#icd

For at least 6 years (from 2008 to 2014) Tony suffered from arrhythmia and had a pacemaker and ICD (implantable cardioverter-defibrillator) in his chest along with arc reactor. How do we know this:

IM1 0:25:55 - There's no need to "run a heart" if there's only shrapnel in the chest. Yinsen's words only make sense if there is something running the heart that requires electricity from the reactor - a pacemaker and ICD.

IM1 0:51:10 - In the scene where Pepper changes his reactor and takes out the old magnet, we hear Tony's heart went into tachycardia and he was about to get a cardiac arrest (caused by arrhythmias). After connecting the new reactor, Tony received an electric shock and his heart rate returned to normal. What happened: It wasn't the shrapnel that caused this reaction - even without magnet, the shrapnel would have been too slow to cause immediate danger. A pacemaker-ICD is a power source, chip, and electrodes that go to a heart. In this case, the power source is the reactor itself, the chip is part of the reactor, and the electrodes run from the base of the socket to Tony's heart. When Tony connected the reactor cable to the base plate, he connected it to the electrodes so that his pacemaker could work and save him from his irregular heartbeats. Apparently connecting the reactor to the base plate was necessary to power his pacemaker and nothing else, since the old magnet had been pulled out by Pepper and the new reactor had its own magnet. Without reactor-pacemaker-ICD, he had no protection against arrhythmia. So when Pepper touched the socket walls, it gave Tony a shock and disrupted his hearth rhythm (similar happened to him in Endgame), then she pulled out the magnet and that stressed him enough to give him tachycardia, and as soon as the reactor was reconnected, the pacemaker-ICD worked again and corrected Tony's heart rhythm by sending him a therapeutic electric shock.

IM1 1:37:00 - Stane pulled out the reactor with pacemaker out of Tony's chest. Without the pacemaker, due to temporary paralysis and stress Tony's heart went to bradycardia (abnormally slow heartbeat), which gives us the diagnosis - Sick Sinus Syndrome (tachycardia-bradycardia syndrome). Tony managed to get to his lab and connect the old reactor. Shrapnel and electromagnet had nothing to do with it, because, as I already mentioned, shrapnel is too slow to cause damage in such a short time, and we also have to remember that the old magnet was outside the reactor and was pulled out by Pepper. So there was no magnet in this reactor. From that moment until the end of the battle with Stane, the shrapnel in Tony's chest was free. Tony needed this reactor first to correct the arrhythmia, and then to power the armor, and not to stop the shrapnel. He plugged it in, received a treatment shock that eliminated the bradycardia, and may have lost consciousness, which is why he was lying on the floor when Rhodes found him.

IM3 Deleted scene "Tony, Harley and EJ" - Tony saves EJ using his reactor's ICD function. He had to take it out of his chest and give the boy shocks, receiving them himself, which disrupted his heart rhythm. This sent Tony into ventricular fibrillation, and Harley had to reconnect the reactor so the ICD could deliver the treatment shock you see in the second gif.

Avengers: Endgame (1:20:30) - Tony asked Scott to induce a mild cardiac dysrhythmia (another name for arrhythmia) in his 2012 copy by pulling out a pin inside the reactor. This appeared to disrupt the normal functioning of his pacemaker and caused him to have a series of abnormal shocks that led to an arrhythmia and him falling to the ground in convulsions. Note that Tony knew what to do and that it (probably) wouldn't kill him, meaning his pacemaker-ICD would eventually solve the problem on its own, even without Thor's help.

And finally:

Covert DID vs Overt DID & Possession vs Non-possession: They don't mean what you think they mean!

Here's a bunch of facts and info in no particular order!

I saw a post about how masking isn't a type of covert DID, and I'm here to tell you that

Masking was the original covert!

Dissociation and the Dissociative Disorders (by Dorahy, Gold & O'Neil, 2nd edition, 2023)

You know the statistic in the DSM about covert/overt systems? It's taken from Kluft, above. And it includes masking.

Covert and overt aren't actually used all that often clinically, but it actually has several meanings, INCLUDING MASKING. Neither has to do with possession or non-possession, but they're unfortunately often incorrectly equated as "possession form = overt" and "non-possession = covert". They can overlap, but this is incorrect!

Possession's biggest use is for a disorder that no longer exists as a separate entry in the DSM 5.

Possession-Trance disorder still exists in the ICD, though, and we'll start there.

Trance disorder

"The trance state is not characterised by the experience of being replaced by an alternate identity."

"Trance Disorder is characterized by recurrent or single and prolonged involuntary marked alteration in an individual’s state of consciousness involving a trance state (without possession)."

"The trance state is not characterized by the experience of being replaced by an alternate identity."

"The identities of the possessing agents typically correspond to figures from the religious traditions in the society."

"In Possession Trance Disorder, the individual’s normal sense of personal identity is experienced as being replaced by an external ‘possessing’ spirit, power, deity or other spiritual entity, which is not the case in Trance Disorder. Possession trance states often include more complex activities (e.g., coherent conversations, characteristic gestures, facial expressions, specific verbalizations) than are typical of trance states, which tend to involve less complex activities (e.g., staring, falling)."

We can already see how this is starting to play out with overt/covert and non-possession/possession form.

Possession trance disorder

"Possession trance disorder is characterised by trance states in which there is a marked alteration in the individual’s state of consciousness and the individual’s customary sense of personal identity is replaced by an external ‘possessing’ identity and in which the individual’s behaviours or movements are experienced as being controlled by the possessing agent."

"Trance episodes are attributed to the influence of an external ‘possessing’ spirit, power, deity or other spiritual entity."

"During possession trance states, the activities performed are often relatively complex (e.g., coherent conversations, characteristic gestures, facial expressions, specific verbalizations that are frequently culturally accepted as belonging to a particular possessing agent)."

"Presumed possessing agents in Possession Trance Disorder are usually spiritual in nature (e.g., spirits of the dead, gods, demons, or other spiritual entities) and are often experienced as making demands or expressing animosity."

"The identities of the possessing agents typically correspond to figures from the religious traditions in the society."

"This is distinguished from Dissociative Identity Disorder and Partial Dissociative Identity Disorder, which are characterized by the experience of two or more distinct, alternate personality states that are not attributed to an external possessing agent. Individuals describing both internally and externally attributed alternate identities should receive a diagnosis of Dissociative Identity Disorder or Partial Dissociative Identity Disorder. In this situation, an additional diagnosis of Possession Trance Disorder should not be assigned."

From Dissociative Identity Disorder, I only want to note one thing:

"Individuals who describe both internal distinct personality states that assume executive control as well as episodes of being controlled by an external possessing identity should receive a diagnosis of Dissociative Identity Disorder rather than Possession Trance Disorder."

So, already, we've learned that possession and non-possession have to do with whether the entities are experienced as internal or external agents.

You'll note that the ICD doesn't mention covert or overt at all.

So back to the DSM-- “possession” was diagnosed as Atypical Dissociative Disorder in the DSM-III or DDNOS in DSM-III-R. In DSM-IV, possession and trance were diagnosed as sub-categories of the Dissociative Trance Disorder (DTD), and in DSM-IV-TR they were merged into one, and recognized as a cultural variant of the Dissociative Disorder Not Otherwise Specified [DDNOS]. In DSM-5, possession-form presentations are linked with criterion A of DID: “Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession” (p. 292).

Another common myth has to do with amnesia and covert/overt. The facts are:

Covert DID is associated with the highest levels of blackout amnesia. That's how it stays covert. People have amnesia for their own amnesia. It's an incredible phenomenon that's highly documented.

Overt DID typically has the same or less amnesia. It's much harder to explain away noticeable behaviour so people are much more aware of their own gaps in memory and can begin treatment sooner. They're much more easily diagnosed. As internal dialogue and intrusion are far more different in these entities, people become aware sooner and experience more grey out amnesia thanks to this basic awareness.

Covert DID is no longer diagnosed as OSDD 1a. The DSM 5 introduced new reporting criteria that allow the patient and their family to self report switches. OSDD and DDNOS 1a were primarily used for situations where the clinician didn't witness a switch during interviewing. As such, OSDD these days mainly covers P-DID presentations where switching is genuinely rare, if it happens at all. While P-DID is less associated with amnesia, OSDD 1a will require it. P-DID without amnesia will fall into 1b or DID itself, thanks to the DSM's updated amnesia wording.

For this next bit, I'll be using the DSM 5, as that's what I have in front of me, for the purposes of this conversation, this version will do fine.

"Dissociative identity disorder is characterized by a) the presence of two or more distinct personality states or an experience of possession."

"The fragmentation of identity may vary with culture (e.g., possession-form presentations) and circumstance. Thus, individuals may experience discontinuities in identity and memory that may not be immediately evident to others or are obscured by attempts to hide dysfunction."

You know, overt/covert, and wow, it doesn't just have to do with the entities, BUT HOW YOU DESCRIBE YOUR DISORDER?!

You mean... like masking?

Holy shit, yeah, the DSM just said that.

These terms are not as interchangeable as some people think they are. They have very unique meanings and are very different concepts, not only from each other, but from how they're often used within the community.

To reiterate:

Possession form = external entities

Non-possession = internal entities

Overt = noticeable behaviour and mannerisms

Covert = hidden or sneaky behaviour or mannerisms

These can and do overlap, but exist as separate concepts.

More from the DSM:

"The defining feature of dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession (Criterion A). The overtness or covertness of these personality states, however, varies as a function of psychological motivation, current level of stress, culture, internal conflicts and dynamics, and emotional resilience."

Oh, wow, it changes over time and can vary between alters themselves?! Wow.

"Sustained periods of identity disruption may occur when psychosocial pressures are severe and/or prolonged. In many possession-form cases of dissociative identity disorder, and in a small proportion of non-possession-form cases, manifestations of alternate identities are highly overt. Most individuals with non-possession-form dissociative identity disorder do not overtly display their discontinuity of identity for long periods of time; only a small minority present to clinical attention with observable alternation of identities."

"Possession-form identities in dissociative identity disorder typically manifest as behaviors that appear as if a “spirit,” supernatural being, or outside person has taken control, such that the individual begins speaking or acting in a distinctly different manner. For example, an individual’s behavior may give the appearance that her identity has been replaced by the “ghost” of a girl who committed suicide in the same community years before, speaking and acting as though she were still alive. Or an individual may be “taken over” by a demon or deity, resulting in profound impairment, and demanding that the individual or a relative be punished for a past act, followed by more subtle periods of identity alteration."

So, yes, according to the DSM, purposefully masking is a covert presentation, and it has nothing to do with possession or non-possession form. The way a system "naturally" presents will change many times over the course of their disorder.

IN FACT, if we want to get technical, covert actually refers specifically to heavy fragmentation in most clinical texts. Fragments are typically experienced internally and as intrusion, rather than switches. Here's a source.

Covert DID is a less dramatic and more subtle form of the disorder. In this variant, individuals with DID do not display overt switches or distinct personalities. Instead, they experience a fragmentation of their identity, leading to a lack of continuity in their sense of self and memory. These individuals may not even be aware of their condition and might attribute their memory lapses and identity shifts to stress, forgetfulness, or other factors.

Covert DID can be challenging to diagnose because the symptoms are less obvious. It often goes unrecognized for years, and individuals may suffer in silence without understanding the source of their difficulties. Therapy and expert evaluation are essential for identifying and addressing covert DID.

And another.

In addition, diagnostic challenges can result from identity alteration or personality switching not as obvious as expected. In fact, many patients have “covert DID” or “OSDD,” which is characterized by partial dissociation (e.g., dissociative intrusions) rather than full dissociation (i.e., switching plus amnesia).

In the end, though, these terms aren't used all that often, and various uses will still be understood in a clinical setting. Doctors can't even agree on definitions, so use them however you want.

It's not that big of a deal.

I <3 Inugami

The disorder is clearly DID. The quote in the screenshot literally mentions DID by name.

Okay, I'm not mocking disordered systems... in general... but I'll admit that right now, I'm definitely going to mock someone who thinks they're an expert because they "want to go to college to become a therapist" yet thinks the ICD-11 isn't a valid source because it's not a ".gov" or ".edu" link.

And claims it's not an "educational site."