for the ‘posttraumatic stress disorder (PTSD)’ group, and approximately 2.4 points in the ‘non-clinical,’ ‘mood disorders,’ ‘attention deficit hyperactivity disorder,’ and ‘anxiety disorders’ groups . A study on the validity of the A-DES in Korea reported a mean total score of 2.05 points in the ‘traumatized’ group, which was significantly higher than the score of 0.75 points in the ‘normative’ group .
The patient in this case study had high levels of dissociation based on a mean total score of 6.77 points on the A-DES administered during hospitalization. Regarding the item scores in the patient’s A-DES response, items such as “I have strong feelings that don’t seem like they are mine,” “Something inside of me seems to make me do things that I don’t want to do,” and “I feel like there are different people inside of me” in the identity confusion/alteration subdimension had the highest scores, all of them with 10 points. Items such as “I get confused about whether I have done something or only thought about doing it” and “I can’t figure out if things really happened or if I only dreamed or thought about them” in the amnesia subdimension also had high scores (8–10 points). However, items such as “I find myself standing outside of my body, watching myself as if I were another person” in the depersonalization/derealization subdimension were scored very low at 0 points.
Although the patient reported suffering from auditory hallucinations for almost 1 year, there were no clear observations of disorganized speech or behavior, or the negative symptoms of schizophrenia. The patient experienced disruption of identity characterized by three or more distinct personality states. He had gaps in his recall of specific past memories; childhood trauma experiences were discovered and understood thoroughly during the treatment process. In addition, the patient had multiple occasions when he failed to remember the activities that he had done in person, or was surprised when he discovered evidence of such activities after the fact. The combination of such testing results and clinical features suggests that the patient’s diagnostic impression was closer to that of DID than schizophrenia, which was his previous diagnosis from a different clinic.
Regarding the treatment for DID, various methods are being implemented, including pharmacotherapy, cognitive behavior therapy, and eye movement desensitization and reprocessing (EMDR) . One of these methods is ego state therapy, where the clinician comes face-to-face with various ego states within the patient . Ego state therapy also uses hypnosis as a treatment method and has been combined with trauma processing therapy methods (e.g., EMDR) to be developed into a therapeutic intervention for patients with symptoms of trauma and dissociation . Ego state therapy aims to promote the proper functioning of a patient’s internal system, which is composed of multiple ego states, by connecting the memory of each state with those of the others, while accepting the differences that exist between the states and respecting the values of reciprocity and cooperativity [9-11]. During the course of two hospitalizations for treatment, the following were administered: psychoeducation regarding emotions, trauma-focused psychotherapy that includes stabilization, and family therapy. In addition, since the patient lacked awareness of his alters and experienced a loss of control, the clinician also utilized ego state therapy to identify and approach the patient’s alters. Pharmacotherapy was administered as an accompanying treatment to control the patient’s underlying symptoms of depression, anxiety, impulsiveness, and aggression (first hospitalization: 200 mg sertraline and 300 mg quetiapine; second hospitalization: 100 mg sertraline and 5 mg aripiprazole).
In ego state therapy, the patient was allowed to explore the space of his mind through hypnosis with his eyes closed; the clinician and the patient have named that space the ‘Mind’s Room.’ Inside the Mind’s Room, as described by the patient, was a table, a sofa, three dogs, and 15 trees; on the ceiling, there was a large eye that could observe the inside of the room. There were four doors, each leading to either the ‘Computer Room,’ ‘Jungle,’ ‘Desert,’ or ‘Basement.’ The three alters reported by the patient could be met in the Mind’s Room; as ego state therapy progressed, the other spaces connected to the main room by the four doors were explored, resulting in the discovery of nine total alters (Table 1). Each time a new alter was discovered, the clinician could recognize the identity alteration, as the patient’s facial expression, manner and content of speech, and posture would also be changed simultaneously. There were alters that were aware of each other, but there were also those who had no knowledge of the other until the clinician introduced them to each other. Among these alters, some had been perceived by the patient, whereas others were affecting the patient without the patient knowing their existence. For each of the nine alters, the patient gave names derived from birthstones. According to the patient’s report, excluding ‘Emerald’ who came into existence when he was 4 years old, all alters were created when he was about 15 years old. Centered around ‘Agate,’ who served as the leader, there were dynamic relationships between the alters, with each alter playing a role related to the major emotions of the patient.
At the time of hospitalization, while the patient had some awareness of the beings inside himself, he had lost his sense of control over the auditory hallucinations and the timing of amnesia and/or identity alteration. Through ego state therapy, the patient experienced a detailed inspection and understanding of his own ego states. In a safe treatment space that could be controlled by the clinician, the patient explored the Mind’s Room together with the clinician; when the patient experienced anxiety, stabilization (such as grounding and containment) was used to control the patient’s sense of anxiety. Through this process, the patient increased his awareness of his own states and had more control over himself. Since the patient was fond of drawing, he depicted the Mind’s Room and each of the alters with pictures. Through the treatment process, he organized the changes in his mind by making drawings that captured the characteristics of each alter (Figs. 1 and 2).
Prior to treatment, the patient’s alters increased the patient’s sense of confusion by being activated separately, or by confronting each other in the patient’s mind. Through the treatment process, these alters gained awareness of each other’s existence in the patient’s psychic world, understood each other’s positions, and acknowledged the existence of each other. When the patient was faced with difficult decisions, he occasionally found an appropriate measure by having a meeting between the alters; this was different from the past, where the alters would intemperately expose their emotions uncontrollably. As a result, the alters who were alone and isolated in the past became capable of living with each other and started to show signs of communication and understanding between them. The relationship between the alters, which have become intimate and comfortable with each other, has been depicted in the patient’s drawing (Fig. 3).
Since the process of building expertise on ‘acknowledging and making decisions regarding one’s emotions’ is accompanied by heavy responsibilities for the patient, there were moments when the patient wanted to give up his pursuit of the process. During the hospitalization period, a different female patient asked the current patient if they could meet outside the clinic. As the patient was not attracted by the female patient, he wanted to refuse the offer; however, it was difficult for the patient to behave in a manner that matched his emotions. The patient wanted to escape from the burden of such decisions and wished some other alters in his mind to take his place and make the tough decision for him. The patient retreated in his psychic world, telling the clinician that this was unbearable for him. In the absence of the controlling entity, other alters took turns appearing in front of the clinician. The clinician could associate this moment with the formation process of the patient’s alters: when the patient decided that he wanted to escape from difficult emotions, the alters were created to bear the emotions in his place. However, during the treatment process, the patient realized that he cannot delegate all of his decisions to the other alters within his mind and recognized the need to behave autonomously based on the emotions he felt himself. He then communicated his polite yet honest refusal to the female patient. The patient was starting to develop his own capability, so that he no longer had to rely on the alters. The patient, who had let go of his control over emotion regulation since he was afraid of sensing his emotions, has acknowledged through the treatment process the fact that he needs emotions, as well as the ability to control them.
For the patient, whose emotions had been divided into the alters, controlling his emotions meant the same as being able to control his alters. Throughout the treatment process, the patient’s control gradually grew until he had the most influence; over time, the alters could no longer expose themselves at their will and could surface only if the patient allowed them to, in cases of necessity. In this process, the frequency of appearance of the alters decreased over time, and the patients’ sense of confusion was also reduced. At the time of hospitalization, the patient reported that he could not sense emotions, and his emotions were represented by alters. For the patient who had difficulty recognizing his own emotions, it was even more difficult to empathize with the emotions of others. During treatment, the patient had experienced having his emotions understood by the hospital medical staff in a stable relationship and had received education on perceiving and expressing his emotions. Gradually, the patient was able to express his emotions with verbal terms (e.g., anger, depression, and anxiety) rather than expressing them through the activation of his alters. This is considered to be the result of the patient being less afraid of his own emotions due to the novel experience of ‘a sense of security’ in the treatment environment, something that he could not experience in his previous relationships.Therapeutic process outside
After discharge from the first hospitalization, the patient showed a remarkable decrease in impulsive and aggressive behavior, with a decrease in the frequency of appearance of the alters; however, it was difficult for him to adapt to reality. Sensing the emotions that had been delegating to the alters on his own and determining his behavior accordingly can be considered more difficult for the patient, in a certain sense. The patient’s family members have difficulty empathizing with the patient, who still finds it difficult to adapt to reality, which then worsened the conflict. In this process, a second hospitalization was performed to help the patient with emotional difficulties and adaptation.
If the first hospitalization focused on treating the patient’s internal dimensions, the second admission focused on external dimensions, such as family conflicts and school refusal. By providing psychoeducation on DID to the family, the clinician attempted to help the family understand that symptoms such as dissociation and amnesia were the best means of survival for the patient in his circumstances, rather than an escape mechanism or intentional malingering from the patient. Likewise, through psychoeducation, the patient understood that it was difficult for laypersons, such as the patient’s mother, to understand an illness like DID and that this process could take some time. He realized that his mother’s inability to understand him was, in reality, the consequence of the difficulty she had in understanding the illness. The clinician intervened in the impulsive and hurtful speech between both parties, communicating the presence of sincere worries and love contained within such words and disentangled misunderstandings that had been left unresolved, which had occurred in multiple occasions.
Through family therapy, the family members tried to understand each other’s positions; thus, the conflict between the patient and his mother decreased markedly compared to that in the past. The patient had time to self-reflect on the consequences of his immature behavior and showed a decrease in problematic behaviors. In turn, he was able to return to school and became capable of living in his daily life since his life pattern had been restored. Since he started receiving treatment at our clinic, he had better access to treatment resources, which enabled him to receive financial support for his studies. Despite such improvements, reality remains a series of difficult experiences for the patient, and there are times when he faces surges of anger, depression, and voidness. Through interventions for the patient’s disruption of identity, provided through the two hospitalizations and outpatient treatment, the patient no longer suffered from the external symptoms of abrupt identity disturbance. However, the patient’s inner conflict persisted, along with the feeling of depression caused by the conflict. Nevertheless, the patient chooses to sense such emotions and make judgments himself, rather than delegating the task to the alters in his mind. In a sense, this is even more difficult for the patient, but he is still living his life as he deals with such challenges. The patient is deprived of developmental experiences, has a weak ego function, and is still in his adolescence, that is, he is still immature compared to an adult. In future treatment processes, longterm procedures of ‘working through’ will be even more necessary to promote the continuous growth of the patient’s developmental level and ego functions.
There have been four cases of DID reported in Korea, all of which have been adults [12-14]. In Korea, this case study is the first reported case of DID in an adolescent. The prevalence rate of DID is reported to be significantly lower in Asian nations (0%–0.5%), compared to that reported in Western countries of North America and Europe (1%–5%) . This is considered to be the consequence of previously diagnosing DID mainly as a possession disorder in Asian nations  and the fact that Korean clinicians are not accustomed to the diagnosis of DID . Specifically, it is important to pay attention to this matter, since undiagnosed DID in Asian nations can be understood as a ‘possession state’ by the patient’s acquaintances, leading the patient to rely on shamanistic interventions rather than appropriate treatment methods, in which the patient may even experience adverse effects.
In systematic ecological research, it has been observed that most DID patients have a history of severe and chronic child abuse . A high proportion of patients with pathological DID also have a history of childhood trauma . It has been observed that there is a statistically significant association between trauma, including physical abuse, and symptoms of dissociation . Insecure attachment relationships also affect the relationship between childhood trauma and symptoms of dissociation in adulthood. This leads to imperfections in the function of resilience (i.e., vulnerability in the functionality of autonomous emotion regulation), which increases the likelihood of dissociative reactions, potentially resulting in the dissociation of identity such as identity alteration .
As such, repeated exposure to trauma, including childhood abuse, are painful experiences that cannot be integrated within the patient . In this case, where there were many traumatic experiences, dissociation was used as a defense mechanism to protect oneself from painful experiences; by being incapable of sensing emotions, the patient could avoid the agony of such experiences. However, since emotion is an essential component of life, entities were created within the patient’s psychic world to sense the patient’s emotions in his place; therefore, the patient’s alters acquired their characteristic emotions, each being in charge of a major one. During ego state therapy, the alters have voluntarily reported to the clinician that, “We are like vigilantes who had no choice but to mobilize, in order to protect ourselves in a state of anarchy.”
Through an amnesic barrier, dissociation can prevent the patient from recognizing major experiences . The Mind’s Room of this case was separated into different spaces by the four doors found in it. During the ego state therapy, treatment procedures conducted in a specific space were not recognized by the alters that were located in the other spaces. It seems that a dissociative barrier had been embodied in the patient’s psychic world, which prevents the alters from recognizing the existence of each other depending on the characteristic or role of each alter; this is also associated with the symptoms of amnesia commonly observed in patients with dissociation. Depictions in the drawings of the patient in this case study (e.g., his alters and the structure of the Mind’s Room; Figs. 1-3) are considered a useful resource for clinicians who wish to understand the internal dimensions of DID patients.
Through this case study, the authors emphasize the importance of DID diagnosis, as well as its differential diagnosis from other illnesses. Symptom patterns of DID, which are generally subtle and covert, differ from those portrayed in the media, which are more dramatic or histrionic . Across studies, patients with DID spend an average of 5–12.4 years in the mental health system before correct diagnosis, receiving an average of 3–4 incorrect diagnosis . For adolescents with symptoms of mental illness, such as auditory hallucinations, especially those with a history of exposure to traumatic experiences, the differential diagnosis of DID is necessary prior to the diagnosis of schizophrenia. Over 80% of patients with DID report auditory hallucinations , and research also suggests that patients with DID report auditory hallucinations more often than patients with schizophrenia, with both groups being younger than 18 years of age . Unlike schizophrenia, DID does not have prominent symptoms of formal thought disorders or any negative symptoms . For an accurate differential diagnosis, it is necessary to check whether the patient has a history of childhood trauma and whether the patient is experiencing symptoms such as amnesia, identity alteration, and dissociative experiences. For the evaluation of dissociative experiences in adolescents, measures such as the A-DES can be helpful.
Patients with DID are sometimes misdiagnosed as bipolar disorder, most commonly as bipolar II disorder. Patients with bipolar disorder are episodic and show slower mood changes; in contrast, patients with DID show rapid and subjective shifts in mood across their dissociative states . Dissociation can also occur in patients with bipolar disorder; symptoms of dissociation can appear prior to the onset of bipolar disorder and are associated with a worse prognosis and larger numbers of mood swings for patients with bipolar disorder . In a patient with DID and comorbid bipolar disorder, the bipolar disorder responded to pharmacotherapy, and it was only possible for psychotherapy as treatment for DID to demonstrate its efficacy after the symptoms of bipolar disorder had been controlled; thus, it can be hypothesized that the effectiveness of pharmacotherapy can be used to differentiate the two illnesses .
Since identity alteration observed in DID can be considered to be elaborate displays of trauma-related symptoms (e.g., intrusion and avoidance) that appear in PTSD, the two illnesses have similarities. However, since DID has distinct identities that can be identified at the conscious level (multiple “I” selves), it is different from PTSD .
This case had severe behavioral problems when he lost his sense of control and clearly displayed alterations between different identities during hospitalization. With high scores of dissociation indicated on the A-DES results and reports of ‘relationships with other people being changed without the patient’s knowledge’ during the psychiatric interviews based on the diagnostic criteria of the DSM-5, the patient also reported recurring gaps in the recall of everyday events. The patient reported amnesia for the following: major accidents in the past, parental abuse, and verbal assault toward his parents. Through such evaluative and treatment procedures, the patient was diagnosed with DID, and the influence of other medical conditions, substances, or mental illnesses was ruled out by reviewing the results of the psychiatric evaluation, laboratory tests, brain imaging studies, electroencephalography, and full psychological tests for adolescents. Through such diagnostic procedures, the patient was somewhat relieved, as he started to gain an understanding of his symptoms, which had been causing him a lot of confusion.
DID is occasionally misdiagnosed, making it difficult for patients to receive appropriate treatment. When childhood and adolescent traumatic experiences (e.g., school bullying, chronic abuse and neglect) are present in a patient, similar to that of this case study, the clinician need to be ready to evaluate and treat dissociative disorders. Specifically, for adolescent patients starting to develop symptoms of nonspecific psychotic symptoms including hallucination, it is necessary to have detailed evaluations of their traumatic experiences and dissociation.
The datasets generated or analyzed during the study are not publicly available due to the copyright and privacy restriction, but are available from the corresponding author on reasonable request.
The authors have no potential conflicts of interest to disclose.
Concepturalization: Sang-Hun Lee, Duk-Soo Moon. Data curation: Sang-Hun Lee. Formal analysis: all authors. Investigation: Sang-Hun Lee, Duk-Soo Moon. Methodology: all authors. Project administration: Sang-Hun Lee. Supervision: Na Ri Kang, Duk-Soo Moon. Writing— original draft: Sang-Hun Lee. Writing—review & editing: Duk-Soo Moon.