What is Amitriptyline/Perphenazine?


Amitriptyline/perphenazine (Duo-Vil, Etrafon, Triavil, Triptafen) is a formulation that contains the tricyclic antidepressant amitriptyline and the medium-potency typical (first-generation) antipsychotic, perphenazine. In the United States amitriptyline/perphenazine is marketed by Mylan Pharmaceuticals Inc. and Remedy Repack Inc.

Medical Uses

In the United States amitriptyline/perphenazine is indicated for the treatment of patients with:

  • Moderate-severe anxiety and/or agitation and depression
  • Depression and anxiety in association with chronic physical disease
  • Schizophrenia with prominent depressive symptoms

Adverse Effects

Common (>1% incidence) Adverse Effects Include

  • Sedation
  • Hypertension — high blood pressure.
  • Neurological impairments (such as extrapyramidal side effects which include dystonia, akathisia, parkinsonism, muscle rigidity, etc.)
  • Anticholinergic side effects such as:
    • Blurred vision
    • Constipation
    • Dry mouth
    • Nasal congestion
  • Increased appetite
  • Weight gain
  • Nausea
  • Dizziness
  • Headache
  • Vomiting

Unknown Frequency Adverse Effects Include

  • Diarrhoea
  • Alopecia — hair loss
  • Photophobia
  • Pigmentation
  • Eczema up to exfoliative dermatitis
  • Urticaria
  • Erythema
  • Itching
  • Photosensitivity (increased sensitivity of affected skin to sunlight)
  • Hypersalivation — excessive salivation.
  • Hyperprolactinaemia — elevated blood prolactin levels. This may present with the following symptoms:
    • Galactorrhoea — the release of milk that is not associated with pregnancy or breastfeeding
    • Gynaecomastia — the development of breast tissue in males
    • Disturbances in menstrual cycle
    • Sexual dysfunction
  • Pigmentation of the cornea and lens
  • Hyperglycaemia — elevated blood glucose (sugar) levels.
  • Hypoglycaemia — low blood glucose (sugar) levels.
  • Disturbed concentration
  • Excitement
  • Anxiety
  • Insomnia
  • Restlessness
  • Nightmares
  • Weakness
  • Fatigue
  • Diaphoresis — excessive/abnormal sweating.

Uncommon/Rare Adverse Effects Include

  • Tardive dyskinesia, an often irreversible adverse effect that usually results from chronic use antipsychotic medications, especially the high-potency first-generation antipsychotics. It is characterised by slow (hence tardive), involuntary, repetitive, purposeless muscle movements.
  • Neuroleptic malignant syndrome, a potentially fatal complication of antipsychotic drug use. It is characterised by the following symptoms:
    • Muscle rigidity
    • Tremors
    • Mental status change (e.g. hallucinations, agitation, stupor, confusion, etc.)
    • Hyperthermia — elevated body temperature
    • Autonomic instability (e.g. tachycardia, high blood pressure, diaphoresis, diarrhoea, etc.)
  • Urinary retention — the inability to pass urine despite having urine to pass.
  • Blood dyscrasias e.g. agranulocytosis (a potentially fatal drop in white blood cell count), leukopenia (a drop in white blood cell counts but not to as extreme an extent as agranulocytosis), neutropoenia (a drop in neutrophil [the cells of the immune system that specifically destroy bacteria] count), thrombocytopaenia (a dangerous drop in platelet [a cell found in the blood that plays a crucial role in the blood clotting process] counts), purpura (the appearance of red or purple discolouration’s of the skin that do not blanch when pressure is applied), eosinophilia (raised eosinophil [the cells of the immune system that specifically fights off parasites] count)
  • Hepatitis — inflammation of the liver
  • Jaundice
  • Pigmentary retinopathy
  • Anaphylactoid reactions
  • Oedema — the abnormal build-up of fluids in the tissues
  • Asthma
  • Coma
  • Seizures
  • Confusional states
  • Disorientation
  • Incoordination
  • Ataxia
  • Tremors
  • Peripheral neuropathy — nerve damage
  • Numbness, tingling and paraesthesia of the extremities
  • Dysarthria
  • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
  • Tinnitus — falsely hearing ringing in the ears.
  • Alteration in EEG patterns
  • Paralytic ileus — cessation of the peristaltic waves that propel partially digested food through the digestive tract.
  • Hyperpyrexia (elevated body temperature)
  • Disturbance of accommodation
  • Increased intraocular pressure
  • Mydriasis

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Amitriptyline/perphenazine >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Social Connection?


Social connection is the experience of feeling close and connected to others. It involves feeling loved, cared for, and valued, and forms the basis of interpersonal relationships.

“Connection is the energy that exists between people when they feel seen, heard and valued; when they can give and receive without judgement; and when they derive sustenance and strength from the relationship.” Brené Brown, Professor of social work at the University of Houston.

Increasingly, social connection is understood as a core human need, and the desire to connect as a fundamental drive. It is crucial to development; without it, social animals experience distress and face severe developmental consequences. In humans, one of the most social species, social connection is essential to nearly every aspect of health and well-being. Lack of connection, or loneliness, has been linked to inflammation, accelerated aging and cardiovascular health risk, suicide, and all-cause mortality.

Feeling socially connected depends on the quality and number of meaningful relationships one has with family, friends, and acquaintances. Going beyond the individual level, it also involves a feeling of connecting to a larger community. Connectedness on a community level has profound benefits for both individuals and society.

Related Terms

Social support is the help, advice, and comfort that we receive from those with whom we have stable, positive relationships. Importantly, it appears to be the perception, or feeling, of being supported, rather than objective number of connections, that appears to buffer stress and affect our health and psychology most strongly.

Close relationships refer to those relationships between friends or romantic partners that are characterised by love, caring, commitment, and intimacy.

Attachment is a deep, emotional bond between two or more people, a “lasting psychological connectedness between human beings.” Attachment theory, developed by John Bowlby during the 1950s, is a theory that remains influential in psychology today.

Conviviality has many different interpretations and understandings, one of which denotes the idea of living together and enjoying each other’s company. This understanding of the term is derived from the French convivialité, which can be traced back to Jean Anthelme Brillat-Savarin in the 19th Century. Other interpretations of conviviality include the art of living in the company of others; everyday experiences of community cohesion and togetherness in diverse settings; and the capacity of individuals to interact creatively and autonomously with one another and their environment for the satisfaction of their needs. This third interpretation is rooted in the work of Ivan Illich from the 1970s onwards. Social connection is fundamental to all of these interpretations of conviviality.

A Basic Need

In his influential theory on the hierarchy of needs, Abraham Maslow proposed that our physiological needs are the most basic and necessary to our survival, and must be satisfied before we can move on to satisfying more complex social needs like love and belonging. However, research over the past few decades has begun to shift our understanding of this hierarchy. Social connection and belonging may in fact be a basic need, as powerful as our need for food or water. Mammals are born relatively helpless, and rely on their caregivers not only for affection, but for survival. This may be evolutionarily why mammals need and seek connection, and also for why they suffer prolonged distress and health consequences when that need is not met.

In 1965, Harry Harlow conducted his landmark monkey studies. He separated baby monkeys from their mothers, and observed which surrogate mothers the baby monkeys bonded with: a wire “mother” that provided food, or a cloth “mother” that was soft and warm. Overwhelmingly, the baby monkeys preferred to spend time clinging to the cloth mother, only reaching over to the wire mother when they became too hungry to continue without food. This study questioned the idea that food is the most powerful primary reinforcement for learning. Instead, Harlow’s studies suggested that warmth, comfort, and affection (as perceived from the soft embrace of the cloth mother) are crucial to the mother-child bond, and may be a powerful reward that mammals may seek in and of itself. Although historically significant, it is important to acknowledge that this study does not meet current research standards for the ethical treatment of animals.

In 1995, Roy Baumeister proposed his influential belongingness hypothesis: that human beings have a fundamental drive to form lasting relationships, to belong. He provided substantial evidence that indeed, the need to belong and form close bonds with others is itself a motivating force in human behaviour. This theory is supported by evidence that people form social bonds relatively easily, are reluctant to break social bonds, and keep the effect on their relationships in mind when they interpret situations. He also contends that our emotions are so deeply linked to our relationships that one of the primary functions of emotion may be to form and maintain social bonds, and that both partial and complete deprivation of relationships leads to not only painful but pathological consequences. Satisfying or disrupting our need to belong, our need for connection, has been found to influence cognition, emotion, and behaviour.

In 2011, Roy Baumeister furthered this notion of belongingness by proposing the Need to Belong Theory, which asserts that humans have an inherent drive to maintain a minimum number of social relationships to foster a sense of belonging. Baumeister highlights the importance of satiation and substitution in driving human behaviour and social connection. Motivational satiation is a phenomenon in which an individual may desire something, but at a certain point, they may reach a point where they have had enough and no longer want or need any more of it. This concept can be applied to the formation of friendships, where an individual may desire social connections, but they may reach a point where they have enough friends and do not seek any more. However, Baumeister suggests that people still require a certain minimum amount of social connection, and to some extent, these bonds can substitute for each other. The Need to Belong Theory is a primary motivator of human behaviour, providing a framework for understanding social relationships as a basic, fundamental need for psychological health and well-being.


Brain Areas

While it appears that social isolation triggers a “neural alarm system” of threat-related regions of the brain (including the amygdala, dorsal anterior cingulate cortex (dACC), anterior insula, and periaqueductal gray (PAG)), separate regions may process social connection. Two brain areas that are part of the brain’s reward system are also involved in processing social connection and attention to loved ones: the ventromedial prefrontal cortex (VMPFC), a region that also responds to safety and inhibits threat responding, and the ventral striatum (VS) and septal area (SA), part of a neural system that is activated by taking care of one’s own young.

Key Neurochemicals


In 1978, neuroscientist Jaak Panksepp observed that small doses of opiates reduced the distressed cries of puppies that were separated from their mothers. As a result, he developed the brain opioid theory of attachment, which posits that endogenous (internally produced) opioids underlie the pleasure that social animals derive from social connection, especially within close relationships. Extensive animal research supports this theory. Mice who have been genetically modified to not have mu-opioid receptors (mu-opioid receptor knockout mice), as well as sheep with their mu-receptors blocked temporarily following birth, do not recognise or bond with their mother. When separated from their mother and conspecifics, rats, chicks, puppies, guinea pigs, sheep, dogs, and primates emit distress vocalisations, however giving them morphine (i.e. activating their opioid receptors), quiets this distress. Endogenous opioids appear to be produced when animals engage in bonding behaviour, while inhibiting the release of these opioids results in signs of social disconnection. In humans, blocking mu-opioid receptors with the opioid antagonist naltrexone has been found to reduce feelings of warmth and affection in response to a film clip about a moment of bonding, and to increase feelings of social disconnection towards loved ones in daily life as well as in the lab in response to a task designed to elicit feelings of connection. Although the human research on opioids and bonding behaviour is mixed and ongoing, this suggests that opioids may underlie feelings of social connection and bonding in humans as well.


In mammals, oxytocin has been found to be released during childbirth, breastfeeding, sexual stimulation, bonding, and in some cases stress. In 1992, Sue Carter discovered that administering oxytocin to prairie voles would accelerate their monogamous pair-bonding behaviour. Oxytocin has also been found to play many roles in the bonding between mother and child. In addition to pair-bonding and motherhood, oxytocin has been found to play a role in prosocial behaviour and bonding in humans. Nicknamed the “love drug” or “cuddle chemical,” plasma levels of oxytocin increase following physical affection, and are linked to more trusting and generous social behaviour, positively biased social memory, attraction, and anxiety and hormonal responses. Further supporting a nuanced role in adult human bonding, greater circulating oxytocin over a 24-hour period was associated with greater love and perceptions of partner responsiveness and gratitude, however was also linked to perceptions of a relationship being vulnerable and in danger. Thus oxytocin may play a flexible role in relationship maintenance, supporting both the feelings that bring us closer and the distress and instinct to fight for an intimate bond in peril.


Consequences of Disconnection

A wide range of mammals, including rats, prairie voles, guinea pigs, cattle, sheep, primates, and humans, experience distress and long-term deficits when separated from their parent. In humans, long-lasting health consequences result from early experiences of disconnection. In 1958, John Bowlby observed profound distress and developmental consequences when orphans lacked warmth and love of our first and most important attachments: our parents. Loss of a parent during childhood was found to lead to altered cortisol and sympathetic nervous system reactivity even a decade later, and affect stress response and vulnerability to conflict as a young adult.

In addition to the health consequences of lacking connection in childhood, chronic loneliness at any age has been linked to a host of negative health outcomes. In a meta-analytic review conducted in 2010, results from 308,849 participants across 148 studies found that people with strong social relationships had a 50% greater chance of survival. This effect on mortality is not only on par with one of the greatest risks, smoking, but exceeds many other risk factors such as obesity and physical inactivity. Loneliness has been found to negatively affect the healthy function of nearly every system in the body: the brain, immune system, circulatory and cardiovascular systems, endocrine system, and genetic expression.

Not only is social isolation harmful to health, but it is more and more common. As many as 80% of young people under 18 years old, and 40% of adults over the age of 65 report being lonely sometimes, and 15-30% of the general population feel chronic loneliness. These numbers appear to be on the rise, and researchers have called for social connection to be public health priority.

Social Immune System

One of the main ways social connection may affect our health is through the immune system. The immune system’s primary activity, inflammation, is the body’s first line of defence against injury and infection. However, chronic inflammation has been tied to atherosclerosis, Type II diabetes, neurodegeneration, and cancer, as well as compromised regulation of inflammatory gene expression by the brain. Research over the past few decades has revealed that the immune system not only responds to physical threats, but social ones as well. It has become clear that there is a bidirectional relationship between circulating biomarkers of inflammation (e.g. the cytokine IL-6) and feelings of social connection and disconnection; not only are feelings of social isolation linked to increased inflammation, but experimentally induced inflammation alters social behaviour and induces feelings of social isolation. This has important health implications. Feelings of chronic loneliness appear to trigger chronic inflammation. However, social connection appears to inhibit inflammatory gene expression and increase antiviral responses. Performing acts of kindness for others were also found to have this effect, suggesting that helping others provides similar health benefits.

Why might our immune system respond to our perceptions of our social world? One theory is that it may have been evolutionarily adaptive for our immune system to “listen” in to our social world to anticipate the kinds of bacterial or microbial threats we face. In our evolutionary past, feeling socially isolated may have meant we were separated from our tribe, and therefore more likely to experience physical injury or wounds, requiring an inflammatory response to heal. On the other hand, feeling connected may have meant we were in relative physical safety of community, but at greater risk of socially transmitted viruses. To meet these threats with greater efficiency, the immune system responds with anticipatory changes. A genetic profile was discovered to initiate this pattern of immune response to social adversity and stress – up-regulation of inflammation, down-regulation of antiviral activity – known as Conserved Transcriptional Response to Adversity. The inverse of this pattern, associated with social connection, has been linked to positive health outcomes as well as eudaemonic well-being.

Positive Pathways

Social connection and support have been found to reduce the physiological burden of stress and contribute to health and well-being through several other pathways as well, although there remains a subject of ongoing research. One way social connection reduces our stress response is by inhibiting activity in our pain and alarm neural systems. Brain areas that respond to social warmth and connection (notably, the septal area) have inhibitory connections to the amygdala, which have the structural capacity to reduce threat responding.

Another pathway by which social connection positively affects health is through the parasympathetic nervous system (PNS), the “rest and digest” system which parallels and offsets the “flight or fight” sympathetic nervous system (SNS). Flexible PNS activity, indexed by vagal tone, helps regulate the heart rate and has been linked to a healthy stress response as well as numerous positive health outcomes. Vagal tone has been found to predict both positive emotions and social connectedness, which in turn result in increased vagal tone, in an “upward spiral” of well-being. Social connection often occurs along with and causes positive emotions, which themselves benefit our health.


Social Connectedness Scale

This scale was designed to measure general feelings of social connectedness as an essential component of belongingness. Items on the Social Connectedness Scale reflect feelings of emotional distance between the self and others, and higher scores reflect more social connectedness.

UCLA Loneliness Scale

Measuring feelings of social isolation or disconnection can be helpful as an indirect measure of feelings of connectedness. This scale is designed to measure loneliness, defined as the distress that results when one feels disconnected from others.

Relationship Closeness Inventory (RCI)

This measure conceptualises closeness in a relationship as a high level of interdependence in two people’s activities, or how much influence they have over one another. It correlates moderately with self-reports of closeness, measured using the Subjective Closeness Index (SCI).

Liking and Loving Scales

These scales were developed to measure the difference between liking and loving another person – critical aspects of closeness and connection. Good friends were found to score highly on the liking scale, and only romantic partners scored highly on the loving scale. They support Zick Rubin’s conceptualisation of love as containing three main components: attachment, caring, and intimacy.

Personal Acquaintance Measure (PAM)

This measure identifies six components that can help determine the quality of a person’s interactions and feelings of social connectedness with others:

  • Duration of relationship
  • Frequency of interaction with the other person
  • Knowledge of the other person’s goals
  • Physical intimacy or closeness with the other person
  • Self-disclosure to the other person
  • Social network familiarity – how familiar is the other person with the rest of your social circle

Experimental Manipulations

Social connection is a unique, elusive, person-specific quality of our social world. Yet, can it be manipulated? This is a crucial question for how it can be studied, and whether it can be intervened on in a public health context. There are at least two approaches that researchers have taken to manipulate social connection in the lab:

Social Connection Task

This task was developed at UCLA by Tristen Inagaki and Naomi Eisenberger to elicit feelings of social connection in the laboratory. It consists of collecting positive and neutral messages from 6 loved ones of a participant, and presenting them to the participant in the laboratory. Feelings of connection and neural activity in response to this task have been found to rely on endogenous opioid activity.

Closeness-Generating Procedure

Arthur Aron at the State University of New York at Stony Brook and collaborators designed a series of questions designed to generate interpersonal closeness between two individuals who have never met. It consists of 36 questions that subject pairs ask each other over a 45-minute period. It was found to generate a degree of closeness in the lab, and can be more carefully controlled than connection within existing relationships.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Social_connection >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is the Quality of Well-Being Scale?


The Quality of Well-Being Scale (QWB) is a general health quality of life questionnaire which measures overall status and well-being over the previous three days in four areas:

  • Physical activities;
  • Social activities;
  • Mobility; and
  • Symptom/problem complexes.

It consists of 71 items and takes 20 minutes to complete. There are two different versions of the QWB; the original was designed to be administered by an interviewer, and the second development (the QWB-SA) was designed to be self-administered.

The four domain scores of the questionnaire are combined into a total score that ranges from 0 to 1.0, with 1.0 representing optimum function and 0 representing death.


The QWB was originally known as the Health Status Index, then the Index of Well-Being, and then eventually became the Quality of Well-Being Scale. It has undergone several modifications since its development.

The process of administering the QWB can be described in three stages. They are the assessment of:

  • Functional status;
  • Scaling the responses; and
  • Indicating prognosis.

Assessment of functional status involves a structured interview which records the symptoms and problems experienced over the last eight days. It is used to classify the patient’s level of functioning. The interview takes about seven minutes or longer, according to the patient’s level of health. Questions in the interview covered three criteria of functioning: physical activity, social activity and mobility and confinement. The interview also records the presence of symptoms or problem complexes, which are problems that were experienced on the previous day, but were not being experienced at the present time.

The responses from the interview were then scaled. Preference weights were given for each function level by 867 raters. The preference weights indicated the social judgement of the importance of each function level. A score is generated, which is known as W.W. can then be adjusted to reflect the prognosis of a given medical condition.

International Use

Since the development of the Quality of Well-Being Scale and the consequent Quality of Well-Being Scale-Self Administered, the questionnaire has been utilised in numerous studies worldwide. Due to the general nature of the questionnaire, it has proven useful in a variety of different formats and contexts.

One way in which the QWB and the QWB-SA has been utilised is that it has been a comparator used to validate other measures, or a starting point for creating subscales of the questionnaire. An example of this is a subscale developed for use with the QWB-SA that assesses mental health, a comparator study seeking to investigate the Health and Activity Limitation Index and a study seeking to validate a new questionnaire called the Assessment of Quality of Life (AQoL)-8D.

The QWB and the QWB-SA have also been validated or assessed for suitability in various cultures and countries. The QWB has been assessed for use in Trinidad and Tobago and the QWB-SA has been validated for German patients with prostate disease, as well as Chinese patients with epilepsy.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Quality_of_well-being_scale >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is the Physical Quality of Life Index?


The Physical Quality of Life Index (PQLI) is an attempt to measure the quality of life or well-being of a country.

The value is the average of three statistics:

  • Basic literacy rate at the age of 15 years;
  • Infant mortality; and
  • Life expectancy at age one,

all equally weighted on a 1 to 100 scale.

Refer to Happiness Economics.


It was developed for the Overseas Development Council in the mid-1970s by Pratyush and his company, as one of a number of measures created due to dissatisfaction with the use of GNP as an indicator of development. He thought that they would cover a wide range of indicators like health, sanitation, drinking water, nutrition, education etc. PQLI might be regarded as an improvement but shares the general problems of measuring quality of life in a quantitative way. It has also been criticised because there is considerable overlap between infant mortality and life expectancy.

The UN Human Development Index is a more widely used means of measuring well-being.

Steps to Calculate Physical Quality of Life:

  1. Find percentage of the population that is literate (literacy rate).
  2. Find the infant mortality rate. (out of 1000 births) INDEXED Infant Mortality Rate = (166 – infant mortality) × 0.625
  3. Find the Life Expectancy. INDEXED Life Expectancy = (Life expectancy – 42) × 2.7
  4. Physical Quality of Life = (Literacy Rate + INDEXED Infant Mortality Rate + INDEXED Life Expectancy) divided by 3.

Notes about the PQLI:

  • Increase in national income and per capita income are not the real indicators of economic development, as it has a number of limitations.
  • Increasing incomes of the country are concentrated (generally) in the hands of a few people, which is not development.
  • The development of a country should be such that the living standards of the poor rise, and the basic requirements of the citizens are fulfilled.
  • Keeping this in mind, Morris Davis Morris presented the physical quality of life index, in short known as the PQLI.
  • In this index, betterment of physical quality of life of human beings is considered economic development.
  • The level of physical quality of life determines the level of economic development.
  • If any country’s physical quality of life is higher than that of the other country, then that country is considered as more developed.
  • There are three standards to measure the physical quality, which are depicted here:
    • Extent of Education;
    • Life Expectancy; and
    • Infant Mortality Rate.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Physical_Quality_of_Life_Index >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

Facing Suicide (2022)


Explore the crisis of suicide, including risk factors and prevention strategies.


Facing Suicide combines the poignant personal stories of people impacted by suicide with profiles of scientists at the forefront of research to reveal new insights into one of America’s most pressing mental health crises. Shining a light on this difficult topic can destigmatise suicide while revealing that there is help as well as hope for those at risk and their loved ones.

988 Suicide & Crisis Lifeline

If you are considering suicide, or if you or someone you know is in emotional crisis, please call or text 988. The 988 Suicide & Crisis Lifeline is a national network of local crisis centres that provides free and confidential emotional support to people in suicidal crisis or emotional distress.

Production & Filming Details

  • Narrator(s):
    • Josh Charles
  • Director(s):
    • James Barrat
  • Producer(s):
  • Writer(s):
  • Music:
  • Cinematography:
  • Editor(s):
  • Production:
    • Twin Cities PBS
    • PBS Distribution
  • Distributor(s):
    • PBS Distribution.
  • Release Date: 25 October 2022.
  • Running Time: 60 minutes.
  • Rating: Unknown (but contains Mature content).
  • Country: US.
  • Language: English.

What is Dissociative Identity Disorder?


Dissociative identity disorder (DID), formerly known as multiple personality disorder, and commonly referred to as split personality disorder or dissociative personality disorder, is a member of the family of dissociative disorders classified by the DSM-5, DSM-5-TR, ICD-10, ICD-11, and Merck Manual for diagnosis. It remains a controversial diagnosis.

Dissociative identity disorder is characterised by the presence of at least two distinct and relatively enduring personality states. The disorder is accompanied by memory gaps more severe than could be explained by ordinary forgetfulness. The personality states alternately show in a person’s behaviour; however, presentations of the disorder vary. Other conditions that often occur in people with DID include post-traumatic stress disorder, personality disorders (especially borderline, Schizotypal and avoidant), depression, substance use disorders, conversion disorder, somatic symptom disorder, eating disorders, obsessive–compulsive disorder, and sleep disorders. Self-harm, non-epileptic seizures, flashbacks with amnesia for content of flashbacks, anxiety disorders, and suicidality are also common.

DID requires an unintegrated mind to form. Genetic and biological factors are also believed to play a role. The diagnosis should not be made if the person’s condition is better accounted for by substance use disorder, seizures, other medical problems, imaginative play in children, or religious practices.

According to the DSM-5-TR, early life trauma, typically before the age of 10, can place someone at risk of developing dissociative identity disorder. Across diverse geographic regions, 90% of individuals diagnosed with dissociative identity disorder report experiencing multiple forms of childhood abuse, such as neglect or severe bullying. Other traumatic childhood experiences that have been reported include painful medical or surgical procedures, war, terrorism, attachment disturbance, natural disaster, cult, and occult abuse, loss of a loved one or loved ones, human trafficking, and dysfunctional family dynamics.

There is no medication to treat DID directly. Medications can be used for comorbid disorders or targeted symptom relief, for example antidepressants or treatments to improve sleep, however. Treatment generally involves supportive care and psychotherapy. The condition usually persists without treatment. It is believed to affect about 1.5% of the general population (based on a small US community sample) and 3% of those admitted to hospitals with mental health issues in Europe and North America. DID is diagnosed about six times more often in women than in men. The number of recorded cases increased significantly in the latter half of the 20th century, along with the number of identities reported by those affected.

It is unclear whether increased rates of the disorder are due to better recognition or sociocultural factors such as mass media portrayals. The typical presenting symptoms in different regions of the world may also vary depending on culture, such as alter identities taking the form of possessing spirits, deities, ghosts, or mythical creatures and figures in cultures where normative possession states are common. The possession form of dissociative identity disorder is involuntary and distressing, and occurs in a way that violates cultural or religious norms.


Dissociation, the term that underlies dissociative disorders including DID, lacks a precise, empirical, and generally agreed upon definition.

A large number of diverse experiences have been termed dissociative, ranging from normal failures in attention to the breakdowns in memory processes characterized by the dissociative disorders. It is therefore unknown if there is a commonality between all dissociative experiences, or if the range of mild to severe symptoms is a result of different aetiologies and biological structures. Other terms used in the literature, including personality, personality state, identity, ego state, and amnesia, also have no agreed upon definitions. Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones.

Due to the lack of consensus regarding terminology in the study of DID, several terms have been proposed. One is ego state (behaviours and experiences possessing permeable boundaries with other such states but united by a common sense of self), while the other term is alters (each of which may have a separate autobiographical memory, independent initiative and a sense of ownership over individual behaviour).

Ellert Nijenhuis and colleagues suggest a distinction between personalities responsible for day-to-day functioning (associated with blunted physiological responses and reduced emotional reactivity, referred to as the “apparently normal part of the personality” or ANP) and those emerging in survival situations (involving fight-or-flight responses, vivid traumatic memories and strong, painful emotions – the “emotional part of the personality” or EP). “Structural dissociation of the personality” is used by Onno van der Hart and colleagues to distinguish dissociation they attribute to traumatic or pathological causes, which in turn is divided into primary, secondary and tertiary dissociation. According to this theory, primary dissociation prototypically involves one ANP and one EP, while secondary dissociation prototypically involves an ANP and at least two EPs, and tertiary dissociation, typically characterised in DID, is described as having at least two ANPs and at least two EPs. Others have suggested dissociation can be separated into two distinct forms, detachment and compartmentalisation, the latter of which, involving a failure to control normally controllable processes or actions, is most evident in DID. Efforts to psychometrically distinguish between normal and pathological dissociation have been made.

Signs and Symptoms

The full presentation of dissociative identity disorder can onset at any age, although symptoms typically begin at ages 5-10. According to DSM-5, symptoms of DID include “the presence of two or more distinct personality states” accompanied by the inability to recall personal information beyond what is expected through normal memory issues. Other DSM-5 symptoms include a loss of identity as related to individual distinct personality states, loss of one’s subjective experience of the passage of time, and degradation of a sense of self and consciousness. In each individual, the clinical presentation varies and the level of functioning can change from severe impairment to minimal impairment. The symptoms of dissociative amnesia are subsumed under a DID diagnosis, and thus should not be diagnosed separately if DID criteria are met. Individuals with DID may experience distress from both the symptoms of DID (intrusive thoughts or emotions) and the consequences of the accompanying symptoms (dissociation rendering them unable to remember specific information). The majority of patients with DID report childhood sexual or physical abuse. Amnesia between identities may be asymmetrical; identities may or may not be aware of what is known by another. Individuals with DID may be reluctant to discuss symptoms due to associations with abuse, shame, and fear. DID patients may also frequently and intensely experience time disturbances.

Around half of people with DID have fewer than 10 identities and most have fewer than 100; although as many as 4,500 have been reported. The average number of identities has increased over the past few decades, from two or three to now an average of approximately 16. However, it is unclear whether this is due to an actual increase in identities, or simply that the psychiatric community has become more accepting of a high number of compartmentalised memory components.

Comorbid Disorders

The psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures. The most common presenting complaint of DID is depression, with headaches being a common neurological symptom. Comorbid disorders can include substance use disorder, eating disorders, anxiety disorders, bipolar disorder, and personality disorders. A significant percentage of those diagnosed with DID have histories of borderline personality disorder and post-traumatic stress disorder (PTSD). Presentations of dissociation in people with schizophrenia differ from those with DID as not being rooted in trauma, and this distinction can be effectively tested, although both conditions share a high rate of dissociative auditory hallucinations. Other disorders that have been found to be comorbid with DID are somatization disorders, major depressive disorder, as well as history of a past suicide attempt, in comparison to those without a DID diagnosis. Disturbed and altered sleep has also been suggested as having a role in dissociative disorders in general and specifically in DID, alterations in environments also largely affecting the DID patient. Individuals diagnosed with DID demonstrate the highest hypnotisability of any clinical population. Although DID has high comorbidity and its development is related to trauma, there exists evidence to suggest that DID merits a separate diagnosis from other conditions like PTSD.



There are two competing theories on what causes dissociative identity disorder to develop. The trauma-related model suggests that trauma or severe adversity in childhood, also known as developmental trauma, increases the risk of someone developing dissociative identity disorder. The non-trauma related model, also referred to as the Sociocognitive model or the fantasy model, suggests that dissociative identity disorder is developed through high fantasy-proneness or suggestibility, roleplaying, or sociocultural influences.

The DSM-5-TR states that “early life trauma (e.g. neglect and physical, sexual, and emotional abuse, usually before ages 5-6 years) represents a risk factor for dissociative identity disorder.” Other risk factors reported include painful medical procedures, war, terrorism, or being trafficked in childhood. Dissociative disorders frequently occur after trauma, and the DSM-5-TR places them after the trauma- and stressor-related disorders to reflect this close relationship.

Trauma-Related Model

Dissociative identity disorder is often conceptualised as “the most severe form of a childhood onset post-traumatic stress disorder.” According to many researchers, the aetiology of dissociative identity is multifactorial, involving a complex interaction between developmental trauma, sociocultural influences, and biological factors.

People diagnosed with dissociative identity disorder often report that they have experienced physical or sexual abuse during childhood (although the accuracy of these reports has been disputed); others report overwhelming stress, serious medical illness, or other traumatic events during childhood. They also report more historical psychological trauma than those diagnosed with any other mental illness.

Severe sexual, physical, or psychological trauma in childhood has been proposed as an explanation for its development; awareness, memories, and emotions of harmful actions or events caused by the trauma are removed from consciousness, and alternate personalities or subpersonalities form with differing memories, emotions and behaviour. Dissociative identity disorder is attributed to extremes of stress or disorders of attachment. What may be expressed as post-traumatic stress disorder (PTSD) in adults may become dissociative identity disorder when occurring in children, possibly due to their greater use of imagination as a form of coping.

Possibly due to developmental changes and a more coherent sense of self past the age of six, the experience of extreme trauma may result in different, though also complex, dissociative symptoms and identity disturbances. A specific relationship between childhood abuse, disorganized attachment, and lack of social support are thought to be a necessary component of dissociative identity disorder. Although what role a child’s biological capacity to dissociate to an extreme level remains unclear, some evidence indicates a neurobiological impact of developmental stress.

Delinking early trauma from the aetiology of dissociation has been explicitly rejected by those supporting the early trauma model. However, a 2012 review article supports the hypothesis that current or recent trauma may affect an individual’s assessment of the more distant past, changing the experience of the past and resulting in dissociative states. Giesbrecht et al. have suggested there is no actual empirical evidence linking early trauma to dissociation, and instead suggest that problems with neuropsychological functioning, such as increased distractibility in response to certain emotions and contexts, account for dissociative features. A middle position hypothesizes that trauma, in some situations, alters neuronal mechanisms related to memory. Evidence is increasing that dissociative disorders are related both to a trauma history and to “specific neural mechanisms”. It has also been suggested that there may be a genuine but more modest link between trauma and dissociative identity disorder, with early trauma causing increased fantasy-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of dissociative identity disorder. Another suggestion made by Hart indicates that there are triggers in the brain that can be the catalyst for different self-states, and that victims of trauma are more susceptible to these triggers than non-victims of trauma; these triggers are said to be related to dissociative identity disorder.

Paris states that the trauma model of dissociative identity disorder increased the appeal of the diagnosis among health care providers, patients and the public as it validated the idea that child abuse had lifelong, serious effects. Paris asserts that there is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption.

Non-Trauma-Related Model

The prevailing trauma-related model of dissociation and dissociative disorders is contested. It has been hypothesized that symptoms of dissociative identity disorder may be created by therapists using techniques to “recover” memories (such as the use of hypnosis to “access” alter identities, facilitate age regression or retrieve memories) on suggestible individuals. Referred to as the non-trauma-related model, or the sociocognitive model or fantasy model, it proposes that dissociative identity disorder is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes, with unwitting therapists providing cues through improper therapeutic techniques. This model posits that behaviour is enhanced by media portrayals of dissociative identity disorder.

Proponents of the non-trauma-related model note that the dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of dissociative identity disorder who, through the process of eliciting, conversing with, and identifying alters, shape or possibly create the diagnosis. While proponents note that dissociative identity disorder is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are sceptical of the trauma-related aetiology suggested by proponents of the trauma-related model. Proponents of non-trauma-related dissociative identity disorder are concerned about the possibility of hypnotisability, suggestibility, frequent fantasisation and mental absorption predisposing individuals to dissociation. They note that a small subset of doctors are responsible for diagnosing the majority of individuals with dissociative identity disorder.

Psychologist Nicholas Spanos and others have suggested that in addition to therapy caused cases, dissociative identity disorder may be the result of role-playing, though others disagree, pointing to a lack of incentive to manufacture or maintain separate identities and point to the claimed histories of abuse. Other arguments that therapy can cause dissociative identity disorder include the lack of children diagnosed with DID, the sudden spike in rates of diagnosis after 1980 (although dissociative identity disorder was not a diagnosis until DSM-IV, published in 1994), the absence of evidence of increased rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities (such as those claiming to be animals or mythological creatures) and an increase in the number of alternate identities over time (as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy). These various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably borderline personality disorder, which is commonly comorbid with dissociative identity disorder. In addition, presentations can vary across cultures, such as Indian patients who only switch alters after a period of sleep – which is commonly how dissociative identity disorder is presented by the media within that country.

Proponents of non-trauma-related dissociative identity disorder state that the disorder is strongly linked to (possibly suggestive) psychotherapy, often involving recovered memories (memories that the person previously had amnesia for) or false memories, and that such therapy could cause additional identities. Such memories could be used to make an allegation of child sexual abuse. There is little agreement between those who see therapy as a cause and trauma as a cause. Supporters of therapy as a cause of dissociative identity disorder suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position though it has also been claimed that higher rates of diagnosis in specific countries like the United States may be due to greater awareness of DID. Lower rates in other countries may be due to artificially low recognition of the diagnosis. However, false memory syndrome per se is not regarded by mental health experts as a valid diagnosis, and has been described as “a non-psychological term originated by a private foundation whose stated purpose is to support accused parents,” and critics argue that the concept has no empirical support, and further describe the False Memory Syndrome Foundation as an advocacy group that has distorted and misrepresented memory research.


The rarity of dissociative identity disorder diagnosis in children is cited as a reason to doubt the validity of the disorder, and proponents of both aetiologies believe that the discovery of dissociative identity disorder in a child who had never undergone treatment would critically undermine the non-trauma related model. Conversely, if children are found to develop dissociative identity disorder only after undergoing treatment it would challenge the trauma-related model. As of 2011, approximately 250 cases of dissociative identity disorder in children have been identified, though the data does not offer unequivocal support for either theory. While children have been diagnosed with dissociative identity disorder before therapy, several were presented to clinicians by parents who were themselves diagnosed with dissociative identity disorder; others were influenced by the appearance of dissociative identity disorder in popular culture or due to a diagnosis of psychosis due to hearing voices – a symptom also found in dissociative identity disorder. No studies have looked for children with dissociative identity disorder in the general population, and the single study that attempted to look for children with dissociative identity disorder not already in therapy did so by examining siblings of those already in therapy for dissociative identity disorder. An analysis of diagnosis of children reported in scientific publications, 44 case studies of single patients were found to be evenly distributed (i.e. each case study was reported by a different author) but in articles regarding groups of patients, four researchers were responsible for the majority of the reports.

The initial theoretical description of dissociative identity disorder was that dissociative symptoms were a means of coping with extreme stress (particularly childhood sexual and physical abuse), but this belief has been challenged by the data of multiple research studies. Proponents of the trauma-related model claim the high correlation of child sexual and physical abuse reported by adults with dissociative identity disorder corroborates the link between trauma and dissociative identity disorder. However, the link between dissociative identity disorder and maltreatment has been questioned for several reasons. The studies reporting the links often rely on self-report rather than independent corroborations, and these results may be worsened by selection and referral bias. Most studies of trauma and dissociation are cross-sectional rather than longitudinal, which means researchers can not attribute causation, and studies avoiding recall bias have failed to corroborate such a causal link. In addition, studies rarely control for the many disorders comorbid with dissociative identity disorder, or family maladjustment (which is itself highly correlated with dissociative identity disorder). The popular association of dissociative identity disorder with childhood abuse is relatively recent, occurring only after the publication of Sybil in 1973. Most previous examples of “multiples” such as Chris Costner Sizemore, whose life was depicted in the book and film The Three Faces of Eve, disclosed no history of child abuse.


Despite research on DID including structural and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, event-related potential, and electroencephalography, no convergent neuroimaging findings have been identified regarding DID, making it difficult to hypothesize a biological basis for DID. In addition, many of the studies that do exist were performed from an explicitly trauma-based position, and did not consider the possibility of therapy as a cause of DID. There is no research to date regarding the neuroimaging and introduction of false memories in DID patients, though there is evidence of changes in visual parameters and support for amnesia between alters. DID patients also appear to show deficiencies in tests of conscious control of attention and memorisation (which also showed signs of compartmentalisation for implicit memory between alters but no such compartmentalization for verbal memory) and increased and persistent vigilance and startle responses to sound. DID patients may also demonstrate altered neuroanatomy. Experimental tests of memory suggest that patients with DID may have improved memory for certain tasks, which has been used to criticise the hypothesis that DID is a means of forgetting or suppressing memory. Patients also show experimental evidence of being more fantasy-prone, which in turn is related to a tendency to over-report false memories of painful events.



DSM-5 diagnoses DID according to the diagnostic criteria found under code 300.14 (dissociative disorders). DID is often initially misdiagnosed because clinicians receive little training about dissociative disorders or DID, and often use standard diagnostic interviews that do not include questions about trauma, dissociation, or post-traumatic symptoms. This contributes to difficulties diagnosing the disorder, and clinician bias.

DID is rarely diagnosed in children, despite the average age of appearance of the first alter being three years old. The criteria require that an individual be recurrently controlled by two or more discrete identities or personality states, accompanied by memory lapses for important information that is not caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures. In children the symptoms must not be better explained by “imaginary playmates or other fantasy play”. Diagnosis is normally performed by a clinically trained mental health professional such as a psychiatrist or psychologist through clinical evaluation, interviews with family and friends, and consideration of other ancillary material. Specially designed interviews (such as the SCID-D) and personality assessment tools may be used in the evaluation as well. Since most of the symptoms depend on self-report and are not concrete and observable, there is a degree of subjectivity in making the diagnosis. People are often disinclined to seek treatment, especially since their symptoms may not be taken seriously; thus dissociative disorders have been referred to as “diseases of hiddenness”.

The diagnosis has been criticized by supporters of therapy as a cause or the sociocognitive hypothesis as they believe it is a culture-bound and often health care induced condition. The social cues involved in diagnosis may be instrumental in shaping patient behaviour or attribution, such that symptoms within one context may be linked to DID, while in another time or place the diagnosis could have been something other than DID. Other researchers disagree and argue that the existence of the condition and its inclusion in the DSM is supported by multiple lines of reliable evidence, with diagnostic criteria allowing it to be clearly discriminated from conditions it is often mistaken for (schizophrenia, borderline personality disorder, and seizure disorder). That a large proportion of cases are diagnosed by specific health care providers, and that symptoms have been created in nonclinical research subjects given appropriate cueing has been suggested as evidence that a small number of clinicians who specialise in DID are responsible for the creation of alters through therapy. The condition may be under-diagnosed due to scepticism and lack of awareness from mental health professionals, made difficult due to the lack of specific and reliable criteria for diagnosing DID as well as a lack of prevalence rates due to the failure to examine systematically selected and representative populations.

Differential Diagnoses

People with DID are diagnosed with five to seven comorbid disorders on average – much higher than other mental illnesses.

Due to overlapping symptoms, the differential diagnosis includes schizophrenia, normal and rapid-cycling bipolar disorder, epilepsy, borderline personality disorder, and autism spectrum disorder. Delusions or auditory hallucinations can be mistaken for speech by other personalities. Persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotisability and reports from family members or other associates indicating a history of such changes can help distinguish DID from other conditions. A diagnosis of DID takes precedence over any other dissociative disorders. Distinguishing DID from malingering is a concern when financial or legal gains are an issue, and factitious disorder may also be considered if the person has a history of help or attention-seeking. Individuals who state that their symptoms are due to external spirits or entities entering their bodies are generally diagnosed with dissociative disorder not otherwise specified rather than DID due to the lack of identities or personality states. Most individuals who enter an emergency department and are unaware of their names are generally in a psychotic state. Although auditory hallucinations are common in DID, complex visual hallucinations may also occur. Those with DID generally have adequate reality testing; they may have positive Schneiderian symptoms of schizophrenia but lack the negative symptoms. They perceive any voices heard as coming from inside their heads (patients with schizophrenia experience them as external). In addition, individuals with psychosis are much less susceptible to hypnosis than those with DID. Difficulties in differential diagnosis are increased in children.

DID must be distinguished from, or determined if comorbid with, a variety of disorders including mood disorders, psychosis, anxiety disorders, PTSD, personality disorders, cognitive disorders, neurological disorders, epilepsy, somatoform disorder, factitious disorder, malingering, other dissociative disorders, and trance states. An additional aspect of the controversy of diagnosis is that there are many forms of dissociation and memory lapses, which can be common in both stressful and non-stressful situations and can be attributed to much less controversial diagnoses. Individuals faking or mimicking DID due to factitious disorder will typically exaggerate symptoms (particularly when observed), lie, blame bad behaviour on symptoms and often show little distress regarding their apparent diagnosis. In contrast, genuine people with DID typically exhibit confusion, distress, and shame regarding their symptoms and history.

A relationship between DID and borderline personality disorder has been posited, with various clinicians noting overlap between symptoms and behaviours and it has been suggested that some cases of DID may arise “from a substrate of borderline traits”. Reviews of DID patients and their medical records concluded that the majority of those diagnosed with DID would also meet the criteria for either borderline personality disorder or more generally borderline personality.

The DSM-5 elaborates on cultural background as an influence for some presentations of DID:

Many features of dissociative identity disorder can be influenced by the individual’s cultural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common. Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the characteristics of other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion.


DID is among the most controversial of the dissociative disorders and among the most controversial disorders found in the DSM-5. The primary dispute is between those who believe DID is caused by traumatic stresses forcing the mind to split into multiple identities, each with a separate set of memories, and the belief that the symptoms of DID are produced artificially by certain psychotherapeutic practices or patients playing a role they believe appropriate for a person with DID. The debate between the two positions is characterized by intense disagreement. Research into this hypothesis has been characterized by poor methodology. Psychiatrist Joel Paris notes that the idea that a personality is capable of splitting into independent alters is an unproven assertion that is at odds with research in cognitive psychology.

Some people, such as Russell A. Powell and Travis L. Gee, believe that DID is caused by health care, i.e. symptoms of DID are created by therapists themselves via hypnosis. This belief also implies that those with DID are more susceptible to manipulation by hypnosis and suggestion than others. The iatrogenic model also sometimes states that treatment for DID is harmful. According to Brand, Loewenstein, and Spiegel, “[t]he claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID”. Their claim is evidenced by the fact that only 5%–10% of people receiving treatment worsen in their symptoms.

Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation – the fact that people with DID report childhood trauma does not mean trauma causes DID – and point to the rareness of the diagnosis before 1980 as well as a failure to find DID as an outcome in longitudinal studies of traumatised children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as “personality state” and “identities”, and question the evidence for childhood abuse beyond self-reports, the lack of definition of what would indicate a threshold of abuse sufficient to induce DID and the extremely small number of cases of children diagnosed with DID despite an average age of appearance of the first alter of three years. Psychiatrist Colin Ross disagrees with Piper and Merskey’s conclusion that DID cannot be accurately diagnosed, pointing to internal consistency between different structured dissociative disorder interviews (including the Dissociative Experiences Scale, Dissociative Disorders Interview Schedule and Structured Clinical Interview for Dissociative Disorders) that are in the internal validity range of widely accepted mental illnesses such as schizophrenia and major depressive disorder. In his opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses. He also asserts that Piper and Merskey have cherry-picked data and not incorporated all relevant scientific literature available, such as independent corroborating evidence of trauma.

A study in 2018 revealed that the phenomena of pathological dissociation (including identity alteration) had been portrayed in the ancient Chinese medicine literature, suggesting that pathological dissociation is a cross-cultural condition.

A paper published in 2022 in the journal Comprehensive Psychiatry described how prolonged social media use, especially on video-sharing platforms including TikTok, has exposed young people, largely adolescent females, a core user group of TikTok, to a growing number of content creators making videos about their self-diagnosed disorders.

“An increasing number of reports from the US, UK, Germany, Canada, and Australia have noted an increase in functional tic-like behaviors prior to and during the Covid-19 pandemic, coinciding with an increase in social media content related to[…]dissociative identity disorder.”

The paper concluded by saying there:

“is an urgent need for focused empirical research investigation into this concerning phenomenon that is related to the broader research and discourse examining social media influences on mental health”.


Perhaps due to their perceived rarity, the dissociative disorders (including DID) were not initially included in the Structured Clinical Interview for DSM-IV (SCID), which is designed to make psychiatric diagnoses more rigorous and reliable. Instead, shortly after the publication of the initial SCID a freestanding protocol for dissociative disorders (SCID-D) was published. This interview takes about 30 to 90 minutes depending on the subject’s experiences. An alternative diagnostic instrument, the Dissociative Disorders Interview Schedule, also exists but the SCID-D is generally considered superior. The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.

Other questionnaires include the Dissociative Experiences Scale (DES), Perceptual Alterations Scale, Questionnaire on Experiences of Dissociation, Dissociation Questionnaire, and the Mini-SCIDD. All are strongly intercorrelated and except the Mini-SCIDD, all incorporate absorption, a normal part of personality involving narrowing or broadening of attention. The DES is a simple, quick, and validated questionnaire that has been widely used to screen for dissociative symptoms, with variations for children and adolescents. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cut-off is set, people who would subsequently be diagnosed can be missed. An early recommended cut-off was 15-20. The reliability of the DES in non-clinical samples has been questioned.


Treatment aims to increase integrated functioning. The International Society for the Study of Trauma and Dissociation has published guidelines for phase-oriented treatment in adults as well as children and adolescents that are widely used in the field of DID treatment. The guidelines state that “a desirable treatment outcome is a workable form of integration or harmony among alternate identities”. Some experts in treating people with DID use the techniques recommended in the 2011 treatment guidelines. The empirical research includes the longitudinal TOP DD treatment study, which found that patients showed “statistically significant reductions in dissociation, PTSD, distress, depression, hospitalisations, suicide attempts, self-harm, dangerous behaviours, drug use, and physical pain” and improved overall functioning. Treatment effects have been studied for over thirty years, with some studies having a follow-up of ten years. Adult and child treatment guidelines exist that suggest a three-phased approach, and are based on expert consensus. Highly experienced therapists have few patients that achieve a unified identity.

Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive behavioural therapy (CBT), insight-oriented therapy, dialectical behavioural therapy (DBT), hypnotherapy, and eye movement desensitisation and reprocessing (EMDR).

Hypnosis should be carefully considered when choosing both treatment and provider practitioners because of its dangers. For example, hypnosis can sometimes lead to false memories and false accusations of abuse by family, loved ones, friends, providers, and community members. Those who suffer from dissociative identity disorder have commonly been subject to actual abuse (sexual, physical, emotional, financial) by therapists, family, friends, loved ones, and community members.

Some behaviour therapists initially use behavioural treatments such as only responding to a single identity, and then use more traditional therapy once a consistent response is established. Brief treatment due to managed care may be difficult, as individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic alliance. Regular contact (at least weekly) is recommended, and treatment generally lasts years – not weeks or months. Sleep hygiene has been suggested as a treatment option, but has not been tested. In general there are very few clinical trials on the treatment of DID, none of which were randomised controlled trials.

Therapy for DID is generally phase oriented. Different alters may appear based on their greater ability to deal with specific situational stresses or threats. While some patients may initially present with a large number of alters, this number may reduce during treatment – though it is considered important for the therapist to become familiar with at least the more prominent personality states as the “host” personality may not be the “true” identity of the patient. Specific alters may react negatively to therapy, fearing the therapist’s goal is to eliminate the alter (particularly those associated with illegal or violent activities). A more realistic and appropriate goal of treatment is to integrate adaptive responses to abuse, injury, or other threats into the overall personality structure. There is debate over issues such as whether exposure therapy (reliving traumatic memories, also known as abreaction), engagement with alters and physical contact during therapy are appropriate and there are clinical opinions both for and against each option with little high-quality evidence for any position.

Brandt et al., commenting on the lack of empirical studies of treatment effectiveness, conducted a survey of 36 clinicians expert in treating dissociative disorder (DD) who recommended a three-stage treatment. They agreed that skill building in the first stage is important so the patient can learn to handle high risk, potentially dangerous behaviour, as well as emotional regulation, interpersonal effectiveness and other practical behaviours. In addition, they recommended “trauma-based cognitive therapy” to reduce cognitive distortions related to trauma; they also recommended that the therapist deal with the dissociated identities early in treatment. In the middle stage, they recommended graded exposure techniques, along with appropriate interventions as needed. The treatment in the last stage was more individualized; few with DD [sic] became integrated into one identity.

The first phase of therapy focuses on symptoms and relieving the distressing aspects of the condition, ensuring the safety of the individual, improving the patient’s capacity to form and maintain healthy relationships, and improving general daily life functioning. Comorbid disorders such as substance use disorder and eating disorders are addressed in this phase of treatment. The second phase focuses on stepwise exposure to traumatic memories and prevention of re-dissociation. The final phase focuses on reconnecting the identities of disparate alters into a single functioning identity with all its memories and experiences intact.

A study was conducted to develop an “expertise-based prognostic model for the treatment of complex post-traumatic stress disorder (PTSD) and dissociative identity disorder (DID)”. Researchers constructed a two-stage survey and factor analyses performed on the survey elements found 51 factors common to complex PTSD and DID. The authors concluded from their findings:

“The model is supportive of the current phase-oriented treatment model, emphasizing the strengthening of the therapeutic relationship and the patient’s resources in the initial stabilization phase. Further research is needed to test the model’s statistical and clinical validity.”


Little is known about prognosis of untreated DID. It rarely, if ever, goes away without treatment, but symptoms may resolve from time to time or wax and wane spontaneously. Patients with mainly dissociative and post-traumatic symptoms face a better prognosis than those with comorbid disorders or those still in contact with abusers, and the latter groups often face lengthier and more difficult treatment. Suicidal ideation, suicide attempts, and self-harm also may occur. Duration of treatment can vary depending on patient goals, which can range from merely improving inter-alter communication and cooperation, to reducing inter-alter amnesia, to integration of all alters, but generally takes years.



According to the American Psychiatric Association, the 12-month prevalence of DID among adults in the US is 1.5%, with similar prevalence between women and men. Population prevalence estimates have been described to widely vary, with some estimates of DID in inpatient settings suggesting 1-9.6%.” Reported rates in the community vary from 1% to 3% with higher rates among psychiatric patients. As of 2017, evidence suggested a prevalence of DID of 2–5% among psychiatric inpatients, 2–3% among outpatients, and 1% in the general population, with rates reported as high as 16.4% for teenagers in psychiatric outpatient services. Dissociative disorders in general have a prevalence of 12.0%–13.8% for psychiatric outpatients.

As of 2012, DID was diagnosed 5 to 9 times more common in women than men during young adulthood, although this may have been due to selection bias as men meeting DID diagnostic criteria were suspected to end up in the criminal justice system rather than hospitals. In children, rates among men and women are approximately the same (5:4). DID diagnoses are extremely rare in children; much of the research on childhood DID occurred in the 1980s and 1990s and does not address ongoing controversies surrounding the diagnosis. DID occurs more commonly in young adults and declines in prevalence with age.

There is a poor awareness of DID in the clinical settings and the general public. Poor clinical education (or lack thereof) for DID and other dissociative disorders has been described in literature: “most clinicians have been taught (or assume) that DID is a rare disorder with a florid, dramatic presentation.” Symptoms in patients are often not easily visible, which complicates diagnosis. DID has a high correlation with, and has been described as a form of, complex post-traumatic stress disorder. There is a significant overlap of symptoms between borderline personality disorder and DID, although symptoms are understood to originate from different underlying causes.

Historical Prevalence

Rates of diagnosed DID were increasing in the late 20th century, reaching a peak of diagnoses at approximately 40,000 cases by the end of the 20th century, up from less than 200 diagnoses before 1970. Initially DID along with the rest of the dissociative disorders were considered the rarest of psychological conditions, diagnosed in less than 100 by 1944, with only one further case reported in the next two decades. In the late 1970s and ’80s, the number of diagnoses rose sharply. An estimate from the 1980s placed the incidence at 0.01%. Accompanying this rise was an increase in the number of alters, rising from only the primary and one alter personality in most cases, to an average of 13 in the mid-1980s (the increase in both number of cases and number of alters within each case are both factors in professional scepticism regarding the diagnosis). Others explain the increase as being due to the use of inappropriate therapeutic techniques in highly suggestible individuals, though this is itself controversial while proponents of DID claim the increase in incidence is due to increased recognition of and ability to recognize the disorder. Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries.

A 1996 essay suggested three possible causes for the sudden increase of DID diagnoses, among which the author suspects the first being most likely:

  • The result of therapist suggestions to suggestible people, much as Charcot’s hysterics acted in accordance with his expectations.
  • Psychiatrists’ past failure to recognise dissociation being redressed by new training and knowledge.
  • Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: “hysteria”.

Dissociative disorders were excluded from the Epidemiological Catchment Area Project.

North America

DID is considered a controversial diagnosis and condition, with much of the literature on DID still being generated and published in North America, to the extent that it was once regarded as a phenomenon confined to that continent. Although research has appeared discussing the appearance of DID in other countries and cultures and the condition has been described in non-English speaking nations and non-Western cultures, these reports all occur in English-language journals authored by international researchers who cite Western scientific literature and are therefore not isolated from Western influences. Etzel Cardeña and David Gleaves believed the overrepresentation of DID in North America was the result of increased awareness and training about the condition.

Brief History

Early References

In the 19th century, “dédoublement”, or “double consciousness”, the historical precursor to DID, was frequently described as a state of sleepwalking, with scholars hypothesizing that the patients were switching between a normal consciousness and a “somnambulistic state”.

An intense interest in spiritualism, parapsychology and hypnosis continued throughout the 19th and early 20th centuries, running in parallel with John Locke’s views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings. Hypnosis, which was pioneered in the late 18th century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke’s association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.

In the 19th century, there were a number of reported cases of multiple personalities which Rieber estimated would be close to 100. Epilepsy was seen as a factor in some cases, and discussion of this connection continues into the present era.

By the late 19th century, there was a general acceptance that emotionally traumatic experiences could cause long-term disorders which might display a variety of symptoms. These conversion disorders were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivet (1863–?), who had a traumatic experience as a 17-year-old when he encountered a viper. Vivet was the subject of countless medical papers and became the most studied case of dissociation in the 19th century.

Between 1880 and 1920, various international medical conferences devoted time to sessions on dissociation. It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot’s students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation. One of the first individuals diagnosed with multiple personalities to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality.

20th Century

In the early 20th century, interest in dissociation and multiple personalities waned for several reasons. After Charcot’s death in 1893, many of his so-called hysterical patients were exposed as frauds, and Janet’s association with Charcot tarnished his theories of dissociation. Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.

In 1908, Eugen Bleuler introduced the term “schizophrenia” to represent a revised disease concept for Emil Kraepelin’s dementia praecox. Whereas Kraepelin’s natural disease entity was anchored in the metaphor of progressive deterioration and mental weakness and defect, Bleuler offered a reinterpretation based on dissociation or “splitting” (Spaltung) and widely broadened the inclusion criteria for the diagnosis. A review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States. The rise of the broad diagnostic category of dementia praecox has also been posited in the disappearance of “hysteria” (the usual diagnostic designation for cases of multiple personalities) by 1910. A number of factors helped create a large climate of scepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.

Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports. With the rise of a uniquely American reframing of dementia praecox/schizophrenia as a functional disorder or “reaction” to psychobiological stressors – a theory first put forth by Adolf Meyer in 1906—many trauma-induced conditions associated with dissociation, including “shell shock” or “war neuroses” during World War I, were subsumed under these diagnoses. It was argued in the 1980s that DID patients were often misdiagnosed with schizophrenia.

The public, however, was exposed to psychological ideas which took their interest. Mary Shelley’s Frankenstein, Robert Louis Stevenson’s Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe had a formidable impact.

The Three Faces of Eve

In 1957, with the publication of the bestselling book The Three Faces of Eve by psychiatrists Corbett H. Thigpen and Hervey M. Cleckley, based on a case study of their patient Chris Costner Sizemore, and the subsequent popular movie of the same name, the American public’s interest in multiple personality was revived. More cases of dissociative identity disorder were diagnosed in the following years. The cause of the sudden increase of cases is indefinite, but it may be attributed to the increased awareness, which revealed previously undiagnosed cases or new cases may have been induced by the influence of the media on the behaviour of individuals and the judgement of therapists. During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.

History in the DSM

The DSM-II used the term hysterical neurosis, dissociative type. It described the possible occurrence of alterations in the patient’s state of consciousness or identity, and included the symptoms of “amnesia, somnambulism, fugue, and multiple personality”. The DSM-III grouped the diagnosis with the other four major dissociative disorders using the term “multiple personality disorder”. The DSM-IV made more changes to DID than any other dissociative disorder, and renamed it DID. The name was changed for two reasons: First, the change emphasizes the main problem is not a multitude of personalities, but rather a lack of a single, unified identity and an emphasis on “the identities as centers of information processing”. Second, the term “personality” is used to refer to “characteristic patterns of thoughts, feelings, moods, and behaviors of the whole individual”, while for a patient with DID, the switches between identities and behaviour patterns is the personality. It is, for this reason, the DSM-IV-TR referred to “distinct identities or personality states” instead of personalities. The diagnostic criteria also changed to indicate that while the patient may name and personalise alters, they lack independent, objective existence. The changes also included the addition of amnesia as a symptom, which was not included in the DSM-III-R because despite being a core symptom of the condition, patients may experience “amnesia for the amnesia” and fail to report it. Amnesia was replaced when it became clear that the risk of false negative diagnoses was low because amnesia was central to DID.

The ICD-10 places the diagnosis in the category of “dissociative disorders”, within the subcategory of “other dissociative (conversion) disorders”, but continues to list the condition as multiple personality disorder.

The DSM-IV-TR criteria for DID have been criticised for failing to capture the clinical complexity of DID, lacking usefulness in diagnosing individuals with DID (for instance, by focusing on the two least frequent and most subtle symptoms of DID) producing a high rate of false negatives and an excessive number of DDNOS diagnoses, for excluding possession (seen as a cross-cultural form of DID), and for including only two “core” symptoms of DID (amnesia and self-alteration) while failing to discuss hallucinations, trance-like states, somatoform, depersonalisation, and derealisation symptoms. Arguments have been made for allowing diagnosis through the presence of some, but not all of the characteristics of DID rather than the current exclusive focus on the two least common and noticeable features. The DSM-IV-TR criteria have also been criticised] for being tautological, using imprecise and undefined language and for the use of instruments that give a false sense of validity and empirical certainty to the diagnosis.

The DSM-5 updated the definition of DID in 2013, summarizing the changes as:

Several changes to the criteria for dissociative identity disorder have been made in DSM-5. First, Criterion A has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. Second, Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions.

Between 1968 and 1980, the term that was used for dissociative identity disorder was “Hysterical neurosis, dissociative type”. The APA wrote in the second edition of the DSM: “In the dissociative type, alterations may occur in the patient’s state of consciousness or in his identity, to produce such symptoms as amnesia, somnambulism, fugue, and multiple personality.” The number of cases sharply increased in the late 1970s and throughout the 80s, and the first scholarly monographs on the topic appeared in 1986.

Book and Film Sybil

In 1974, the highly influential book Sybil was published, and later made into a miniseries in 1976 and again in 2007. Describing what Robert Rieber called “the third most famous of multiple personality cases,” it presented a detailed discussion of the problems of treatment of “Sybil Isabel Dorsett”, a pseudonym for Shirley Ardell Mason.

Though the book and subsequent films helped popularize the diagnosis and trigger an epidemic of the diagnosis, later analysis of the case suggested different interpretations, ranging from Mason’s problems having been caused by the therapeutic methods and sodium pentathol injections used by her psychiatrist, C.B. Wilbur, or an inadvertent hoax due in part to the lucrative publishing rights, though this conclusion has itself been challenged.

David Spiegel, a Stanford psychiatrist whose father treated Shirley Ardell Mason on occasion, says that his father described Mason as “a brilliant hysteric. He felt that Wilbur tended to pressure her to exaggerate on the dissociation she already had.” As media attention on DID increased, so too did the controversy surrounding the diagnosis.


With the publication of the DSM-III, which omitted the terms “hysteria” and “neurosis” (and thus the former categories for dissociative disorders). There was no category eliminated, it was renamed to Anxiety disorders. The DSM-III also created the controversial PTSD diagnosis -controversial due to Vietnam vets.}} dissociative diagnoses became “orphans” with their own categories with dissociative identity disorder appearing as “multiple personality disorder”.

In the opinion of McGill University psychiatrist Joel Paris, this inadvertently legitimized them by forcing textbooks, which mimicked the structure of the DSM, to include a separate chapter on them and resulted in an increase in diagnosis of dissociative conditions. Once a rarely occurring spontaneous phenomenon (research in 1944 showed only 76 cases), the diagnosis became “an artifact of bad (or naïve) psychotherapy” as patients capable of dissociating were accidentally encouraged to express their symptoms by “overly fascinated” therapists.

In a 1986 book chapter (later reprinted in another volume), philosopher of science Ian Hacking focused on multiple personality disorder as an example of “making up people” through the untoward effects on individuals of the “dynamic nominalism” in medicine and psychiatry. With the invention of new terms, entire new categories of “natural kinds” of people are assumed to be created, and those thus diagnosed respond by re-creating their identity in light of the new cultural, medical, scientific, political and moral expectations. Hacking argued that the process of “making up people” is historically contingent, hence it is not surprising to find the rise, fall, and resurrection of such categories over time. Hacking revisited his concept of “making up people” in a 2006.

“Interpersonality amnesia” was removed as a diagnostic feature from the DSM III in 1987, which may have contributed to the increasing frequency of the diagnosis. There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990. Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995. Scientific publications regarding DID peaked in the mid-1990s then rapidly declined.

There were several contributing factors to the rapid decline of reports of multiple personality disorder/dissociative identity disorder. One was the discontinuation in December 1997 of Dissociation: Progress in the Dissociative Disorders, the journal of The International Society for the Study of Multiple Personality and Dissociation.[151] The society and its journal were perceived as uncritical sources of legitimacy for the extraordinary claims of the existence of intergenerational satanic cults responsible for a “hidden holocaust” of Satanic ritual abuse that was linked to the rise of MPD reports. In an effort to distance itself from the increasing scepticism regarding the clinical validity of MPD, the organisation dropped “multiple personality” from its official name in 1993, and then in 1997 changed its name again to the International Society for the Study of Trauma and Dissociation.

In 1994, the fourth edition of the DSM replaced the criteria again and changed the name of the condition from “multiple personality disorder” to the current “dissociative identity disorder” to emphasize the importance of changes to consciousness and identity rather than personality. The inclusion of interpersonality amnesia helped to distinguish DID from dissociative disorder not otherwise specified (DDNOS), but the condition retains an inherent subjectivity due to difficulty in defining terms such as personality, identity, ego-state, and even amnesia. The ICD-10 classified DID as a “Dissociative [conversion] disorder” and used the name “multiple personality disorder” with the classification number of F44.81. In the ICD-11, the World Health Organisation have classified DID under the name “dissociative identity disorder” (code 6B64), and most cases formerly diagnosed as DDNOS are classified as “partial dissociative identity disorder” (code 6B65).

21st Century

A 2006 study compared scholarly research and publications on DID and dissociative amnesia to other mental health conditions, such as anorexia nervosa, alcohol use disorder, and schizophrenia from 1984 to 2003. The results were found to be unusually distributed, with a very low level of publications in the 1980s followed by a significant rise that peaked in the mid-1990s and subsequently rapidly declined in the decade following. Compared to 25 other diagnosis, the mid-1990s “bubble” of publications regarding DID was unique. In the opinion of the authors of the review, the publication results suggest a period of “fashion” that waned, and that the two diagnoses “[did] not command widespread scientific acceptance.”

Society and Culture


The public’s long fascination with DID has led to a number of different books and films, with many representations described as increasing stigma by perpetuating the myth that people with mental illness are usually dangerous. Movies about DID have been also criticised for poor representation of both DID and its treatment, including “greatly overrepresenting” the role of hypnosis in therapy, showing a significantly smaller number of personalities than many people with DID have, and misrepresenting people with DID as having flamboyant and obvious personalities. Some movies are parodies and ridicule DID, for instance, Me, Myself & Irene, which also incorrectly states that DID is schizophrenia. In some stories DID is used as a plot device, e.g. in Fight Club, and in whodunnit stories like Secret Window.

United States of Tara was reported to be the first US television series with DID as its focus, and a professional commentary on each episode was published by the International Society for the Study of Trauma and Dissociation. More recently, the award winning Korean TV series Kill Me, Heal Me (Korean: 킬미, 힐미; RR: Kilmi, Hilmi) featured a wealthy young man with seven identities, one of whom falls in love with the beautiful psychiatry resident who tries to help him.

In a Dissociative Identity Disorder documentary by A&E named, Many Sides Of Jane, it follows a young mom struggling to be a single mom with Dissociative Identity Disorder. Jane wants to bring awareness to the disorder.

Most people with DID are believed to downplay or minimise their symptoms rather than seeking fame, often due to shame or fear of the effects of stigma. Therapists may discourage people with DID from media work due to concerns that they may feel exploited or traumatised, for example as a result of demonstrating switching between personality states to entertain others.

However, a number of people with DID have publicly spoken about their experiences, including comedian and talk show host Roseanne Barr, who interviewed Truddi Chase, author of When Rabbit Howls; Chris Costner Sizemore, the subject of The Three Faces of Eve, Cameron West, author of First Person Plural: My life as a multiple, and NFL player Herschel Walker, author of Breaking Free: My life with dissociative identity disorder.

In The Three Faces of Eve (1957) hypnosis is used to identify a childhood trauma which then allows her to fuse from three identities into just one. However, Sizemore’s own books I’m Eve and A Mind of My Own revealed that this did not last; she later attempted suicide, sought further treatment, and actually had twenty-two personalities rather than three. Sizemore re-entered therapy and by 1974 had achieved a lasting recovery. Voices Within: The Lives of Truddi Chase portrays many of the 92 personalities Chase described in her book When Rabbit Howls, and is unusual in breaking away from the typical ending of integrating into one. Frankie & Alice (2010), starring Halle Berry; and the TV mini-series Sybil were also based on real people with DID. In popular culture dissociative identity disorder is often confused with schizophrenia, and some movies advertised as representing dissociative identity disorder may be more representative of psychosis or schizophrenia, for example Psycho (1960).

In his book The C.I.A. Doctors: Human Rights Violations by American Psychiatrists, psychiatrist Colin A. Ross states that based on documents obtained through freedom of information legislation, a psychiatrist linked to Project MKULTRA reported being able to deliberately induce dissociative identity disorder using a variety of aversive or abusive techniques, creating a Manchurian Candidate for military purposes.

A DID community exists on social media, including YouTube, Reddit, Discord, and TikTok. However, numerous high-profile members of this community have been criticised for faking their condition for views, or for portraying the disorder lightheartedly. Conversely, psychologist Naomi Torres-Mackie, head of research at The Mental Health Coalition, has stated “All of a sudden, all of my adolescent patients think that they have this, and they don’t … Folks start attaching clinical meaning and feeling like, ‘I should be diagnosed with this. I need medication for this’, when actually a lot of these experiences are normative and don’t need to be pathologized or treated.”

In the USA Network television production Mr. Robot, the protagonist Elliot Alderson was created using anecdotal experiences of DID of the show’s creator’s friends. Sam Esmail said he consulted with a psychologist who “concretized” the character’s mental health conditions, especially his plurality.

In M. Night Shyamalan’s Unbreakable superhero film series (specifically the films, Split and Glass), one character is diagnosed with DID, and that some of the personalities have super-human powers. Some advocates believe that the films are a negative portrayal and promote the stigmatization of the disorder.

Bollywood thriller Bhool Bhulaiyaa (2007) featured Vidya Balan as Avni, an individual diagnosed with DID who associated herself with Manjulika, a deceased dancer in a royal palace. Although the movie was criticised for being insensitive, it was also lauded for spreading awareness about DID and contributing towards removing stigma around mental health.

In Marvel Comics, the character of Moon Knight is shown to have DID. In the TV series Moon Knight based on the comic book character, protagonist Marc Spector is depicted with DID; the website for the National Alliance on Mental Illness appears in the series’ end credits. Another Marvel character, Legion, has DID in the comics, although he has schizophrenia in the TV show version.

Legal Issues

People with dissociative identity disorder may be involved in legal cases as a witness, defendant, or as the victim/injured party. Claims of DID have been used only rarely to argue criminal insanity in court. In the United States dissociative identity disorder has previously been found to meet the Frye test as a generally accepted medical condition, and the newer Daubert standard. Within legal circles, DID has been described as one of the most disputed psychiatric diagnoses and forensic assessments are needed. For defendants whose defence states they have a diagnosis of DID, courts must distinguish between those who genuinely have DID and those who are malingering to avoid responsibility. Expert witnesses are typically used to assess defendants in such cases, although some of the standard assessments like the MMPI-2 were not developed for people with a trauma history and the validity scales may incorrectly suggest malingering. The Multiscale Dissociation Inventory (Briere, 2002) is well suited to assessing malingering and dissociative disorders, unlike the self-report Dissociative Experiences Scale. In DID, evidence about the altered states of consciousness, actions of alter identities and episodes of amnesia may be excluded from a court if they not considered relevant, although different countries and regions have different laws. A diagnosis of DID may be used to claim a defence of not guilty by reason of insanity, but this very rarely succeeds, or of diminished capacity, which may reduce the length of a sentence. DID may also affect competency to stand trial. A not guilty by reason of insanity plea was first used successfully in an American court in 1978, in the State of Ohio v. Milligan case. However, a DID diagnosis is not automatically considered a justification for an insanity verdict, and since Milligan the few cases claiming insanity have largely been unsuccessful.

Advocacy Movement

In the context of neurodiversity, the experience of dissociative identities has been called multiplicity and has led to advocacy for the recognition of ‘positive plurality’ and the use of plural pronouns such as “we” and “our”. Liz Fong-Jones states those with this condition might have fear in regard to “coming out” about their DID, as it could put them in a vulnerable position.

In particular, advocates have challenged the necessity of integration. Timothy Baynes argues that alters have full moral status, just as their host does. He states that as integration may entail the (involuntary) elimination of such an entity, forcing people to undergo it as a therapeutic treatment is “seriously immoral”.

A DID (or Dissociative Identities) Awareness Day takes place on 05 March annually, and a multicoloured awareness ribbon is used, based on the idea of a “crazy quilt”.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Dissociative_identity_disorder >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Co-Rumination?


The theory of co-rumination refers to extensively discussing and revisiting problems, speculating about problems, and focusing on negative feelings with peers.

Although it is similar to self-disclosure in that it involves revealing and discussing a problem, it is more focused on the problems themselves and thus can be maladaptive. While self-disclosure is seen in this theory as a positive aspect found in close friendships, some types of self-disclosure can also be maladaptive. Co-rumination is a type of behaviour that is positively correlated with both rumination and self-disclosure and has been linked to a history of anxiety because co-ruminating may exacerbate worries about whether problems will be resolved, about negative consequences of problems, and depressive diagnoses due to the consistent negative focus on troubling topics, instead of problem-solving. However, co-rumination is also closely associated with high-quality friendships and closeness.

Developmental Psychology and Gender Differences

According to these hypothesized dynamics, girls are more likely than boys to co-ruminate with their close friends, and co-rumination increases with age in children. Female adolescents are more likely to co-ruminate than younger girls, because their social worlds become increasingly complex and stressful. This is not true for boys, however as age differences are not expected among boys because their interactions remain activity focused and the tendency to extensively discuss problems is likely to remain inconsistent with male norms.

Unfortunately, while providing this support, this tendency may also reinforce internalising problems such as anxiety or depression, especially in adolescent girls, which may account for higher depression among girls than boys. For boys, lower levels of co-rumination may help buffer them against emotional problems if they spend less time with friends dwelling on problems and concerns, though less sharing of personal thoughts and feelings can potentially interfere with creating high-quality friendships.

Co-rumination has been found to partially explain (or mediate) gender differences in anxiety and depression; females have reported engaging in more co-rumination in close friendships than males, as well as elevated co-rumination was associated with females’ higher levels of depression, but not anxiety. Co-rumination is also linked with romantic activities, which have been shown to correlate with depressive symptoms over time, because they are often the problem discussed among adolescents.

Research suggests that within adolescents, children who currently exhibit high levels of co-rumination would predict the onset of depressive diagnoses than in children who exhibit lower levels of co-rumination. In addition, this link was maintained even when children with current diagnoses were excluded, as well as statistically controlling for current depressive symptoms. This further suggests that the relation between co-rumination and a history of depressive diagnoses is not due simply to current levels of depression. Another study looking at 146 adolescents (69% female) ranging in age from 14 to 19 suggests that comparing gender differences in co-rumination across samples, it appears as if these differences intensify through early adolescence but begin to narrow shortly thereafter and remain steady through emerging adulthood.

Stress Hormones, Co-Rumination and Depression

Co-rumination, or talking excessively about each other’s problems, is common during adolescent years, especially among girls, as mentioned before. On a biological basis, a study has shown that there is an increase in the levels of stress hormones during co-rumination. This suggests that since stress hormones are released during co-rumination, they may also be released in greater amounts during other life stressors. If someone exhibits co-rumination in response to a life problem it may become more and more common for them to co-ruminate about all problems in their life.

Studies have also shown that co-rumination can predict internalising symptoms such as depression and anxiety. Since co-rumination involves repeatedly going over problems again and again this clearly may lead to depression and anxiety. Catastrophising, when one takes small possibilities and blows them out of proportion into something negative, is common in depression and anxiety and may very well be a result of constantly going over problems that may not be as bad as they seem.

Effects in Daily Life

Co-rumination, or lack thereof, leads to different behaviours in daily life. For example, studies have examined the link between co-rumination and weekly drinking habits, specifically, negative thoughts. Worry co-rumination leads to less drinking weekly, while angry co-rumination leads to a significant increase in drinking. There have also been some gender differences found as well in the same study. In general, negative co-rumination increased the likelihood that women would binge drink weekly, versus men who would drink less weekly. When dealing with specific negative emotions, women drank less when taking part in worry co-rumination (as opposed to other negative emotions), while there appeared to be a lack of significant difference in men.


Co-rumination treatment typically consists of cognitive emotion regulation therapy for rumination with the patient. This therapy focuses both on the patient themselves and their habits of continually co-ruminating with a friend or friends. Therapies may need to be altered depending on the gender of each patient. As suggested by Zlomke and Hahn (2010) men showed vast improvement in anxiety and worrying symptoms by focusing their attention on how to handle a negative event through “refocus on planning”. For women, accepting a negative event/emotion and re-framing it in a positive light was associated with decreased levels of worry. In other words, some of the cognitive emotion regulation strategies that work for men do not necessarily work for women and vice versa. Patients are encouraged to talk about their problems with friends and family members, but need to focus on a solution instead of focusing on the exact problem.

Types of Relationships

While the majority of studies have been conducted with youth same-sex friendships, others have explored co-rumination and correlates of co-rumination within other types of relationships. Research on co-rumination in the workplace has shown that discussions about workplace problems have led to mixed results, especially regarding gender differences. In high abusive supervision settings, the effects of co-rumination were shown to intensify its negative effects for women, while associating lower negative effects for men. In low abusive supervision settings, results show that there were no significant effects for women, but had negative outcomes for men. The study suggests the reason men are at risk for job dissatisfaction and depression in low stress supervision, is due to the gender differences at an early age. At a young age, girls report to co-ruminate more than boys, and as they age girls’ scores tend to rise, while boys’ scores tend to drop. The study further suggests that in adulthood, men have less experience with co-rumination than women, however some men may learn skills through interacting with women or the interaction style with other men in adulthood has changed from activity-based to conversation-based; suggesting that not only do men and women co-ruminate differently, but that the level of stress may be a factor as well. In another study, co-rumination was seen to increase the negative effects of burnout on perceived stress among co-workers, thereby indicating that, while co-rumination may be seen as a socially-supportive interaction, it could have negative psychological outcomes for co-workers.

Within the context of mother-adolescent relationships, a study that examines 5th, 8th, and 11th graders has found greater levels of co-rumination among mother and daughter than mother and son relationships. In addition, mother-adolescent co-rumination was related to positive relationship quality, but also to enmeshment which was unique to co-rumination. These enmeshment as well as internalising relations were strongest when co-ruminating was focused on the mother’s problems.

Other relationships have also been studied. For instance, one study found that graduate students engage in co-rumination. Furthermore, for those graduate students, co-rumination acted as a partial mediator, which suppressed the positive effects of social support on emotional exhaustion.

Primary Researchers

Researchers in psychology and communication have studied the conceptualization of co-rumination along with the effects of the construct. A few primary researchers have focused attention on the construct including Amanda Rose Professor of Psychology at the University of Missouri, who was one of the first scholars to write about the construct. Others who are doing work on co-rumination include Justin P. Boren, Associate Professor of Communication at Santa Clara University, Jennifer Byrd-Craven, Associate Professor of Psychology at Oklahoma State University, and Dana L. Haggard, Professor of Management at Missouri State University.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Co-rumination >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Quality of Life?


Quality of life (QOL) is defined by the World Health Organisation (WHO) as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.

Standard indicators of the quality of life include wealth, employment, the environment, physical and mental health, education, recreation and leisure time, social belonging, religious beliefs, safety, security and freedom. QOL has a wide range of contexts, including the fields of international development, healthcare, politics and employment. Health related QOL (HRQOL) is an evaluation of QOL and its relationship with health.

Refer to Physical Quality of Life Index.

Engaged Theory

One approach, called engaged theory, outlined in the journal of Applied Research in the Quality of Life, posits four domains in assessing quality of life:

  1. Ecology;
  2. Economics;
  3. Politics; and
  4. Culture.

In the domain of culture, for example, it includes the following subdomains of quality of life:

  • Beliefs and ideas
  • Creativity and recreation
  • Enquiry and learning
  • Gender and generations
  • Identity and engagement
  • Memory and projection
  • Well-being and health

Under this conception, other frequently related concepts include freedom, human rights, and happiness. However, since happiness is subjective and difficult to measure, other measures are generally given priority. It has also been shown that happiness, as much as it can be measured, does not necessarily increase correspondingly with the comfort that results from increasing income. As a result, standard of living should not be taken to be a measure of happiness. Also sometimes considered related is the concept of human security, though the latter may be considered at a more basic level and for all people.

Quantitative Measurement

Unlike per capita GDP or standard of living, both of which can be measured in financial terms, it is harder to make objective or long-term measurements of the quality of life experienced by nations or other groups of people. Researchers have begun in recent times to distinguish two aspects of personal well-being: Emotional well-being, in which respondents are asked about the quality of their everyday emotional experiences – the frequency and intensity of their experiences of, for example, joy, stress, sadness, anger and affection – and life evaluation, in which respondents are asked to think about their life in general and evaluate it against a scale. Such and other systems and scales of measurement have been in use for some time. Research has attempted to examine the relationship between quality of life and productivity. There are many different methods of measuring quality of life in terms of health care, wealth, and materialistic goods. However, it is much more difficult to measure meaningful expression of one’s desires. One way to do so is to evaluate the scope of how individuals have fulfilled their own ideals. Quality of life can simply mean happiness, the subjective state of mind. By using that mentality, citizens of a developing country appreciate more since they are content with the basic necessities of health care, education and child protection.

According to ecological economist Robert Costanza:

While Quality of Life (QOL) has long been an explicit or implicit policy goal, adequate definition and measurement have been elusive. Diverse “objective” and “subjective” indicators across a range of disciplines and scales, and recent work on subjective well-being (SWB) surveys and the psychology of happiness have spurred renewed interest.

Human Development Index

Perhaps the most commonly used international measure of development is the Human Development Index (HDI), which combines measures of life expectancy, education, and standard of living, in an attempt to quantify the options available to individuals within a given society. The HDI is used by the United Nations (UN) Development Programme in their Human Development Report. However, since year 2010, The Human Development Report introduced an Inequality-adjusted Human Development Index (IHDI). While the original HDI remains useful, it stated that:

“the IHDI is the actual level of human development (accounting for inequality), while the original HDI can be viewed as an index of ‘potential’ human development (or the maximum level of HDI) that could be achieved if there was no inequality.”

World Happiness Report

The World Happiness Report is a landmark survey on the state of global happiness. It ranks 156 countries by their happiness levels, reflecting growing global interest in using happiness and substantial well-being as an indicator of the quality of human development. Its growing purpose has allowed governments, communities and organisations to use appropriate data to record happiness in order to enable policies to provide better lives. The reports review the state of happiness in the world today and show how the science of happiness explains personal and national variations in happiness.

Developed again by the UN and published recently along with the HDI, this report combines both objective and subjective measures to rank countries by happiness, which is deemed as the ultimate outcome of a high quality of life. It uses surveys from Gallup, real GDP per capita, healthy life expectancy, having someone to count on, perceived freedom to make life choices, freedom from corruption, and generosity to derive the final score. Happiness is already recognised as an important concept in global public policy. The World Happiness Report indicates that some regions have in the past been experiencing progressive inequality of happiness.

Other Measures

The Physical Quality of Life Index (PQLI) is a measure developed by sociologist M.D. Morris in the 1970s, based on basic literacy, infant mortality, and life expectancy. Although not as complex as other measures, and now essentially replaced by the Human Development Index, the PQLI is notable for Morris’s attempt to show a “less fatalistic pessimistic picture” by focusing on three areas where global quality of life was generally improving at the time, while ignoring gross national product and other possible indicators that were not improving.

The Happy Planet Index, introduced in 2006, is unique among quality of life measures in that, in addition to standard determinants of well-being, it uses each country’s ecological footprint as an indicator. As a result, European and North American nations do not dominate this measure. The 2012 list is instead topped by Costa Rica, Vietnam and Colombia.

In 2010, Gallup researchers trying to find the world’s happiest countries found Denmark to be at the top of the list. For the period 2014-2016, Norway surpasses Denmark to be at the top of the list. uSwitch publishes an annual quality of life index for European countries. France topped the list from 2009 to 2011.

A 2010 study by two Princeton University professors looked at 1,000 randomly selected US residents over an extended period. It concludes that their life evaluations – that is, their considered evaluations of their life against a stated scale of one to ten – rise steadily with income. On the other hand, their reported quality of emotional daily experiences (their reported experiences of joy, affection, stress, sadness, or anger) levels off after a certain income level (approximately $75,000 per year in 2010); income above $75,000 does not lead to more experiences of happiness nor to further relief of unhappiness or stress. Below this income level, respondents reported decreasing happiness and increasing sadness and stress, implying the pain of life’s misfortunes, including disease, divorce, and being alone, is exacerbated by poverty.

Gross national happiness and other subjective measures of happiness are being used by the governments of Bhutan and the United Kingdom. The World Happiness report, issued by Columbia University is a meta-analysis of happiness globally and provides an overview of countries and grassroots activists using GNH. The OECD (Organisation for Economic Co-operation and Development) issued a guide for the use of subjective well-being metrics in 2013. In the US, cities and communities are using a GNH metric at a grassroots level.

The Social Progress Index measures the extent to which countries provide for the social and environmental needs of their citizens. Fifty-two indicators in the areas of basic human needs, foundations of wellbeing, and opportunity show the relative performance of nations. The index uses outcome measures when there is sufficient data available or the closest possible proxies.

Day-Reconstruction Method was another way of measuring happiness, in which researchers asked their subjects to recall various things they did on the previous day and describe their mood during each activity. Being simple and approachable, this method required memory and the experiments have confirmed that the answers that people give are similar to those who repeatedly recalled each subject. The method eventually declined as it called for more effort and thoughtful responses, which often included interpretations and outcomes that do not occur to people who are asked to record every action in their daily lives.


The term quality of life is also used by politicians and economists to measure the liveability of a given city or nation. Two widely known measures of liveability are the Economist Intelligence Unit’s Where-to-be-born Index and Mercer’s Quality of Living Reports. These two measures calculate the liveability of countries and cities around the world, respectively, through a combination of subjective life-satisfaction surveys and objective determinants of quality of life such as divorce rates, safety, and infrastructure. Such measures relate more broadly to the population of a city, state, or country, not to individual quality of life. Liveability has a long history and tradition in urban design, and neighbourhoods design standards such as LEED-ND are often used in an attempt to influence liveability.


Some crimes against property (e.g., graffiti and vandalism) and some “victimless crimes” have been referred to as “quality-of-life crimes.” American sociologist James Q. Wilson encapsulated this argument as the broken windows theory, which asserts that relatively minor problems left unattended (such as litter, graffiti, or public urination by homeless individuals) send a subliminal message that disorder, in general, is being tolerated, and as a result, more serious crimes will end up being committed (the analogy being that a broken window left broken shows an image of general dilapidation).

Wilson’s theories have been used to justify the implementation of zero tolerance policies by many prominent American mayors, most notably Oscar Goodman in Las Vegas, Richard Riordan in Los Angeles, Rudolph Giuliani in New York City and Gavin Newsom in San Francisco. Such policies refuse to tolerate even minor crimes; proponents argue that this will improve the quality of life of local residents. However, critics of zero tolerance policies believe that such policies neglect investigation on a case-by-case basis and may lead to unreasonably harsh penalties for crimes.

In Healthcare

Within the field of healthcare, quality of life is often regarded in terms of how a certain ailment affects a patient on an individual level. This may be a debilitating weakness that is not life-threatening; life-threatening illness that is not terminal; terminal illness; the predictable, natural decline in the health of an elder; an unforeseen mental/physical decline of a loved one; or chronic, end-stage disease processes. Researchers at the University of Toronto’s Quality of Life Research Unit define quality of life as “The degree to which a person enjoys the important possibilities of his or her life” (UofT). Their Quality of Life Model is based on the categories “being”, “belonging”, and “becoming”; respectively who one is, how one is connected to one’s environment, and whether one achieves one’s personal goals, hopes, and aspirations.

Experience sampling studies show substantial between-person variability in within-person associations between somatic symptoms and quality of life. Hecht and Shiel measure quality of life as “the patient’s ability to enjoy normal life activities” since life quality is strongly related to wellbeing without suffering from sickness and treatment. There are multiple assessments available that measure Health-Related Quality of Life, e.g. AQoL-8D, EQ5D – Euroqol, 15D, SF-36, SF-6D, HUI.

In International Development

Quality of life has been deemed an important concept in the field of international development because it allows development to be analysed on a measure that is generally accepted as more comprehensive than standard of living. Within development theory, however, there are varying ideas concerning what constitutes desirable change for a particular society. The different ways that quality of life is defined by institutions, therefore, shape how these organisations work for its improvement as a whole.

Organisations such as the World Bank, for example, declare a goal of “working for a world free of poverty”, with poverty defined as a lack of basic human needs, such as food, water, shelter, freedom, access to education, healthcare, or employment. In other words, poverty is defined as a low quality of life. Using this definition, the World Bank works towards improving quality of life through the stated goal of lowering poverty and helping people afford a better quality of life.

Other organisations, however, may also work towards improved global quality of life using a slightly different definition and substantially different methods. Many non-governmental organisations (NGOs) do not focus at all on reducing poverty on a national or international scale, but rather attempt to improve the quality of life for individuals or communities. One example would be sponsorship programmes that provide material aid for specific individuals. Although many organisations of this type may still talk about fighting poverty, the methods are significantly different.

Improving quality of life involves action not only by NGOs but also by governments. Global health has the potential to achieve greater political presence if governments were to incorporate aspects of human security into foreign policy. Stressing individuals’ basic rights to health, food, shelter, and freedom addresses prominent inter-sectoral problems negatively impacting today’s society and may lead to greater action and resources. Integration of global health concerns into foreign policy may be hampered by approaches that are shaped by the overarching roles of defence and diplomacy.

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What is the SnackWell Effect?


The SnackWell effect is a phenomenon whereby dieters will eat more low-calorie cookies, such as SnackWells, than they otherwise would for normal cookies.


Also known as moral license, it is also described as a term for the way people go overboard once they are given a free pass or the tendency of people to overconsume when eating more of low-fat food due to the belief that it is not fattening.

The term, which emerged as a reaction to dietary trends in the 1980s and 1990s, is also used for similar effects in other settings, such as energy consumption, where it is termed the “rebound effect”. For example, according to a 2008 study, people with energy-efficient washing machines wash more clothes. People with energy-efficient lights leave them on longer, and lose 5–12% of the expected energy savings of 80%.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/SnackWell_effect >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Biohappiness?


Biohappiness, or bio-happiness, is the elevation of wellbeing in humans through biological methods, including germline engineering through screening embryos with genes associated with a high level of happiness, or the use of drugs intended to raise baseline levels of happiness.

The object is to facilitate the achievement of a state of “better than well.”


Proponents of biohappiness include the transhumanist philosopher David Pearce, whose goal is to end the suffering of all sentient beings and the Canadian ethicist Mark Alan Walker. Walker has sought to defend biohappiness on the grounds that happiness ought to be of interest to a wide range of moral theorists; and that hyperthymia, a state of high baseline happiness, is associated with better outcomes in health and human achievement.

The concept of biohappiness also has its high-profile critics, including Leon Kass, who served on the President’s Council on Bioethics during the presidency of George W. Bush.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Biohappiness >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.