your thoughts are like river water running over stones

The basics

In short, DID can only develop in response to complex trauma before the age of 6, up to about 8 at the latest. To be more specific, DID requires the child to experience multiple severe, prolonged and varied traumas involving betrayal or abandonment from their primary caregivers. A genetic predisposition to dissociation is also required, but that isn’t as relevant to this post. 

When does the personality integrate?

Most people are aware that DID has to develop before the personality has fully integrated, which happens in early childhood. There isn’t an exact set age for when this happens, as psychological development is variable and hard to measure. 

However, people will often claim that it happens far later than it actually does. To understand why this is wrong we have to understand what we actually mean when we talk about the personality integrating. 

The human personality is made up of several different psychobiological systems of mental and physical actions we can take in response to our environment, and our understanding of those actions in relation to ourselves and the world.

These systems represent different functions of personality, such as attachment, self-care, exploration, reproduction, defense from threats, etc. There are multiple subsystems within these broader systems as well. 

These systems maintain themselves through the continuous integration of the experiences had within these domains. If this integration fails, their cohesive functioning will falter and dissociation may develop (as dissociating away from the memories held within these systems will naturally cause the systems themselves to dissociate away from each other as well).

Both dissociation and integration are active processes, they must continuously maintain themselves and they will turn into the other if they fail to do so. 

In a healthy adult, these personality systems function fluidly and cohesively, neither fully open nor fully closed to each other. They allow the person to seamlessly transition between different aspects of their personality as required, and create a base for a consistent identity to form on top of (which begins in late childhood and adolescence). It is not true that these parts all fuse into one singular entity; they simply come to achieve a basic level of cohesion that cannot be fully undone afterwards. 

In early childhood, these parts still function quite rigidly. In order for them to achieve this baseline level of integration, the child needs to continuously process the experiences they have within these domains, and be able to make sense of them in relation to each other. This is a long process that makes up the majority of the psychological development of early childhood. 

A child with an unintegrated personality will experience their personality systems separately, and will not be able to seamlessly transition between them. This is why young children seem so all over the place. 

For example, a younger child may be happily playing by themselves one minute, and then screaming and crying for their mother the next. This is because the personality functions of exploration (subfunction: play) and attachment (subfunction: attachment cry) have not yet integrated, and therefore they cannot function fluidly.  

An older child may instead quietly put down their toy and go to find their mother, because those two personality systems have been integrated. This is why the estimates for the exact age of when the personality integrates keep getting younger as the research progresses. Because how many children do you know above the age of 7 or 8 that function like the former instead of the latter? 

For DID to develop, there must be a total failure in the integration of these systems due to the structural dissociation of traumatic memory preventing them from being processed as part of a cohesive whole.

And as we have established, dissociation is an active process. One singular instance of dissociation is not enough to prevent the integration of the personality systems. In order for them to be as separated as required for the development of DID, heavy dissociation must be maintained before these parts are expected to achieve full integration. 

As such, the trauma (and resulting dissociation) must be prolonged before the age of around 6 to 8. Otherwise, the child will have made too much progress towards integration and not enough towards dissociation in order to form alters (although other trauma disorders are still a possibility). You can see this in the fact that on average, people with DID can trace back their first appearance of alters to around age 6 as stated here. 

“The typical patient who is diagnosed with DID is a woman, about age 30. A retrospective review of that patient’s history will typically reveal...emergence of alters at about the age of 6” 

To form noticeable alters, the person must have already experienced prolonged dissociation. Therefore, in order for the average patient to have alters emerge at age 6, their dissociation must have already been prolonged by that point, and the multiple traumas that caused said dissociation must have started significantly earlier. This is why the trauma itself starts at least before the age of 5-6, and often in infancy or the early toddler years.

From the DSM-V: 

“In the context of family and attachment pathology, early life trauma (e.g. neglect and physical, sexual and emotional abuse, usually before ages 5–6 years) represents a risk factor for dissociative identity disorder."

From here (again): 

“Putnam and his colleagues propose that DID arises from traumatized children’s inability to form a cohesive sense of self, leading to the emergence of alternate identities. This phenomenon is especially apparent when traumatic experiences occur before the age of 5.” 

And from The Haunted Self: 

“The older the child is prior to abuse and neglect, the more likely action systems of daily life have become more cohesive, and thus it is less likely that more than a single ANP would develop.” 

This is why things such as bullying are very unlikely to cause DID on their own (although they may be a part of the person’s overall trauma history). That would require preschool children to be able to bully someone to the severity necessary to develop DID (more on that later), as any older age group would be too late to create the necessary degree of separation before the age of integration is reached. 

Therefore, the complex trauma needs to occur long before the age of 6–8, almost always before the age of 5–6.

What is complex trauma?

The definition of complex trauma can vary slightly from source to source, but it is most consistently defined as experiencing multiple severely distressing events that are repeated and prolonged, involve betrayal or abandonment from primary caregivers, and occur at developmentally sensitive time periods.  

See the following definitions, sourced from here: 

“We define complex psychological trauma as resulting from exposure to severe stressors that (1) are repetitive or prolonged, (2) involve harm of abandonment by caregivers or other ostensibly responsible adults, and (3) occur at developmentally vulnerable times in the victim’s life, such as early childhood or adolescence.” 

And here: 

“Complex trauma describes both children’s exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term effects of this exposure. These events are severe and pervasive, such as abuse or profound neglect. They usually occur early in life and can disrupt many aspects of the child’s development and the formation of a sense of self. Since these events often occur with a caregiver, they interfere with the child’s ability to form a secure attachment.” 

It is important to contrast complex trauma from the other two classifications of trauma: acute and chronic. They are defined as follows: 

Acute: a singular, isolated traumatic event that engages a short-term sympathetic nervous system response. Includes one-off physical or sexual assault, natural disasters, accidents, etc. 

Chronic: a prolonged or repeated experience of a traumatic event that engages a more long-term sympathetic nervous system response. Includes experiencing one type of prolonged abuse, prolonged medical trauma, etc. 

More details here. 

Acute and chronic trauma cannot cause DID, and neither can regular stressors (more on that in the next section). Low stress tolerance also cannot make acute or chronic trauma “turn into” complex trauma; they are distinct phenomena. Complex trauma always requires the experience of multiple different prolonged traumas involving betrayal or abandonment from primary caregivers. 

It is important to note that while severity of trauma is subjective, complexity of trauma is not. Perceiving a non-complex trauma as being more severe than an average person would does not transform that experience into complex trauma.

Why is complex trauma required for DID?

DID exists on what is called the tertiary level of structural dissociation. Structural dissociation refers to the abnormal dissociative compartmentalization of traumatic memories, which leads to a divide between the personality systems of daily life and defense from threats (and in more complex forms; the division of these systems within themselves).  

The resulting divisions are apparently normal parts (ANPs) who do not contain traumatic memories and instead handle daily life, and emotional parts (EPs) who contain traumatic memories and the resulting emotional and behavioural responses. 

There are three levels of structural dissociation that are cumulative, meaning they each build off the level that precedes them: 

PTSD is on the primary level of structural dissociation, involving one ANP that comprises the majority of the personality and a rudimentary EP that holds the traumatic memory (which is usually acute, sometimes chronic). The separation between these parts is minimal. 

C-PTSD and trauma-based personality disorders are on the secondary level, involving one ANP that still compromises most of the personality, but several EPs that may be slightly more elaborated than in PTSD. This occurs when a person experiences multiple traumas that are too distinct for them to be contained in one EP, or when a repeated/prolonged trauma increases in severity in later instances and the existing EP’s threshold for re-traumatization is crossed. This causes the EP to structurally dissociate away from those experiences, creating another. 

DID is on the tertiary level, involving multiple ANPs and multiple EPs that have a high degree of complexity and separation from each other. This is caused by multiple severe traumas necessitating the creation of multiple EPs, and the trauma being so integrated into daily life at such a young age that daily life itself becomes traumatic, necessitating multiple ANPs. 

This means that in order to develop DID, the person must be pushed past the point of developing both PTSD and C-PTSD. They need to experience multiple different traumas to structurally dissociate their subfunctions of defense and create multiple EPs, and said traumas need to be extremely pervasive in daily life from a very young age in order to structurally dissociate their subfunctions of daily life and create multiple ANPs. 

From The Haunted Self: 

“Various traumatizing events may induce different sets of EPs. Each group of EPs usually experiences and contains traumatic memories related to a specific cluster of traumatic experiences. Groups of EPs are most often seen in tertiary structural dissociation, as DID patients tend to have experienced the most severe and multiple traumatizing events.” 

“We hypothesize that the origins of the divisions among ANPs lie in the inability of an unsupported, emotionally neglected, and abused child to integrate emerging action systems of daily life when various aspects of daily life themselves are chronically traumatizing.” 

For these parts to reach the level of distinction necessary for DID, multiple types of trauma must occur. This is because multiple instances of the same trauma will simply be contained within the same EP due to the experiences being compatible with what that EP already holds; the creation of a new one needs to push beyond that.  

From The Haunted Self: 

“Development of EPs over the course of time in chronic traumatization perhaps indicates a lowering of mental level for the previous part of the personality, such that another dissociative part is formed.” 

Note that there are multiple experiences that come under the same broad classifications of trauma that may differ from each other significantly on a practical level. For example, being intentionally starved and being hit both fall under physical abuse, however the human mind will likely process them as two distinct events and therefore split two EPs. 

Additionally, ANPs and EPs gain complexity through life experience, specifically from the experiences they are triggered out to handle that other parts are amnesiac for. ANPs and EPs who remember different instances of the same events with minimal differences between them will not be presented with the opportunity to develop distinct traits.

Obviously, some alters within DID may be similar because of this (i.e. fragments), but at least some alters must be distinct in order to meet the criteria. 

From the Haunted Self: 

“Elaboration is concerned with the complexity of a dissociative part’s repertoire of actions, including memory, skills, and sense of self. It is developed when a dissociative part is regularly exposed to external reality or a rich internal reality.” 

“Children who are abused and neglected by their caretakers in early childhood, with maltreatment constituting a substantial part of daily life, will probably have particular difficulty in developing normative daily life systems. This is a common experience of DID patients. These children must alternate so quickly and frequently among emerging defensive and daily life action systems that these systems, hence their EPs and ANPs, can become mixed in quite chaotic manifestations.” 

There is also an entire section of The Haunted Self that goes into all of this in much more detail, called “The Origins of Secondary and Tertiary Structural Dissociation”, found in chapter 4. 

Essentially, your brain cannot just create multiple distinct ANPs and EPs because it “feels like it” or due to any form of stress. It needs to be continuously and severely traumatized in distinct ways that are integrated throughout daily life. Otherwise the person will not develop beyond primary or secondary structural dissociation. Your brain cannot simply skip to the tertiary level without first being pushed beyond the previous two levels.

What is disorganized attachment?

Disorganized attachment is also required for the development of DID and makes up the “betrayal or abandonment from caregivers” aspect of complex trauma. It refers to inconsistent and contradictory behaviour displayed by a child towards their caregiver, where neither separation nor closeness feels safe. This is often the result of abusive or neglectful parenting.

From The Haunted Self: 

“However, what happens when caretakers manifest frightened, hostile, or helpless behavior toward their children? When such behavior is a pattern, a particular attachment style develops in infants (i.e., disorganized/disoriented attachment or D-attachment) ...D-attachment describes the unusual approach-avoidance response patterns of an infant toward a caregiver who should be the source of safety and security, but is also simultaneously the source of fear and threat.” 

And from here: 

“Developmental models suggest that when caregivers are abusive, frightening, or insensitive, children experience an irresolvable inner conflict of flight and approach, leading to disorganized attachment.” 

Why is disorganized attachment required for DID?

Secure attachment (i.e. where the child feels that their primary caregivers are safe and dependable) is key to the integration of the personality systems in early childhood. 

Young children are reliant on their caregivers to regulate them and model healthy behaviour as they begin to understand the world around them and their own identities. Therefore, when attachment is instead disorganized, the child’s ability to integrate their personality systems and subsystems is severely inhibited. 

Specifically, the contradictory nature of disorganized attachment is important to this. The memories associated with personality systems need to be cohesively processed together in order to foster their integration. As such, when caregivers are extremely unpredictable and threatening, confusion develops between these systems as their respective memories are incompatible.  

For example, the personality system of energy regulation experiences the caregivers as being the source of food, but the personality systems of attachment and defense see the caregivers as the source of threat. 

There may also be confusion between the subsystems of individual personality systems as well, such as the system of energy regulation receiving food from the caregivers on some occasions and being starved by them on others.

As these conflicting ideas of the caregivers all across life cannot be integrated together, they must instead be structurally dissociated from each other. 

From The Haunted Self: 

“The young child’s personality is relatively unintegrated, and integrative structures of the brain are still immature (Perry & Pollard, 1998; Teicher, Anderson, Polcari, Anderson, & Navalta, 2002). The quality of the first years of life, particularly secure attachment, is instrumental in laying the groundwork of a personality organization that is rather cohesive across contexts, such as action systems, place, time, and sense of self.” 

“[The development of DID is related to] ...degree of social support, including attachment relationships; disruption of the normal integration of the child’s action systems that requires a secure attachment relationship.” 

And from here (again): 

“Meta-analytic evidence confirms that childhood maltreatment profoundly disrupts attachment organization and predisposes to disorganized attachment...Recent conceptualizations of “attachment trauma” postulate that childhood maltreatment triggers distinct pathogenic processes, such as traumatic disintegration, detachment, and dissociation, which may contribute to identity disturbances.” 

As disorganized attachment is so central in the development of identity pathology, achieving the degree of identity disturbance necessary to form DID, the most severe form of disordered identity, in the absence of disorganized attachment is not possible. This means that a healthy caregiver-child relationship is a direct contradiction to the requirements of DID development. 

Therefore, it is not possible to develop DID without disorganized attachment. This does not necessarily mean that one’s primary caregivers must be irredeemable monsters to form DID, but that they must commit betrayal and/or abandonment against the child that leads to the child’s mind being unable to process them as a safe presence. As such, it is impossible for a person who had a good relationship with their caregivers in childhood to form DID. 

Can trauma other than abuse cause DID?

Technically yes, but there’s a reason why this isn’t common.  

Really, this depends on how you define “abuse”. As we have established, DID requires disorganized attachment resulting from betrayal and/or abandonment from caregivers in order to develop. As a result, there must be at least a partial interpersonal aspect to the trauma that causes DID. 

Even if the caregivers did not outright abuse the child, at a minimum they must have neglected the child to a degree where they could not view them as safe figures. Many people argue that such a level of neglect is abuse in and of itself, and under that understanding abuse must be involved for DID development. 

However, as we have also established, the caregivers themselves do not need to be severely abusive in order for the child to form DID. The child must feel that they are undependable and unsafe, but the multiple severe and prolonged traumas may come from elsewhere (note that this disorganized attachment forms part of the trauma and of itself, it just cannot cause DID alone if the circumstances that led to it do not meet the requirements of “multiple severe prolonged traumas”). 

For example, some people with DID had neglectful or absent parents, and then experienced multiple forms of severe abuse from other family members or other trusted people (again, while absent caregivers are traumatic within their own right, the point is that the “worst” of the trauma does not necessarily have to come from the caregivers). 

This can apply to traumas other than abuse as well. For example, medical trauma in which a child is experiencing multiple distinct traumatic events (such as different kinds of distressing and painful medical procedures or episodes) can result in DID if it occurs young enough and disorganized attachment is present. 

You can interpret this one of two ways: 

Neglect is a form of abuse and therefore DID development requires abuse, although said abuse does not need to be the “main trauma” so to speak 

DID development does not require outright abuse, but at the very least neglect is required 

All in all, due to the fact that DID requires disorganized attachment to primary caregivers, and that the trauma needs to begin at an age where the child is primarily living at home (before the age of around 6, therefore before school-age), the vast majority of DID cases are caused by intrafamilial abuse. 

Again, other circumstances are technically possible, but due to the nature of the requirements, other forms of trauma are much more likely to result in other disorders. 

From the DSM-V: 

“In studies from diverse geographic regions, about 90% of the individuals with the disorder report multiple types of early neglect and childhood abuse, often extending into late adolescence. Some individuals report that maltreatment primarily occurred outside the family, in school, church, and/or neighborhoods, including being bullied severely. Other forms of repeated early-life traumatic experiences include multiple, painful childhood medical and surgical procedures; war; terrorism; or being trafficked beginning in childhood.” 

And from here: 

“The authors interviewed 102 individuals with clinical diagnoses of multiple personality disorder at four centres using the Dissociative Disorders Interview Schedule. The patients reported high rates of childhood trauma: 90.2% had been sexually abused, 82.4% physically abused, and 95.1% subjected to one or both forms of child abuse.” 

Keep in mind that these figures rely on self-report, and true numbers are likely higher due to the amnesia, shame, and nonrealization of trauma commonly experienced by DID patients. 

In conclusion

DID is a specific trauma response with specific requirements; it cannot develop in response to any negative experience that a child experiences, regardless of their stress tolerance. It is specifically a complex trauma-based disorder, caused by experiencing multiple severe and prolonged traumatic events involving betrayal or abandonment from primary caregivers, before the age of around 6 years old. 

This does not mean that other forms of trauma “aren’t bad enough” or aren’t debilitating; they absolutely are. This simply means that those forms of trauma will likely result in other disorders and not DID. 

DID is not “the disorder that you get when your trauma was bad enough”. It’s the disorder you get when you meet the requirements of developing it, and whether or not you have it has no impact on the validity of your trauma or suffering. 

If you believe yourself to have DID when that wouldn't be possible based on your current understanding of your trauma history, that needs to be handled by a professional. It's possible you don't remember your full history or haven't realized your experiences do qualify, or it could be that your self-diagnosis is wrong. 

Either way, spreading misinformation on the internet is not how this should be handled and you are not helping anyone by doing so, let alone yourself.

General Comorbidity

Dissociative Identity Disorder and Its Relationship with Other Diagnoses 

Dissociative identity disorder and dissociative symptoms in people with gender incongruence: a critical review of literature and a case series

Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified 

The psychiatric comorbidity of dissociative identity disorder: an integrated look

Mood & Anxiety Disorders

Dissociative identity disorder associated with mania and change in handedness 

Anxiety sensitivity predicts depression severity in individuals with dissociative identity disorder (not open access) 

Anxiety sensitivity predicts depression severity in individuals with dissociative identity disorder 

The Effect of Depression on Self-Harm and Treatment Outcome in Patients With Severe Dissociative Disorders

Dissociative depression among women in the community

The bidirectional relationship between depression and dissociation: A longitudinal investigation (not open access)

Electroconvulsive therapy in an adolescent with dissociative identity disorder and depression: a case report

Prevalence and correlates of dissociative symptoms among people with depression

Dissociative symptoms in depressive and anxiety disorders: prevalence and clinical correlates in a real-world outpatient sample

Neurodevelopmental Disorders

Attention‐deficit/hyperactivity disorder and dissociative disorder among abused children 

Attention-deficit/hyperactivity disorder and dissociative disorder among abused children 

A case of dissociative identity disorder and attention deficit hyperactivity disorder comorbidity 

Dissociation in autism spectrum disorders: An under-recognized symptom

Management of dissociation in high-functioning autism adolescents

An investigation of dissociative symptoms and related factors in autistic adolescents (not open access)

Eating Disorders & Substance Use

The treatment of dissociative identity disorder in an eating disorder residential treatment setting (not open access)

Dissociative states presenting as an eating disorder (not open access)

Dissociation, abuse and the eating disorders: Evidence from an Australian population (not open access)

Dissociative Experiences and Trauma in Eating Disorders

Dissociative identity disorder and substance abuse: the forgotten relationship (not open access)

Dissociative disorders among inpatients with drug or alcohol dependency (not open access)

The Role of Psychoactive Drugs in the Onset of Dissociative Identity Disorder: A Comparative Study of Alcohol and Drug Abusers

Dissociation, PTSD, and Substance Abuse: An Empirical Study

Psychotic Disorders

Auditory hallucinations in dissociative identity disorder and schizophrenia with and without a childhood trauma history: Similarities and differences 

Dissociation and psychosis in dissociative identity disorder and schizophrenia 

Association Between Psychotic and Dissociative Symptoms: Further Investigation Using Network Analysis

Dissociation and Psychosis in Dissociative Identity Disorder and Schizophrenia (not open access)

Psychotic symptoms in complex dissociative disorders

Dissociation, Dissociative Disorders and Partial Psychosis

Auditory hallucinations in dissociative identity disorder and schizophrenia with and without a childhood trauma history: similarities and differences (not open access)

The Relationship Between Dissociation and Symptoms of Psychosis: A Meta-analysis

Personality Disorders

Co-occurrence of dissociative identity disorder and borderline personality disorder (not open access)

Comparing the symptoms and mechanisms of "dissociation" in dissociative identity disorder and borderline personality disorder

Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy

Case Report: Anomalous Experience in a Dissociative Identity and Borderline Personality Disorder

Childhood trauma history and dissociative experiences among Turkish men diagnosed with antisocial personality disorder

Dissociation in antisocial personality disorder and psychopathy: review of the literature (not open access)

The relationship between self-mutilation, aggression, childhood trauma history and dissociative experiences in antisocial personality disorder (not open access)

Narcissism, a relational aspect of dissociation

A new insight into borderline and narcissistic dissociative experience: the mentalization of attachment trauma (not open access)

The intricate role of dissociation in the relations between childhood maltreatment, self-objectification, and narcissism (not open access)

Defense Mechanisms in Schizotypal, Borderline, Antisocial, and Narcissistic Personality Disorders

Schizoidia in schizophrenia spectrum and personality disorders: Role of dissociation

Personality disorder traits, maladaptive schemas, modes and coping styles in participants with complex dissociative disorders, borderline personality disorder and avoidant personality disorder

Why dissociation and schizotypy overlap: The joint influence of fantasy proneness, cognitive failures, and childhood trauma

Relationship between Dissociative Experiences and Schizotypal Personality Traits: Mediating Role of Inferential Confusion

Obsessive-Compulsive Disorders

Dissociative symptoms and dissociative disorders comorbidity in obsessive compulsive disorder: Symptom screening, diagnostic tools and reflections on treatment 

Dissociative experiences in obsessive-compulsive disorder and trichotillomania: clinical and genetic findings (not open access)

Dissociation in skin picking disorder and trichotillomania

Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and implications for science and practice

The relationship between obsessive-compulsive symptoms and dissociation: a systematic review and meta-analysis (not open access)

Dissociative symptoms in patients with obsessive-compulsive disorder (not open access)

Symptom subtypes of obsessive-compulsive disorder and their relation to dissociation (not open access)

Are trauma and dissociation related to treatment resistance in patients with obsessive–compulsive disorder?

Suicidality & NSSI

Dissociative disorders and suicidality in psychiatric outpatients (not open access) 

Frequency and characteristics of suicide attempts in dissociative identity disorders: A 12-month follow-up study in psychiatric outpatients in Switzerland (not open access) 

Dissociative identity disorder presenting as a suicide attempt or drug overdose: A case report 

The link between dissociation and both suicide attempts and non-suicidal self-injury: Meta-analyses (not open access) 

Multidimensional perspective of dissociation and suicide-related outcomes: A Meta-analysis and systematic review 

Self-Injury and Suicide Attempt in Relation with Trauma and Dissociation among Adolescents with Dissociative and Non-Dissociative Disorders 

Six completed suicides in dissociative identity disorder patients: Clinical observations (not open access) 

Dissociative, depressive, and PTSD symptom severity as correlates of nonsuicidal self-injury and suicidality in dissociative disorder patients 

Neuroanatomical Predictors of Suicidality in Women with Dissociative Identity Disorder 

Establishing safety with patients with dissociative identity disorder 

Suicide and parasuicide in multiple personality disorder (not open access) 

Risk of suicidal acts in patients with dissociative disorder: a population-based cohort study

Other

Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis