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Witnessing vs. Self-Reported Identities

Between the DSM-IV and -V, the criteria now includes self-reporting. This is really a big deal, even though at first glance it might look like the basic criteria are the same.

Psychology is a science. Science is based on observation. Given the lack of putting diagnostic criteria into the language of observation (DSM-IV), the person considering the criteria of diagnosis had to fall back on the scientific method of strictly observation. So the DSM-IV lists criteria, and the diagnosticator (coining a word based on diagnosis for this article to indicate whichever professional is granted the ability to diagnose and thus whose job is considering an individual's criteria for diagnosis) has the job of determining whether a specific situation falls under certain criteria — and the assumption is that the diagnosticator has to observe the checklist themselves. There's no criteria for accepting third-hand accounts in the DSM-IV.

This all changes in the DSM-V which quite explicitly states that the diagnosticator can accept 3rd party reported observations AND self-reports for Criteria A, which is the criteria regarding separate identities. This has not been made a part of criteria B. The diagnosticator has to personally witness gaps in memory, recall of daily events or other significant forgetting.

This means that the so-called diagnostic experts on the DSM review board now believe that a client is unlikely to report they have multiple identities unless it's true. So many uninformed or neglectful diagnosticators are holding off on putting a DID diagnosis on a chart or insurance form because of their personal opinion and lack of first-hand witnessing that people have DID when the client tells them about their separate "identities". They're waiting on confirmation when the insurance companies and the diagnostic criteria panel of experts are basically saying "quit wasting time waiting for proof and move on with treatment."

It's almost like the professionals did something right for once, and the folk on the front lines haven't caught up to it. Just because the doctor doesn't realize the person sitting in front of them is someone else, doesn't mean that the person doesn't have multiple persons running their life. Their skill in detecting changes of person in a single body does not play into the diagnosis anymore. You telling them they exist does. To boot, saying you often don't feel like yourself, and that you don't always feel like you're in control of what you say or do can count, too.

So every day, I read accounts of folk who say they're waiting on diagnosis: "I told them that I have these people, but no one wants to front with the new therapist yet, so they're holding up my diagnosis, waiting to meet someone." Or maybe they're all presenting behind a mask so their differences are mellowed out to nearly undetectable. Being undetected is a a defense mechanism. And a damned good one.

So now, basically, if you report to the diagnosticator that you have many people in your head, you hit Criteria A. If there's strong indication of forgetfulness that's Criteria B — whether you don't remember what happened at your last appointment or you have foggy memories of things and don't remember anything before the age of (name a number) — you qualify for criteria A&B of the DSM-V criteria for DID, without them having direct proof or evidence of either one. The other 3 criteria of DID are relatively easy to determine.

In a world of high insurance rates and insurance not wanting to pay out more than necessary, this change may be motivated by insurance companies. However given the history of the length of DID diagnosis and treatment in particular, it behooves both the insurance companies and the multiple in question to cut through the red tape of getting diagnostic "proof" and get down to the work-at-hand. The DSM-V criteria helps cut down the diagnostic time, but only if the diagnosticators are updated on the change in criteria.

It is a fallacy of modern thought that DID is "rare". Conservative estimates are at 1% of the general population — not 1% of the diagnosed population. That's sufficient to be on the radar and certainly to suggest re-reading the criteria when someone walks into the office and mentions people or hearing voices. In the meantime, many professionals probably haven't cracked open the DSM-V and actually read these changes. At least to revisit the criteria when this specific diagnosis is in consideration. And when diagnosticators read the criteria — really READ it, don't just skim over it. The changes in the criteria are subtle but important.

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