Dissociative Identity Disorder (DID) Explained: Trauma, Neuroscience, Controversies & Recovery

In this episode of the Psychiatry Podcast, Harvard experts from McLean Hospital: Dr. Melissa Kaufman, Dr. Matthew Robinson, and cognitive neuroscientist Dr. Lauren Lebois. Join Dr. David Puder to deliver the clearest, most evidence-based explanation of Dissociative Identity Disorder (DID) available today. Discover how DID is a developmental post-traumatic adaptation rooted in repeated childhood maltreatment, explore the neuroscience behind hyperarousal versus shutdown states (including groundbreaking Reinders studies), debunk persistent media myths like Sybil, and navigate long-standing controversies around validity, Freud versus Janet, false memories, and DID versus BPD. Dr. Kaufman shares her own courageous personal journey from living with DID and PTSD to full integration and recovery, offering real hope that this condition is treatable. Whether you're a clinician, someone with lived experience, or simply seeking the truth about dissociation, trauma, and identity fragmentation, this conversation will transform how you understand one of the most misunderstood psychiatric disorders. Presenters' conflicts of interest: Dr. Lauren Lebois reports unpaid membership on the Scientific Committee for the International Society for the Study of Trauma and Dissociation (ISSTD), spousal IP payments from Vanderbilt University for technology licensed to Acadia Pharmaceuticals and spousal private equity in Violet Therapeutics unrelated to the present work. Dr. Melissa Kaufman reports Member, DSM Review Committee, Internalizing Disorders (unpaid); Primary Investigator, National Institute of Mental Health; Board of Directors (unpaid), International Society for the Study of Trauma and Dissociation. Dr. Matthew Robinson and Dr. David Puder do not have any conflicts to report By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to Blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-262-dissociative-identity-disorder-did-explained-trauma-neuroscience-controversies-amp-recovery Link to YouTube video https://www.youtube.com/watch?v=BrZkCDtv-fo

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome back. I am joined today with three guests. We have Melissa Kaufman, a trauma psychiatrist and researcher at McLean Hospital. She serves as the co-director of the dissociative disorders and trauma research program and the medical director of the Trauma Continuum of Care and associate professor at Harvard Medical School. So I have Matthew Allen Robinson. He is the program director at McLean's Trauma Continuum of Care at the Hill Center specializing in the partial hospitalization and outpatient services for trauma-related disorders. And also Lauren LeBois.

• 0:55David Puder?

  She is a cognitive neuroscientist and assistant professor of psychiatry at Harvard Medical School, director of the dissociative disorders and trauma research group at McLean Hospital with a focus on post-trauma adaptations. Hopefully, I got that all right. Welcome to the show. Thank you.

• 1:14Speaker 01

  Thanks so much for having us.

• 1:15David Puder?

  Yeah, so I'm excited. Today, we're going to be talking about dissociative identity disorder. We're going to be talking about dissociation, trauma. How about we begin with a basic definition of DID, dissociative identity disorder?

• 1:33Speaker 01

  I think that's a great place to start, and thank you again for having us on your program. DID is, I think, a very misunderstood psychiatric condition, but I think that we are at a place in our scientific understanding and clinical understanding where we can easily describe it. DID is really a developmental post-traumatic adaptation. It begins in childhood, and without treatment, children will go on to exhibit symptoms into adulthood. And basically, it is an adaptation for kids who have to sort of, sort of both the biology and the environment.

• 2:18Speaker 01

  I think a lot of people who know about DID think that it is caused by childhood trauma. I would say that that is necessary, but not sufficient. Children need to have the biological capacity to dissociate, which is really mostly normally distributed quality in the population, but it has a long tail at the end. And so if a child is sort of in that, you know, highly dissociative just by biological nature, and that is combined with long-term childhood maltreatment typically at the hands of caretakers, then they may have a propensity to develop dissociative identity disorder.

• 3:02Speaker 01

  And I would say diagnostically, people with DID universally have post-traumatic stress disorder due to the childhood maltreatment. And in addition to all of the symptoms of PTSD, they also have very severe symptoms of dissociation, including depersonalization, which is kind of feelings of detachment from one's sense of self or body. And then derealization, which is symptoms of detachment from or towards one's surroundings. And then two other things, there are gaps in memory, often for traumatic

• 3:47Speaker 01

  episodes during childhood, as well as gaps in awareness during everyday life. And then there is this identity fragmentation, and we can talk a lot more about what that is.

• 3:59David Puder?

  Yeah, thank you for that. You know, I think there's probably some people who are listening who immediately think like, is this, is this a thing? It's in the DSM. You know, what are, what are some of the main controversies around it? And how have you guys made sense of those controversies?

• 4:20Speaker 02

  So I mean, first and foremost, yes, DID is a DSM five diagnostic diagnosis. And it's been highly validated in clinical observation and research and more recently, more rigorous neurobiological research that Lauren and Melissa can can say more about. Some of the misconceptions, the most common ones are that DID is like what is portrayed in the media, which is people drastically changing their appearance or mannerisms as if they are completely different people in in very big ways.

• 5:03Speaker 02

  That's not the typical presentation that that we see. And again, we can say more about that. But also, people think that it's not its own diagnosis and that maybe it's a personality disorder or some other disorder and that it doesn't hold up on its own. Again, Lauren and Melissa can say more about the long list of studies and research that shows in various ways that DID is a real disorder. And certainly, for anyone who's worked with highly traumatized patients and has seen DID, we all know that it's a real thing.

• 5:43Speaker 03

  Yeah. And just to add to that a little bit, I think there's also just a fascinating history to DID and how it's been documented. It's one of the earliest documented psychiatric conditions. And there's, yeah, just a really fascinating historical controversy between, for example, Pierre Genet, who was originally documenting what he would have called hysteria and that we would now understand as some forms of dissociation and DID and showing that it really was in some ways caused by difficult events in childhood, childhood maltreatment.

• 6:25Speaker 03

  And then initially Freud agreeing with and finding some similar, documenting some similar cases and agreeing with Genet's findings. And then a lot of controversy surrounding.

• 6:39Speaker 03

  Freud backing up from those conclusions and then deciding that actually these weren't actual traumas that children had experienced, but rather fantasies that they had instead about what had happened to them. And it seems like, again, a lot of controversy around this, but we have kind of followed Freud and his conclusions in the field for a very long time. And part of his shift going towards more of the fantasy model, he has this letter to Wilhelm Flyes, a friend of his, where he kind of describes that it's kind of improbable that this would happen, this extreme maltreatment would happen to so many people. And so that

• 7:22Speaker 03

  in part explains perhaps some of the shift in this direction, that it's difficult to imagine that this happens to so many people. And it's uncomfortable to think about as well. So I think that can explain part of the controversy. And after the second wave feminism and Vietnam War veterans returning to the US and we started to see what we would now call PTSD, and we started to understand more about childhood maltreatment and domestic violence. And a lot of research started around that time. There was more an acceptance of these, that these things happen to people. And that started to change the tide and lead

• 8:06Speaker 03

  to a lot more dissociation and DID-related research as well.

• 8:10Speaker 01

  I agree with that. I think right around that time of real science, starting in the study of post-traumatic stress disorder and the men and women who returned from Vietnam, that was a time of second wave feminism. And people started to understand domestic violence. Just prior to that battered child syndrome was, you know, really documented while in the clinical literature. And so there was more of an openness to really thinking about that this is real, that child abuse does happen. And I think over the past 10, 20 years, even more so. I think that there's been a societal shift.

• 8:51Speaker 01

  And understanding that there's certainly documentation in definitely documentation of severe child maltreatment, Department of Human Services has done that. So I think we're in an era where that is more accepted. And that has helped to bring some clarity to and understanding to dissociation and what that means.

• 9:14David Puder?

  Excellent. I appreciate you going through the history of I've thought about Freud's departure from Pierre Genet, right? I'm saying that right? And how, you know, he could not hold, right? This thought of the horrific nature of the trauma. It takes a while for a mental health professional to be able to hold it as well. And I hope that conversations like this allow us as mental health professionals to have an increased capacity to hold that, right? It's it's like we don't want to believe something so awful could take place, right? So we don't want to believe.

• 9:56David Puder?

  And yet now I feel like with a lot of my patients, it's staring right in our face with the Epstein file release. We don't need to go a lot into that, but people are talking about it. And then you talked about Vietnam War, and I was thinking about the videos I've seen of World War I and II. It's like shell shock. Their bodies were moving abnormal. They had a lot of functional movement disorder type symptoms. After Vietnam, you get more of the classic PTSD symptoms because it was so stigmatized to have PTSD, I think, prior to Vietnam.

• 10:29Speaker 01

  Yep.

• 10:31David Puder?

  And then, yeah, I think I really appreciate how you bring up the awareness of domestic violence, the push against that, right? And how that's, you know, it was it was like the family secret. It was the thing no one talked about, right? People suffered in silence for decades. Unfortunately, sometimes they still do. So, okay, yeah, so that brings us all the way up to the 80s when it seemed like multiple personality disorder kind of came on.

• 11:04David Puder?

  To the radar of people. And then how do you feel like it went off? You talked a little bit about how it almost like, there's like, kind of like a histrionic version of it, maybe of kind of people that want to be gardener attention, maybe. And then there's the people that are really suffering, right? And so how do you differentiate those two groups of people?

• 11:27Speaker 01

  I think that's a valid point. And just prior to the eighties, I think it was nineteen, I don't know, seventy five, seventy four is when Flora Rita Schreiber wrote the book Civil. And it was a, you know, national bestseller. And then a year or two after that, you know, Sally Field won an Emmy for her portrayal of Civil. And, you know, I wasn't there. I don't know exactly what happened, but sort of piecing it together. You know, that was a, there's, there's, there's enough in the book that rings true in some way. But what I think happened was that the author didn't know how to portray what really is,

• 12:11Speaker 01

  for the most part, an internalized disorder. And so she showed it on paper, what the patient herself was feeling. But, you know, in the, both in the book and in the movie, you know, especially in the movie, you see Sally Field, she won an Emmy, but she's literally talking with different accents. She, you know, her clothes change, her style changes, and it's just right out there in this very externalized way. I mean, I can tell you clinically, I've never met someone that, I mean, that it looks as if there's different people, right? It's not one person, it's multiple, not just personalities, it's multiple people. Well, it's not.

• 12:54Speaker 01

  And I I think that's where it sort of went off the rails a little bit. People with DID, it tends to be a fairly a hidden disorder. Uh, someone uh once famously called it a disorder of hiddenness.

• 13:07Speaker 02

  Hmm.

• 13:07Speaker 01

  And the, you know, it's it's just different aspects of self that had been disowned by a child and personified internally. But it is just not this big, dramatic full by production. I mean, that just has like very little to do with what DID is. DID is uh someone who grew up with intolerable circumstances and and really conflicts. How can I, you know, get up the next day and function? And so, you know, difficult thoughts and feelings and memories are compartmentalized. So you can just get up and and move forward. So the way that it is depicted in popular media, movies, um, books.

• 13:51Speaker 01

  I think therapists got the wrong, you know, mental health professionals had the wrong idea. People had the wrong idea. And so I think that that was very problematic, but we've come a long way in our understanding and public awareness, I think, um, professional awareness to some extent, but we still need to educate people. It's just, it's not what it looks like in the popular media. And were there people, you know, who, uh, you know, probably didn't have DID, may may have been traumatized, but you know, were sort of acting out in these ways or therapists that may have pushed too hard for this type of scenario that there may in fact happen.

• 14:31Speaker 01

  But there's also been a lot of folks that have, you know, had this disorder and did not recognize themselves in these popular portrayals. Uh, therapists who for many years have been doing good work, good research and understanding what is the typical manifestation, which is again, very different than what popular and fictional media portrayals present.

• 14:58David Puder?

  Maybe we can go back a little bit. You mentioned that there's a certain personality type that is more maybe prone to dissociation, maybe. Like, what do you, what do we know about that? Even before the trauma exists, right?

• 15:13Speaker 01

  I think I wouldn't so much call it a personality type. It's a sort of a capacity to dissociate. And really, what is meant by that is, is sort of born with a capacity to become highly, it's absorption. So, many people have this, you know, the typical sort of portrayal, this is like highly highway hypnosis, where you're like driving home, you got the radio on, and you miss your exit, you don't even realize for, you know, four stops. Or you become incredibly absorbed in a movie, and you're like surprised when the lights, you know, go back on, that you weren't like fully in the movie. That's just incredible. That's, that's absorption. And people are born, again, with this different

• 15:57Speaker 01

  capacities. Some, some people don't become absorbed at all. Some people become highly absorbed. And I think in order to be someone that is highly dissociative, you have to have this capacity to become very internally absorbed. And, and that's why it is sort of an internal disorder. It's, it's, it's a way of being able to absorb internally, which also is an ability to not attend emotionally, or, you know, think in a thinking way to sort of compartmentalize that away. So, it's both being able to absorb internally inside, and, and sort of shut out what's going on. And that's, again, just normally distributed,

• 16:42Speaker 01

  except for this high tail at the end.

• 16:45Speaker 02

  I was just gonna add that the, you know, part of the reason the diagnosis was changed from multiple personality disorder to DID is to recognize that this really isn't about personality, or having multiple personalities. It's about not developing a cohesive sense of self at a certain developmental time, because the child's creative capacity was able to have this adaptation that made the abuse that was happening, not me. It was happening to someone else, or... You know, it was a that other boy or girl, not me. And as Melissa mentioned earlier, that allows them to leave what happened the night before with that boy or that girl.

• 17:29Speaker 02

  And the school boy or girl can go to school and listen and pay attention and be social without being bedraggled by the reality of what went on the day before. So it's not a personality disorder. It's not multiple personalities. It's not enough of one because of early life experiences.

• 17:50Speaker 01

  Right. And it feels so, you know, there's not different people inside. There's not really a different little person that goes to school. There's not really a different little person who is, you know, dealing with whatever's happening at home. But it feels very much like that to the person and that's how they cope. Um, it's not, it's not conscious. This is just something that they sort of arrive at because, you know, during early childhood, there's this this sort of this time, and you may remember this yourself, um, when, uh, you personify things, um, where your stuffed, you know, if you don't want to go to school, um, but your mom is saying you have to go to school, you say, well, I'll go, but my stuffed animal, you know,

• 18:35Speaker 01

  is mad at you. He doesn't want to go to school. It's this natural developmental way that kids have of just kind of disavowing feelings or thoughts, um, and then personifying them. And if you have that ability to do that as kid and lots of little children do, and again, really difficult things are happening, you're going to make use of that ability to disavow and personify externally. And that becomes the not me adaptation. So instead of a little child who says, oh, my stuffed animal is mad at you, not, it's not me, I love you, but he's mad at you.

• 19:17Speaker 01

  As a way to figure out how to deal with conflicting feelings that are hard to manage. And at that age, you don't know that your stuffed animal isn't real, right? Santa Claus is real, Superman is real. So that's sort of the developmental.

• 19:33Speaker 01

  Ground that that children are walking on at that age. And again, if they're being, you know, have really tremendous challenges, relational trauma, they're going to use that ability. And again, it's not really conscious. Children don't think to themselves, oh, I'm going to pretend that I'm mad that my stuffed animal is mad. I'm going to just say that because I don't want like my mom to be mad at me. They don't know that. They really feel that that's happening. So that's when DID develops. And that's the sort of disavowal and personification that happens and then just continues because it's because, you know, the child is highly dissociative and they just keep doing this and doing this. And so it feels internally as if these things are real.

• 20:17David Puder?

  Hmm. I'm curious, kind of going to early childhood development, like, for example, something like disorganized attachment style. There's research on kids with disorganized attachment style later have higher degrees of dissociation. Is that part of this pathway in your in your mind? Or is this something different?

• 20:42Speaker 01

  I think it hasn't been shown. They haven't done, you're thinking of Ruth, I can't remember her last name, Lyons. She said she was like.

• 20:50David Puder?

  Lyons Ruth, yep.

• 20:51Speaker 01

  Yeah, thank you.

• 20:53David Puder?

  And Beatrice Beebe as well.

• 20:56Speaker 01

  Yes.

• 20:56David Puder?

  Really impressive research from them showed that Beatrice Beebe at four months was able to predict.

• 21:02Speaker 01

  Right.

• 21:03David Puder?

  Based off of the video of a mother infant died, if a kid would just develop disorganized attachment style at the age of one and one and a half years of age.

• 21:13Speaker 01

  And what Lyons Ruth did was to use the adult attachment inventory, right, that was developed and then follow it along and look at the kids who were predicted using the adult attachment inventory, who may, you know, go on to have disorganized attachments later, followed them longitudinally and saw that they had, they were at higher scores of dissociation. What I don't think has been done yet, but there's a lot of theory about it is there hasn't been the longitudinal. Longitudinal study that goes on to show that people actually develop DID. But theoretically, it makes a lot of sense. And I think there's been some really elegant conceptual

• 21:52Speaker 01

  papers hypothesizing that, you know, children who grew up to have DID have disorganized attachments. It's something that we would actually love to do in the lab is to do an adult attachment inventory on folks with DID and and see. But very hard to do those longitudinal studies for long enough to, you know, see if someone ends up developing DID. But I think it's, it makes a lot of sense.

• 22:20David Puder?

  One thing I, one thing I've seen when I've looked at DID in the past is, is the, the trauma and the horrific nature of the trauma seems so much higher than PTSD, or like it's not a singular event. Can you speak to this? Can you speak to the, the, the extent, the, what research you've seen? What I know you have, you have a lot of, in your group, you, you follow some lived, experienced patients as well. And I know I O P partial kind of attracts, right? A lot of the most horrific trauma. So I imagine you've seen a lot of this stuff.

• 22:56Speaker 02

  Yeah, I think the, the type of trauma that we're talking about that most often results in someone later developing DID are, are situations that are really inescapable and repeated. That's where we get the repeated nature. Because if it happens once and it's, you know, the coping doesn't require the same level of dissociation that, that it does if it's happening repeatedly. And, you know, it doesn't mean that it has to be, you know, I, I hate to categorize like rank trauma. It doesn't have to be the worst things ever. I think for some people, it's the combination

• 23:34Speaker 02

  of this prolonged persistent experience that's confusing and harmful in some way, neglectful. You know, that can be quote unquote enough, because the child needs to escape to survive. And so really, I think it's about that, that need, that need for escapability as opposed to the specific type of trauma. I think correlationally, you probably, I, I've seen in my work at least, people that experienced, you know, repeated childhood sexual or physical abuse will often.

• 24:09Speaker 02

  Develop DID with all the other criteria that we've already discussed. But that's not the only, doesn't have to be those, those things per se.

• 24:18Speaker 03

  I think another interesting piece is thinking about like a gene by environment interaction as well, that which would be true of any psychiatric condition of you could, someone who has a very high genetic loading for like also saying the capacity just to dissociate and for that to turn into DID would need less severe, again, it's weird, like you're saying back to rank traumas, but would need less of a stress to push them down the path of coping using DID versus someone else who had a genetic loading for, I don't know, bipolar disorder, would that stress would push them down that road.

• 24:59Speaker 03

  Someone who had less of a genetic loading for DID, but had a lot more trauma, that would need, that would get them down the DID road. But so I think it's all interacting in that way. And that makes it kind of complex.

• 25:15Speaker 01

  Yeah. I think we're, we're thinking about it in more sophisticated ways as time goes on. There were a number of, quite a few early studies in the eighties, nineties that did show that patients with DID reported more severe childhood maltreatment across, you know, and it typically wasn't one form, right? If you're being sexually abused, odds are you're probably being emotionally abused as well. You may be being neglected, but people with DID in these early studies were reporting more severe levels of childhood trauma across different types of traumatic events at the hands of caretakers. But I also agree with what you're saying, Lauren and Matt, that I think there's also,

• 26:01Speaker 01

  there's more complexity there as well. I've certainly met people who have DID and, you know,

• 26:09Speaker 01

  Certainly, we're raised in very challenging environments, but you know, only had this or only had that, but it was over a long course of time. And if you think about it, if someone's being sexually abused over a long course of time, or physically abused, or emotionally abused, coping skills are probably going to be pretty scarce because that's where we learn how to cope is from our parents. So that's part of it as well. It's not just the abuse or just the biological capacity. It's that there's, there's no other way to cope. The child is left to their own defenses because they're not learning from their parents how to cope well.

• 26:51David Puder?

  I, I know that like it could present a number of ways, but what are some of the typical presentations that make you think this is more DID versus other things like borderline precise disorder? Or like, yeah, what are the things like, how are you actually diagnosing this in your clinics in the IOP partial?

• 27:14Speaker 01

  Yeah, you know, it's not, it's typically not that someone comes in and says, I think I have DID. You know, can you do an hour long assessment and that's it? More typically, but you know, let's say it's someone that's presenting in outpatient treatment. It may be, you know, someone who comes in for treatment and they may be complaining of, you know, longstanding depression or longstanding anxiety. And you start to take a history and what you may notice is a couple of things. One is that it's hard for people with DID to really create a linear narrative. They can be, you know, very high functioning, for example, in their lives. And, you know, be very sophisticated thinkers, but when you start to ask them about their childhood,

• 27:58Speaker 01

  suddenly their narrative becomes difficult to follow. And you may notice that they, you know, may say, you know, I'm kind of getting foggy. This is hard to talk about and it's, there are some.

• 28:15Speaker 01

  Subtle, physical types of manifestation that makes it look like people are really like suddenly really focused internally, blinking of the, you know, sort of blinking, closing their eyes, just having kind of a glazed expression on their face or their eyes and they're just suddenly way more focused internally than than they were. And that that is something, you know, a person who, you know, can say, yeah, you know, I had a tough time growing up, but really can't give me details. And when they start to give details, they start to look like they're dissociative. That that can be a sign. People with DID always have post-traumatic symptoms. So, you know,

• 29:00Speaker 01

  you're looking at someone who's, you know, having nightmares or, you know, clearly avoidant of certain kinds of situations as a startle, you know, response. And then, you know, they're, they're telling you that, you know, yeah, things were tough when I was growing up. You know, I wouldn't know at that point if they have DID or not, but I would want to start to inquire and ask them about symptoms of dissociation. And often what we find is, you know, someone comes in and maybe they have a past diagnosis of PTSD, but when we start to ask them about dissociation, symptoms of depersonalization, derealization, symptoms that don't make a lot of sense, that, you know, sometimes thoughts and feelings don't feel so much like they belong to them,

• 29:45Speaker 01

  even though they know that that's not possible, because this is not psychosis. And they say, no one's ever asked me that before. Like, how, you know, how do you know this? And we're simply inquiring about symptoms of dissociation. And again, a lot of times, people don't ask.

• 29:59David Puder?

  Walk me through that. Like, what, give me the actual questions that you would ask for dissociation? What are the, what, rattle off the ones that you normally?

• 30:08Speaker 01

  Well, I mean, there's certainly, you know, reliable and validated self-report measures and, you know, clinical interviews. But if I, you know, not doing that at, you know, meeting with someone for the first time, I start to notice these things. I might ask, you know, do you ever have periods of time, you know, do you ever feel that you're a little bit detached from your own thoughts or feelings? Do you feel detached from your body sometimes? Do you ever have the experiences where things start to feel dreamlike around you? I mean, there's, there's many, many different ways to ask about dissociation. Maybe you guys can pop in with some other ones.

• 30:48Speaker 02

  Yeah, one of, one of the most common is the experience of feeling like you're watching yourself from another perspective, or that you're on autopilot, sort of like you're riding around in your body and going about your daily life, but watching, not really feeling that you're controlling, you know, you're washing the dishes, you're doing this or that, but not really thinking about it. A lot of people will report that sounds or sights feel louder or quieter than they actually are, or further away or closer than they actually are. That dreamlike thing that Melissa mentioned where it's like, you know, kind of cloudy and fuzzy and.

• 31:24David Puder?

  Do you guys start to feel it? Cause I, like, I know when I'm with someone who's starting to dissociate, they don't have to say anything. Like, I'm just starting, I can start to feel it. And sometimes I'm like, okay, is this me? Is this them?

• 31:38Speaker 01

  I didn't want to say that because that's, I mean, unless you've experienced it, it sounds a little weird. But yeah, sometimes you may, your, your own understanding of it is because you start to feel a little fuzzy or foggy and you become aware that you're sort of thinking about something else and then you're sort of, yeah, you, you can, things can start to feel a little dreamlike, a little foggy. But again, I didn't want to say that because if you haven't really experienced it, it sounds odd.

• 32:09Speaker 02

  It's like our mirror neurons, right? We see it happening or we perceive it and we start to experience it too.

• 32:15David Puder?

  I think if you're an empathic human being, you know, you can't not feel that like, or just like anytime you're with someone when they're talking about something traumatic, you may feel a little bit like that. You may feel a little bit more numb, a little bit more disconnected. You may feel like this sleepy haze come upon you.

• 32:33Speaker 02

  Absolutely.

• 32:34David Puder?

  I find myself sometimes like needing to feel my focus on the sensation of my butt of the chair.

• 32:42Speaker 01

  Ground yourself.

• 32:43David Puder?

  Ground myself, right? Yeah.

• 32:46Speaker 01

  I think you're, you're exactly right. If you've ever seen someone have a trauma related flashback, you also, you know, what this, it is a, you know, the hair on the back of your nut goes up and it feels very much like you're watching something terrible happen in the moment.

• 33:04David Puder?

  Yeah. Yep. I remember.

• 33:06Speaker 01

  Haven't felt that. If you haven't seen that before, it's hard to understand.

• 33:11David Puder?

  Yeah. I mean, I don't want to like dissociate everyone that's listening to this podcast, but I remember this one story, this horrific trauma that one of my patients was delivered by their mother that involved like a near drowning type of situation. And it was very purposeful, very like sadistic from the mother too. It wasn't like a accident, right? And when the patient described this for me, it was like the room just like started like jerking and I was like, I had to like, I was like, what is it? It kind of reminded me of when I used to play, I used to do sport and during a wrestling match, like when you're, when it's, it's like I was about to lose or I was almost about

• 33:56David Puder?

  to get pinned, you know, and I had to like, like there was this moment where I would start to go hazy and then I would like have to try to fight out of it to, to win.

• 34:05Speaker 01

  Yeah.

• 34:05David Puder?

  Or, um, so yeah, I, I think this is kind of like that experience, right? But when you're, with, you're with a patient like this, it could be kind of like a chronic, like you could go, every session feels like this slightly, right? For, for months. Uh, I had one patient who was very dissociative that it was like two years of like trying to come out of the dissociation, varying degrees, right?

• 34:36Speaker 02

  Yeah, I I'm glad we're talking about how this manifests in a treatment room. I would say, though, for your audience and a lot of mental health providers who are really encountering people for one or two times in an emergency room setting, or, you know, that you're you may not get that sense from people because it is, I mean, they are often more guarded. And some of the other, maybe not clinic, not clinical things in the room, things that I would look for are multiple past diagnoses, often bipolar disorder, borderline personality disorder, mood-related psychotic disorder, and sort of you have all three of those and none of them really fit or hold water fully because they didn't have a full manic episode and they

• 35:21Speaker 02

  never really lost reality testing and maybe they have some somatic symptoms. And you see this sort of concoction of diagnoses that follow people and no one's been able to make sense of it. That's always sort of a ding ding ding for me. And, you know, remembering that DID's prevalence is on par with schizophrenia. So you are seeing these people all the time, whether you know it or not, probably. So looking for multiple past diagnoses that don't stick is another common sign. And you you asked about distinguishing between something like BPD and DID, and there's lots we could say about that. But Melissa Lauren and I will often share, I think others in the field would agree, that

• 36:03Speaker 02

  people with DID have a very full, like overly full, overly loud internal experience when you get to know them, whereas people with BPD will often describe feeling empty or having a lack of sense of self, not having enough of a self to really ground themselves or or attach to. And that's you, you can kind of feel that too when you're working with someone, when you meet someone with BPD versus DID.

• 36:28David Puder?

  Say that again, I didn't hear which one was, so the BPD is a lack of internal self, like an emptiness? Is that what you said?

• 36:36Speaker 02

  Yes, like difficulty with identity, fragmentation, sense of self, but in an empty way, whereas people with DID are often conflicted and confused and overwhelmed with how much they have internally to grapple with and make sense of. And that's kind of what keeps them quiet, hidden and confused because it's too much to make sense of.

• 36:58Speaker 01

  I completely agree with that.

• 37:00David Puder?

  I think the way that I understand personality is like, okay, I think that BPD has been stigmatized. I'm more of the psychodynamic where we have neurotic level of functioning, borderline level of functioning, psychotic level of functioning, we have defense mechanisms. Everyone has a personality style, whether the highest functioning person in the world could be a narcissistic personality style and like enjoy the acclaim and very focused on image protection, right, but very high functioning, you know, maybe some world leaders may have that. Or you could have like, you know, a schizoid level where it's like, you know, there's a

• 37:42David Puder?

  rich fantasy life and you have this fear of being consumed. So I'm wondering, like, is it more one personality style or another? Like, could they, could they just as easily be a little bit maybe narcissistic or a little bit schizoid or a little bit histrionic or a little bit dependent personality, depressive personality, hypomanic personality? Or do you, do you guys not think in those categories in your sort of day to day?

• 38:11Speaker 01

  I do, actually, and I'm thinking about Nancy McWilliams' book that

• 38:15David Puder?

  Love it, yeah.

• 38:16Speaker 01

  Exactly what I'm talking about, and I was trained somewhat dynamically. And certainly in that book, she describes the dissociative identity as its own, right, it's a chapter at the end of that great book that she, that she described. So I definitely hear you. I think a lot of people aren't trained that way anymore, just too bad. It's a very interesting way to, to think about it. But I think it's its own, I think there's a dissociative structuring of the mind that happens, that involves compartmentalization of thoughts, feelings, affects, memories. And if we're going along, you know, that sort of line in what you're thinking, there's, you know, there's like horizontal splitting versus vertical splitting.

• 39:01Speaker 01

  And I think that's an interesting way of thinking about it. So it's not repression, it's not, you know, sort of this horizontal divide, it's a vertical And where any of these thoughts and memories and feelings can be accessed at any time, but they're they're shut off by these vertical walls until, you know, they're triggered or there's some unconscious motivation that happens. And so there's the change, but I I I hear what you're saying. I think it's a it's a rich and fascinating way of describing things. It's just not the way we we tend to think about things in the clinic, but I do like that.

• 39:38David Puder?

  Hmm.

• 39:39Speaker 02

  Well, and now that you're saying that, Melissa, it makes me think that, you know, people with DID who are out in the world do have a character style and kind of adult defenses. Like they might have a more narcissistic or whatever way of dealing with their world around them and DID. The DID tends to be more hidden and operating the background. And they have this other sort of style of way of being in the world that's, you know, allows them, just like all of us, to to function. They're organized in a certain way.

• 40:11Speaker 01

  And it's actually can be quite adaptive because if you think about it by compartmentalizing, you know, these very difficult, I keep saying the same thing, but thoughts and feelings and memories. By compartmentalizing that, there's still then the chance to feel humor, feel connection, feel empathy, as opposed to someone that doesn't sort of compartmentalize away. It's so overwhelming and and I I've I've seen people with, you know, PTSD who are in the moment, their symptoms are so much worse because they don't have the capacity to compartmentalize away.

• 40:52Speaker 01

  And that's it's not easy to live with, you know, rampant dissociation and DID in no way. And people with DID have terrible PTSD at times, but they have this ability to compartmentalize things away. So they can be feeling horrible and then get up and go to work, uh, get up, you know, take care of their children. Um, there is this capacity that is defensive and structured, but is quite adaptive.

• 41:20David Puder?

  Hmm.

• 41:22Speaker 02

  And just, just to say one more thing, we're talking about all of these ways of seeing DID. DID is as, there, there's a diverse presentation and experience of DID. So, right, so there are people who really struggle with the symptoms and have a hard time functioning, all the way up to people who you would never know, and they may never tell you have DID, but they've had it all along, and everything in between. So it's not like there is a prototypical DID person, person with DID, obviously.

• 41:55David Puder?

  Maybe I can get Lauren to weigh in on some of the, some of the brain findings, some of the scans, this kind of lowering of the heart rate that can sometimes happen when someone gets under this kind of stress, but it's not like they're, you know, normally we'd expect their heart rate to go up, but their heart rate actually drops. So what are some of those different findings? And, yeah.

• 42:18Speaker 03

  Yeah, thanks, David. I think the, the neuroscience of DID is, has been evolving in exciting ways, but you're right, it kind of lays on the foundation of some of those, those early PTSD studies. And so I think that's a great place to start in the neuroscience to, to help understand what's going on in DID as well. But to go back to what you're saying, there's some really great, they're called symptom provocation studies in PTSD. And how they work is that they ask folks with PTSD to come into the lab and they narrate a traumatic experience that's happened to them personally in the past. They play, they record that, play it back to them while they're in a neuroimaging scan.

• 43:03Speaker 03

  That idea being that they can, they can capture what's happening in the brain while someone is feeling triggered and actively symptomatic with their PTSD symptoms, because they're back in that traumatic memory. And what they find in classic PTSD with more of that kind of dominance of the hyper arousal symptoms, feeling emotionally flooded, is that you have rapid activation of the amygdala. And what would, which is involved in...

• 43:36Speaker 03

  Orienting you to potential salient information in your environment, for an example, would be potential threats. And so in someone without PTSD, that would happen, but then very quickly, the ventromedial prefrontal cortex would come online to help regulate that bodily stress response that the amygdala is helping to mount. And they found in classic PTSD, that fails to occur. So the ventromedial prefrontal cortex is not coming online to help regulate the amygdala. And a metaphor we can use to think about that is if the ventromedial prefrontal cortex, kind of like the brakes, the braking mechanism, isn't there. And so you're getting this continuous stress response being mounted,

• 44:21Speaker 03

  even though that threat is no longer there. They're just listening to a recording of what's happening to them in the past. What Ruth Lanius and her team have done, they've built on these findings, looking at folks who have the dissociative subtype of PTSD. So all the regular PTSD symptoms, but in addition, symptoms of depersonalization or derealization, feeling detached from your sense of self and your environment. And she's found that the opposite thing actually occurs in the dissociative subtype of PTSD, where it's like the brakes are on too tightly. There's actually less amygdala activation and more activation in regions like the ventromedial prefrontal cortex.

• 45:06Speaker 03

  And then Simone Rinders and her team have also done symptom provocation studies in folks with DID. And she finds that depending on what the jargon in the field we use for this is dissociative self-states. So depending on what state someone is experiencing at any moment, they'll either show the classic PTSD pattern or the dissociative subtype PTSD pattern.

• 45:35Speaker 03

  An example of a prototypical self state that someone with DID might experience is one that feels kind of more hyper aroused and activated. They have a sense when they're listening to that trauma memory that it did happen to them personally. And that's where we see the brakes are off in the brain. There's more amygdala activation, less ventromedial prefrontal cortex activation. But when someone with DID is in another prototypical state, which is one that's more numb and detached, has lost a sense of agency and ownership over that trauma memory. So it kind of feels like it happened to somebody else. It's not them. That's where we see that the brakes are on too tightly.

• 46:20Speaker 03

  There's increased ventromedial prefrontal cortex activation and less activity in regions like the amygdala. So I think that's a key set of findings in DID that help place it on a continuum as a post traumatic adaptation. We're seeing these different types of PTSD brain patterns in the the patterns of activation in DID.

• 46:45David Puder?

  Yeah, I don't know if you guys saw recently the polyvagal theory. There was a big paper that came out with like 50 or so people that like co signed it saying this thing is not a thing. And I I've always seen it as like the three stages, you know, rest and relaxation, fight and flight, and more of that dissociation. And I think a lot of this stuff kind of makes sense in that context, right? Where it's like, there's it's not just one nerve in the body like the, you know, the dorsal vagal, as the polyvagal theory says, but it's like this whole like brain system that is dissociation, right? Do you guys have any comments on that?

• 47:22Speaker 01

  I haven't seen the paper. I think it's an eloquent or elegant theory. I agree, it's not one single nerve. And in that way, it seems it seems it always seemed a bit simplistic. But I think theoretically, in thinking about the symptom cascades in that way, that there is a, you know, hyper aroused, there is a more shut down kind of a response that are that some patients have. So, I mean, that makes sense to me clinically.

• 47:54Speaker 01

  I I will look up that paper. What journal was it in?

• 47:57David Puder?

  Uh, I don't recall off the top of my head. The other thing I was thinking was, what do you guys think of false memory syndrome? Or this idea? Cause you know, like 20 years or 10 years ago, if someone said like, oh, you know, I was sexually assaulted by this congressman and this president and this billionaire. You know, we'd be like, oh, is this person crazy? You know, but now post Epstein files, we'd be like, oh, wait, like some of this stuff matches up. You know, like this might've happened, right? So, but then there's also like this, this whole like genre of, you know, there are false memories, right? And there are people that don't remember things, maybe, or they're off, they're off false.

• 48:41David Puder?

  There's the capacity for people to create memories that didn't exist. So how do you differentiate this in your mind? Like, what are your thoughts?

• 48:52Speaker 01

  I mean, I think you just summed it up pretty well. That, I mean, there are, there are all sorts of studies on both camps. And we could sort of debate, you know, is, are there, is dissociation false memories? Are there false memories? Do sometimes people have false memories? I suspect so. Are some memories true? Yep. You know, is it possible to dissociate? Childhood maltreatment? It is. Are people who, you know, grew up to have post traumatic symptoms and dissociation? Have there been documented cases where they go back and look through the records? And in fact, they were abused? Yes.

• 49:35Speaker 01

  Were there therapists at times who may have pushed too hard? Or, you know, had their own agenda or whatever? And there were, you know, people ended up having symptoms that perhaps they didn't walk in with? Probably. I, I tend not to be black and white about it. But if someone comes in and, and, you know, reports a history of childhood abuse and they have all the symptoms of it. I'm not a detective and I'm not going to go back and make sure that, you know, the records are documented. I, I know enough that it does happen. I know that PTSD is a real thing. I know that. DID is a real thing. I know that child abuse does happen.

• 50:20Speaker 01

  At the same time, you want to be really careful as a treater not to. It's your it's your patient's story and it, you know, there's, there's nothing. You don't get any points for, you know, having this, you know, diagnosing someone with this or that, that you have an ethical obligation, right? To practice according to standards of care. Has that happened? Has that not happened at times? Yes. Do I believe my patients when they tell me things and the symptoms are there? And, you know, I, I, I go with what I'm shown. Have I had also, I mean, people can malinger. People can have factitious disorders. I mean, there's, there's all, it's just so gray.

• 51:04Speaker 01

  There's no bright light about any of this.

• 51:06David Puder?

  Hmm.

• 51:08Speaker 03

  But I think that maybe an important thing to hold on to is just because there may be one person who

• 51:13Speaker 01

  Right.

• 51:14Speaker 03

  was factitious or malingering or something, doesn't mean that the majority of cases are that, that, yeah.

• 51:21David Puder?

  Right.

• 51:21Speaker 01

  There's a great paper, uh, two thousand and twelve by, uh, Dahlenberg and colleagues and I would, I would just, um, if you haven't read it, it's great. I would suggest that anyone who's interested, who's listening to that podcast, read that article where it goes through very, very carefully, um, and addresses, uh, these types of issues about, uh, false memory syndrome and, uh, it's really a classic in the field.

• 51:49David Puder?

  Yeah, one thing I had, there's, there's a couple of patients that come to mind that could not remember the abuse until the parent that committed the abuse passed away. And I'm curious if you've seen this at all, um, what do you think might be going on there?

• 52:06Speaker 01

  I have seen that, um, uh, and I've even seen a couple of times, you know, very dramatic, like they literally had no memory of it. However, most, you know, most often there are.

• 52:22Speaker 01

  It's just sort of a central memory maybe missing, but as you, you know, the patient talks to you more, there are. Symptoms that they're expressing that are, you know, post-traumatic and they're, they may not remember like one thing in particular, but you know, their siblings have talked about other things. It's usually not just like a complete, I didn't remember one thing about it and I'm shocked that this happened. Sorry, your question was about when a parent dies. So yes, I have seen that because I think the sort of motivation to not remember or to not know really has its eased in that kind of situation.

• 53:04Speaker 02

  Similarly, I think when a parent's adult children move out of the house, we might see someone's symptoms get worse. Or when, you know, kind of a major life event that changes their need to stay hidden or stay to keep things so compartmentalized goes away, that we see people often start to become symptomatic, you know, later in life, wherever that point is.

• 53:29Speaker 01

  The kids have gone off to college and so they're less, you know, distracted, if you will, by child rearing or, you know, going to school or going out and becoming the, you know, excellent at your job. I mean, those things, I've seen a lot of people in retirement age who are slowing down and all of a sudden, you know, that's what they're left with.

• 53:53David Puder?

  I've also seen people when they stop drinking alcohol heavily. That's when they start to remember or, um, yeah, you're all nodding your heads.

• 54:03Speaker 01

  I mean, in a way, it's just another way to, I don't want to say distract, but the way of, you know, someone who has been busy their whole life raising children or going to school. I mean, all of this stuff has been probably a wonderful distraction. In the same way that, that drinking sort of is, you know, you cope by overworking or taking care of others, you cope by drinking. So I think it's sort of similar in that way. They stopped drinking, that coping, that way of coping with the traumatic thoughts and feelings has gone. So yeah, I agree.

• 54:47David Puder?

  Speak a little bit about, like, it seems like people with DID have like a part of themself that's more of the protector, more, you know, could be more, maybe even angry or violent if necessary. Is this, is this common? Is this something you look for?

• 55:05Speaker 02

  Yeah. I would say it's not, like, in my clinical work, I don't go looking for anything in particular when, when having a self-states.

• 55:15David Puder?

  I appreciate that. I appreciate that.

• 55:17Speaker 02

  And, and you're right, that I think if you think about what a kid would need to survive, or the different ways a kid would need to be in the world to stay hidden, having someone who can be protective and bold, or set boundaries, might be a state. Having someone who holds anger or fear, or like really overwhelming emotion, whatever that is, could be a state. Someone who is soothing and reassuring could be a state. Having a critical, sort of, you know, overly critical voice, or, or, yeah, anger towards the self-voice could be a state. Lauren, yeah.

• 55:59Speaker 01

  Great.

• 56:00Speaker 02

  And those are, I think those are, not everyone has those, but those are commonly reported in, in a person's own words, in a way.

• 56:10Speaker 01

  Yeah, it's, you know, yeah, lots of people with DID are pretty allergic to anger. And right when you're a little kid, and you, you know, you're being harmed, it would be very natural to become angry, but it's not very adaptive when you're very small to show anger. So that's, you know, a huge conflict for a kid. What do they do with it? So it becomes dissociated. So I would say that, yeah, having, you know, an angry self-state, I, I often see that. You'd said, you know, able to become violent. I would say that folks with DID, I would not say that they, I mean, there have been...

• 56:50Speaker 01

  I would say that the people that I have treated that have DID were not violent people. If anything, they were allergic to violence. Despite, you know, there have been some cases that have been quite sensationalized in the media about, you know, folks who have, you know, committed murder and then said, you know, it wasn't me, it was him. And I think a lot of those aren't DID, but some of them are. But, but on the whole, I would say that folks with DID are probably less outwardly violent because there's an internal solution. And it just, it wasn't, it wouldn't, it's not adaptable to be violent if you're a young

• 57:32Speaker 01

  child or, you know, a woman in many ways. So, yeah.

• 57:39David Puder?

  Lauren, I know you have to do some childcare stuff coming up here. Are there other big areas that we haven't even started to talk about that you could maybe take us through?

• 57:52Speaker 03

  Yeah, that's a great question. I feel like, I mean, just kind of sticking with the neuroscience a little bit, there are some other key findings there that might be helpful to hold in mind as a clinician or when you're talking to insurance companies or when you're encountering kind of folks who are giving you a little bit of pushback about what DID is or does it really exist or something. So another big, big line of work that Simone Rinders has taken on is comparing folks with DID to people who stimulate having DID and comparing their brain activity. The idea being that, okay, so maybe the fantasy model of people are making this up

• 58:36Speaker 03

  or role-playing in some way or they're, it's iatrogenic or something. That's

• 58:43Speaker 03

  That's captured by this control condition of someone asked and trained to simulate the symptoms of DID. And they go through pretty elaborate trainings and lots of manipulation checks to make sure someone really gets this. And they ask them, for example, to do the symptom provocation study of remembering their own past traumatic, reimmersing in their own past traumatic memories in one state versus another. And then they compare that to someone who's genuinely diagnosed with DID. What does it look like for them in one state versus another in these different memory conditions? And they, in all studies that have done that, to date, they've never been able to,

• 59:24Speaker 03

  the simulating control has never been able to replicate the brain activation that we see in folks with DID. So that helps to kind of dispel that particular theory about genuine DID. I think that's really important. There's also, a lot of the neuroscience of DID has focused on comparing one dissociative self state to another. And they, I think that's helpful in that it shows that these are, while it's not, as we've been talking about, this caricature of actual different people, they are internally experiencing very, what feels like very distinct states. And we see

• 1:00:06Speaker 03

  that in the brain activation, across paradigms, across different neuroimaging modalities, there's different activity in the brain when someone's in one dissociative self state versus another. And what that specific brain activation is just kind of depends on what you're asking them to do in the scanner. So I think that's helpful to hold on to, that these, these, these are real states that people are experiencing. And then I think, this takes us a little bit out of the neuroscience, but I think another important thing to talk about is that you can,

• 1:00:42Speaker 03

  DID is treatable, you can recover from DID. And yeah, I think that's an important point to hold on to, hope wise, for people who are experiencing this or have loved ones who have this condition, that it is treatable.

• 1:00:56David Puder?

  Yeah, and Melissa Kaufman, I know you shared publicly that this is something that you have struggled with historically. Maybe you could mention a little bit about like your road to recovery? Or what you would like to mention about this, I guess, yeah?

• 1:01:15Speaker 01

  Yeah, I'm happy to do that. I have spoken publicly about the fact that I grew up having DID. I did receive treatment, luckily enough, to find a really excellent treater when I was actually a resident, a psychiatry resident, and fully recovered. I no longer have PTSD or DID. And it's very important to me. That's one of the big reasons that I chose to self-disclose later in life. I really wanted to get the message out that

• 1:01:52Speaker 01

  these things, you can feel much better, and it is treatable. I was treated by a psychiatrist who did have some background in treating people that had been dealt with childhood abuse and neglect. She actually was a psychodynamic psychotherapist. And I think broadly speaking, it was sort of phasic in the way she treated it. It took me a long time to feel comfortable with her. I think a large part of my treatment was sort of building trust and being able to feel like I could talk about these things that had been hidden for so long. I would

• 1:02:33Speaker 01

  say she didn't do any sort of trauma-focused treatment like prolonged exposure or cognitive processing, really because in DID, the trauma is always sort of there. And really, what she taught me was more so how to become less symptomatic and how to

• 1:02:55Speaker 01

  If I were starting to feel dissociative or starting to feel like I was having a flashback, how to manage it. First, she would help me ma-, you know, she would help me manage it. And then I began to be able to manage it myself. And the more that I could do that, the more it felt, I felt very gradually able to go from a sense of, you know, that didn't happen to me. I know that's, you know, I always felt like that sounded crazy. I never wanted to say that because, but I did have this internal sense of having different, you know, people in, inside me, even though I knew that, you know, intellectually, that's not really possible. It was, it was, I was so conflicted about it.

• 1:03:34Speaker 01

  But over time, as she taught me and then I was able to take it my, in myself, um, that I had control. I could stop flashbacks. I could stop dissociating. I didn't have to talk about anything I didn't want to. But if I felt like I could tolerate it, I would talk about it. And gradually over time, uh, there was just this diminishment of sense that it's not me. And then it's like, oh, my God, that was me. No, it couldn't have been. Well, my God, it was me. And then eventually it's like, oh, my gosh, it was me all along. There's this sort of gradual dawning of awareness, if you will. And that was it. It wasn't super dramatic.

• 1:04:16Speaker 01

  Um, and it's like, you know, it, you know, in, I'm thinking about in the movie Sybil. There was this one, I mean, it was like an amazing, uh,

• 1:04:26Speaker 01

  it was an amazing sort of piece of art, um, in terms of drama. But, you know, she, I can't remember exactly what it was, but she remembered something and collapsed. And then it seemed like she didn't have D I D anymore. It, it's just like that. It's just a gradual, more and more able to integrate within oneself. The huge conflicts about being dependent, huge conflicts about saying things about your, you know, about people in your life that you don't want to say bad things about, you know, tho- those kinds of conflicts that people have and they've grown up in challenging situations.

• 1:05:07Speaker 01

  So that, that was my treatment and, um, I feel very fortunate and I, I very much want people to understand. I mean, not everyone wants that either. I mean, not everyone wants to.

• 1:05:22Speaker 01

  Be be integrated that some people with DID don't like that word. And there's some people that it may not make sense to sort of reach that point. It may may more make more sense to arrive at a place where the sort of internal not me states get along better. Um, there's not so much uh conflict anymore. And some people are okay reaching that state and that's okay.

• 1:05:50David Puder?

  Hmm. Do you feel still find it's um? There are moments where you can dissociate maybe more than the average person? Or is that mostly resolved as well?

• 1:06:03Speaker 01

  Yeah, it's interesting. I suspect I've you know, I'm still uh like an absent minded professor. I can get very immersed in books and movies and uh but not like I could, not like I used to.

• 1:06:16David Puder?

  But not like spacing out for?

• 1:06:19Speaker 01

  Not as much as I used to. I'm way more in the outside world than I was before. And um in some ways I miss it. But you know, I I say that, but you know, it's not easy having DID. It's not easy, you know, having post traumatic symptoms. But um I've changed a little bit. Yeah, I'm I'm just not as internally focused as I used to be.

• 1:06:42David Puder?

  Thank you for sharing.

• 1:06:44Speaker 01

  Thanks for asking.

• 1:06:45David Puder?

  Thank you for sharing. Matthew, do you um? Do you have any like treatment pearls?

• 1:06:53Speaker 02

  Yeah, well, I mean, first I want to say that treatment and access to treatment for DID is woefully under there's a huge access problem. Um, and so the more people that can learn about DID, the better. As Melissa described, I think.

• 1:07:13Speaker 02

  The biggest focus of treatment is relationship building and development and helping a person develop the language to understand their mind. So is a very relational, I think, psychodynamic approach in many cases. And treatments like Finding Solid Ground, which is a newly, a new treatment by Bethany Brand, Lanius and colleagues, that can help teach people skills for grounding and managing the sort of active symptoms of dissociation. It's a great adjunct to the work that goes on to, to help a person feel more whole and in control. But I would say a lot of people want to find a DID specialist and I often have to tell

• 1:07:58Speaker 02

  people, find a good therapist. Yeah. Find a good therapist who wants to build a strong relationship and a lot of the work will happen that needs to happen because they know how to do therapy.

• 1:08:12Speaker 01

  And they know how to do therapy. And one thing that's really important is to find a therapist that's really boundaried. That was actually something, you know, I learned as a psychiatrist. I also learned in my own treatment how important that is. I think it can sometimes with folks that have, you know, been through very difficult circumstances, the, the, there may be, you know, a wish to, you know, help more or, or show more or be more to a person. And I think having a very boundaried therapist for many, many reasons, that's one of the most important things.

• 1:08:51Speaker 02

  That's actually the pearl. So Melissa's one of the people that trained and mentored me as a person who feels moderately comfortable treating DID. I've learned a lot from her and I have a voice, her, her voice in my head about just be consistent. Be consistent. Be bound read and paste. And so I've held that in the background as I'm trying to work with someone with DID. That and also, I always remember that it's one person. The person I'm working with can describe their experience in lots of ways. And whether or not, you know, I don't always challenge that or ask about that. But I'm always holding on to the notion, the reality that this is one whole person who experiences themselves

• 1:09:35Speaker 02

  in the world in this way. And so my job is to hold that frame and help them to find the ability to hold that frame for themselves over time.

• 1:09:46Speaker 01

  Yeah, you definitely can empathize. And, you know, you're not going to challenge and say, that's not possible to have, you know? I mean, that, that's just, you, you absolutely can empathize with the fact that subjectively, that is absolutely how it feels. And as Matt is saying, you also hold on, you hold on to both. That is subjectively how people feel and you make in treatment, speak to them. You know, in a way that they can subjectively understand. But also keep reminding yourself, this is one person, this is one person.

• 1:10:20David Puder?

  That's good. Kind of wrapping up our time, I have to go to my own childcare adventures here. Coaching my son's basketball team. So, yeah, I'm curious if there's anything else kind of floating around in your mind that you really wanted to say? I want to give you the chance to do it, maybe Lauren, you go first? Or sorry, Lauren's not here.

• 1:10:43David Puder?

  Melissa, you go first.

• 1:10:45Speaker 01

  Uh, I guess I just want to thank you for having this opportunity. I, it's really, I think, important for people to understand that. But, you know, I, this is what I want to say. I do get tired of saying, you know, DID is real. We don't have to really do that with other psychiatric conditions. So I hope, you know, educational forums like this, we can keep doing this. And thank you for allowing us to do this because at some point, we're going to have to, we can just stop saying that and people can just get on with what needs to be done. And that is getting access and, and care for folks that have dissociative disorders.

• 1:11:22David Puder?

  Yeah, and I hope you don't feel like me putting out the conflicts too early was because I think because I think I even mentalize that when I'm thinking about how people think about it. You know, so I think it's good to put out, put out the that conflict that's it that is in our space, right?

• 1:11:44Speaker 01

  So there you have to talk about it.

• 1:11:46David Puder?

  Yeah, we don't like like Freud. We don't want to think that horrific traumas happen to children. We don't want to think.

• 1:11:56David Puder?

  You know, it would be a nice fantasy to believe it's all fantasy, right?

• 1:12:01Speaker 01

  Absolutely.

• 1:12:04David Puder?

  And also dissociation is is alive and well. It's it's it's very adaptive. It's absolutely adaptive.

• 1:12:14Speaker 01

  Yeah.

• 1:12:15David Puder?

  I'll probably go play some Minecraft tonight with my kids and dissociate from all of the worries of work for half an hour. Yeah.

• 1:12:25Speaker 01

  I appreciate you bringing up the controversies because if you didn't, people would wonder why that would be like pretending as if there is still no controversy. There's still controversy, but we pay great strides. And again, you know, exactly what you're doing, allowing this space to to speak about these things, I could not be more grateful.

• 1:12:45David Puder?

  Matthew, any final thoughts?

• 1:12:48Speaker 02

  Just referencing back to a couple of things you actually said. Thank you. Yes, I agree. It's very glad to have this space. Even though we're talking more about childhood abuse and maltreatment of people and human rights violations, it's in the news more. I still think there's this collective willfulness around action and taking it seriously. And so I would implore kind of anyone listening to when you notice yourself or people around you doing that, you know, it's not happening to me. It's somewhere else, you know, it can't be as bad as it sounds. A lot of my patients right now are horrified about what's in the news and the lack of accountability. And they say to me, this is why I didn't talk about it for so long. It's, I mean,

• 1:13:34Speaker 02

  there's evidence, there's billions of pages of evidence of something and nothing's happening. So I think as mental health providers and, you know, we are here to provide treatment, but we're also here to be advocates and a voice for people who can't voice things for themselves.

• 1:13:52David Puder?

  I all of a sudden, I have this patient who really likes Punisher comic books. And I decided to get a series of Punisher comic books, which are about the child sex trade and the Punisher going after the abusers. And then I was like, I became conscious all of a sudden, like, oh, I bought this for a reason at this point in history, at this point in time, right? And we do want justice, right? We do. It's like, I'm not going to become a vigilante, but we do want justice, right? And we do need to speak out. And, you know, we can go back through the early survivors that did speak out about Epstein and how they were publicly shunned.

• 1:14:36David Puder?

  I was just talking to a therapist today. She said there was a person that she treated that had been horrifically abused by someone in the, you know, in the film industry, early on in her career. And she never spoke out about it because she knew it would be the end of her career. It would be the absolute end of her career. You know, so we collectively need to start to believe, you know, yes, this could happen. It could absolutely happen. And if, if there's good documentation that it has happened, then these people should be brought to some sense of justice, right?

• 1:15:21David Puder?

  Yeah, absolutely.

• 1:15:23Speaker 02

  Agreed. Thank you.

• 1:15:26David Puder?

  Yeah. All right, guys, we'll leave it there for today, okay?

• 1:15:29Speaker 02

  Take care.

• 1:15:30David Puder?

  Part two will probably be like focus on treatment because I feel like we could really go into, like, I mean, you run an IOP partial, there's so much collective wisdom that you guys have for this. So.

• 1:15:43Speaker 02

  Happy to do so.

• 1:15:44David Puder?

  We'll do that another time.

• 1:15:46Speaker 02

  Thank you. Sounds good. Thanks, David.