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DID/OSDD as a Spectrum

Whilst DID and OSDD-1 are not presently classified as spectrum disorders, as they exist as separate diagnoses, the presentation of dissociative symptoms related to the diagnoses could be visualised as a spectrum of different symptoms ranging from “normal” experiences to sub-clinical experiences to clinical experiences.

The Multidimensional Inventory of Dissociation (MID) is one of the more accessible comprehensive measurements of dissociative symptoms, it consists of 218 questions covering multiple scales pertaining mostly to dissociative and post traumatic experiences, the answers are self reported however the administering person may make adjustments to scoring where they see fit. These answers may then be inputted into the MID Analysis excel program, where a report is automatically generated with suggestions towards diagnosis as well as details of individual subcomponents’ scoring.

For the purspose of considering DID/OSDD from a spectrum perspective, the aspects we will be considering are as follows

 – General Patient Dissociative Symptoms

 – Partially-Dissociated Intrusions

 – Fully-Dissociated Actions

There also exists Validity scales as well as measurements of Functioning and Impairment, these influence the results reported by the MID, however they do not directly pertain to symptoms of dissociation, thus they have been omitted for simplicity of analysis.

The below charts depict the average or “norm” scoring of non-dissociative, DID, OSDD-1b, and PTSD test takers based on the data provided in v5.2 of the MID Analysis. The charts use a scale of clinical significance, where a score of 100 or higher on any one measurement is considered clinically significant, and is scaled linearly such that a score of 200 is twice as significant as a score of 100.

A radar chart plotting general dissociative symptoms across individuals without disorders and those with DID, OSDD-1, or PTSD
A radar chart plotting partial dissociation (intrusion) symptoms across individuals without disorders and those with DID, OSDD-1, or PTSD
A radar chart plotting full dissociation (amnesia) symptoms across individuals without disorders and those with DID, OSDD-1, or PTSD

Note:These charts do not include series for OSDD-1a specifically. Whilst the MID does make some considerations towards the continuity in sense of self and agency that the DSM-V refers to, it does not necessarily measure the distinction between alters / personality states referenced in the DSM-IV. Additionally the normed values for the OSDD measurement specifically include the lessened amnesia criteria, such that indviduals with OSDD-1a may be identified as having DID using these measurements, this emphasises the importance of clinical judgement when assessing patients.

Visualising the Spectrum

Sandra L. Paulsen, working off of J.G. Watkins’ prior Ego-State/Dissociative work, devised the following Dissociative Continuum, focusing on the inner conflict and sense of self/selves. This ranges from the normal “part of me wants to do this but another part of me doesn’t” that might arise from regular inner conflict, unrelated to separated senses of self, to DID where the parts are disintegrated and have separate senses of self:

A continuum of dissociative disorders, starting with normal roles and state dependent learning, followed by conflicted ego states and ambivalence, and then ego state disorders and PTSD, and then complex PTSD and DDNOS and DESNOS and lastly ending with DID and complex DID

Lynda Shirar’s book Dissociative Children: Bridging the Inner and Outer Worlds presents a slightly more detailed continuum, displayed below.

The continuum of dissociation by Lynda Shirar, with multiple points displayed along a horizontal line from normal dissociation, to disorders with dissociative symptoms, to dissociative disorders. There is a partial overlap of the last two categories. Under normal dissociation is Fantasy, Daydreaming, Automatic behaviours, Highway hypnosis and, as a separate item Denial. Disorders with Dissociative Symptoms include Acute stress, Post-traumatic stress disorder, Panic disorder, Obsessive-compulsive disorder, Eating disorders, and Depression, the items on the continuum's line are listed in the following order: Repression, Depresonalization, Post-traumatic play, Post-traumatic reenactment, Compulsive  behaviors, Hyperarousal, Flashbacks, Intrusive thoughts/images, Psychic numbing, Dissociative amnesia, fugues. The Dissociative Disorders section also includes Dissociative amnesia, and fugues, but also continues to list Dissociative Disorder not otherwise specified (DDNOS) and then Dissociative identity disorder (DID)

A similar but more detailed continuum, is that of the BASK model of dissociation, pictured below, where Atypical Dissociative Disorder and Atypically Multiple Personality Disorder is representative of OSDD-1a/b and Multiple Personality Disorder is representative of DID.

The Continuum of Dissociation from the BASK model of dissociation, displaying a continuum from normal to dissociative episode to dissociative disorder to PTSD to atypical dissociative disorder to atypical multiple personality disorder to multiple personality disorder. It also includes a lower section of organic disorders underneath.

Another perspective one can take for looking at dissociation in DID/OSDD as a spectrum, would be taking the two differing criteria within OSDD-1a and OSDD-1b (The less than marked discontinuities in sense of self and agency against the lack of narrative amnesia) and plotting them against each other, which would likely vaguely resemble the below chart:

A chart showing a scale between normal levels of dissociation and DID levels of dissociation, with one axis representing amnesia and the other representing discontinuity in sense of sel