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 nonstressful 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 behavior 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 behaviors 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.(p 295) 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. controversy 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, "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 traumatized 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 todissociative 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". screening 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 cutoff is set, people who would subsequently be diagnosed can be missed. an early recommended cutoff was 15–20. the reliability of the des in non-clinical samples has been questioned. treatment 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 behavioral therapy (cbt), insight-oriented therapy, dialectical behavioral therapy (dbt), hypnotherapy, and eye movement desensitization 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 behavior therapists initially use behavioral 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 randomized 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 behavior, as well as emotional regulation, interpersonal effectiveness and other practical behaviors. 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