Episode 262: Dissociative Identity Disorder (DID) Explained: Trauma, Neuroscience, Controversies & Recovery
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Presenters’ conflicts of interest:
Dr. Lauren Lebois reports unpaid membership on the Scientific Committee for the International
Society for the Study of Trauma and Dissociation (ISSTD), spousal IP payments from
Vanderbilt University for technology licensed to Acadia Pharmaceuticals and spousal private
equity in Violet Therapeutics unrelated to the present work.
Dr. Melissa Kaufman reports Member, DSM Review Committee, Internalizing Disorders (unpaid);Primary Investigator, National Institute of Mental Health; Board of Directors (unpaid), International Society for the Study of Trauma and Dissociation;
Dr. Matthew Robinson and Dr. David Puder do not have any conflicts to report
Puder:
All right. Welcome back. I am joined today by three guests. We have Melissa Kaufman, a trauma psychiatrist and researcher at McLean Hospital. She serves as the co-director of the Dissociative Disorders and Trauma Research Program, and the medical director of the Trauma Continuum of Care and associate professor at Harvard Medical School. I also have Matthew Allen Robinson. He is the program director at McLean's Trauma Continuum of Care at the Hill Center, specializing in the partial hospitalization and outpatient services for trauma related disorders. And also Lauren Lebois. She is a cognitive neuroscientist and assistant professor of psychiatry at Harvard Medical School, director of the Dissociative Disorders and Trauma Research Group at McLean Hospital with a focus on post-trauma adaptations. Hopefully, I got that. All right. Welcome to the show.
Robinson:
Thank you.
Kaufman:
Thanks so much for having us.
Puder:
Yes. So I'm excited. Today we're going to be talking about dissociative identity disorder. We're going to be talking about dissociation trauma. How about we begin with a basic definition of DID (dissociative identity disorder).
What Is Dissociative Identity Disorder (DID)? Core Definition & Developmental Origins (01:19)
Kaufman:
I think that's a great place to start, and thank you again for having us on your program. DID is a, I think, very misunderstood psychiatric condition. But I think that we are at a place in our scientific understanding and clinical understanding where we can easily describe it. DID is really a developmental post-traumatic adaptation. It begins in childhood, and without treatment children will go on to exhibit symptoms into adulthood. And basically, it is an adaptation for kids who have to sort out both the biology and the environment. I think a lot of people who know about DID think that it is caused by childhood trauma. I would say that that is necessary, but not sufficient. Children need to have the biological capacity to dissociate, which is really mostly normally distributed quality in the population, but it has a long tail at the end.
Kaufman:
And so, if a child is sort of in that highly dissociative, just by biological nature, and that is combined with long-term childhood maltreatment, typically at the hands of caretakers, then they may have a propensity to develop dissociative identity disorder. And I would say diagnostically people with DID universally have post-traumatic stress disorder due to the childhood maltreatment. And, in addition to all of the symptoms of PTSD, they also have very severe symptoms of dissociation, including depersonalization which is kind of feelings of detachment from one's sense of self or body. And then derealization, which is symptoms of detachment from or towards one's surroundings. And then two other things. There are gaps in memory often for traumatic episodes during childhood, as well as gaps in awareness during everyday life. And then there is this identity fragmentation, and we can talk a lot more about what that is.
DID Controversies: DSM-5 Validity, Media Myths, Freud vs. Janet, & Historical Shifts (03:54)
Puder:
Yes. Thank you for that. You know, I think there's probably some people who are listening who immediately think, “Is this a thing?” It's in the DSM. What are some of the main controversies around it? And how have you guys made sense of those controversies?
Robinson:
Lauren, you want to take that one?
Kaufman:
Go for it, Matt.
Robinson:
So, first and foremost, yes, DID is a DSM-V diagnosis and it's been highly validated in clinical observation and research and more recently, more rigorous neurobiological research that Lauren and Melissa can say more about. Some of the misconceptions, the most common ones are that DID is like what is portrayed in the media, which is people drastically changing their appearance or mannerisms as if they are completely different people in very big ways. That's not the typical presentation that we see. And again, we can say more about that. But also people think that it's not its own diagnosis, and that maybe it's a personality disorder or some other disorder and that it doesn't hold up on its own. Again, Lauren and Melissa can say more about the long list of studies and research that shows in various ways that DID is a real disorder. And, certainly for anyone who's worked with highly traumatized patients and has seen DID, we all know that it's a real thing.
Lebois:
Yes. And just to add that a little bit, I think there's also just a fascinating history to DID and how it's been documented. It's one of the earliest documented psychiatric conditions. And there's just a really fascinating historical controversy between, for example, Pierre Janet, who was originally documenting what he would've called hysteria, and that we would now understand as some forms of dissociation and DID and showing that it really was in some ways caused by difficult events in childhood, childhood maltreatment. And then, initially Freud agreeing with and finding some similar, documenting some similar cases and agreeing with Janet's findings. And then a lot of controversy surrounding Freud backing up from those conclusions, and then deciding that actually these weren't actual traumas that children had experienced, but rather fantasies that they had instead about what had happened to them. And it seems like, again, a lot of controversy around this part, but we have kind of followed Freud and his conclusions in the field for a very long time.
Lebois:
And part of his shift going towards more of the fantasy model, he has this letter to Wilhelm Fliess, a friend of his, where he kind of describes that it's kind of improbable that this would happen, this extreme maltreatment would happen to so many people. And so that, in part, explains perhaps some of the shift in this direction that it's difficult to imagine that this happens to so many people, and it's uncomfortable to think about as well. So I think that can explain part of the controversy. And after the second wave feminism and Vietnam War veterans returning to the U.S. and we started to see what we would now call PTSD, and we started to understand more about childhood maltreatment and domestic violence. And a lot of research started around that time. There was more acceptance that these things happened to people. And that sort of started to change the tide and lead to a lot more dissociation and DID related research, as well.
From Sybil to Modern Understanding: How Media Portrayals Distorted DID (08:15)
Kaufman:
I agree with that. I think right around that time of real science starting in the study of post-traumatic stress disorder and the men and women who returned from Vietnam, that was a time of second wave feminism and people started to understand domestic violence. Just prior to that, battered child syndrome was really documented well in the clinical literature. And so, there was more of an openness to really thinking about that this is real, that child abuse does happen. And I think over the past 10, 20 years, even more, so I think that there's been a societal shift in understanding that there's certainly documentation and definitely documentation of severe child maltreatment. [The] Department of Human Services has done that. So I think we're in an era where that is more accepted, and that has helped to bring some clarity to, and understanding to dissociation and what that means.
Puder:
Excellent. I appreciate you going through the history. I've thought about Freud's departure from Pierre Janet. Right? I'm saying that right? And how, you know, he could not hold this thought of the horrific nature of the trauma. It takes a while for mental health professionals to be able to hold it, as well. And I hope that conversations like this allow us, as mental health professionals, to have an increased capacity to hold that. It's like we don't want to believe something so awful could take place. Right? So we don't want to believe. And yet, now, I feel like with a lot of my patients, it's staring right in our face with the Epstein file release. We don't need to go a lot into that, but people are talking about it. And yeah, and then you talked about the Vietnam War, and I was thinking about the videos I've seen of World Wars I and II, it's like shell shock. Their bodies were moving abnormally. They had a lot of functional movement disorder type symptoms. After Vietnam, you get more of the classic PTSD symptoms because it was so stigmatized to have PTSD, I think prior to Vietnam.
Puder:
And then, I think I really appreciate how you bring up the awareness of domestic violence. The push against that. Right? And how it was like “the family secret.” It was the thing no one talked about. Right? People suffered in silence for decades. Unfortunately, sometimes they still do. So, okay, that brings us all the way up to the eighties when it seemed like multiple personality disorder kind of came on to the radar of people. And then how do you feel like it went off? You talked a little bit about how there's kind of like a histrionic version of it. Maybe people that want to garner attention, maybe. And then there's the people that are really suffering. Right? And so, how do you differentiate those two groups of people?
The Hidden Nature of DID: Internal vs. External Presentation & Why It's Not "Multiple People" (11:37)
Kaufman:
I think that's a valid point. And just prior to the eighties, I think it was 19-, I don't know, 75, 74, is when Flora Rheta Schreiber wrote the book Sybil. And it was a national bestseller. And then, a year or two after that, Sally Fields won an Emmy for her portrayal of Sybil. I wasn't there. I don't know exactly what happened, but sort of piecing it together, there's enough in the book that rings true in some way. But what I think happened, was that the author didn't know how to portray what really is, for the most part, an internalized disorder. And so she showed it on paper what the patient herself was feeling. But, you know, both in the book and in the movie, especially in the movie, you see Sally Fields, she won an Emmy, but she's literally talking with different accents.
Kaufman:
Her clothes change, her style changes, and it's just right out there in this very externalized way. I mean, I can tell you clinically, I've never met someone that it looks as if there's different people. Right? It's not one person. It's multiple, not just personalities, it's multiple people. Well, it's not, and I think that's where it sort of went off the rails a little bit. People with DID, it tends to be a hidden disorder. Someone once famously called it a disorder of hiddenness. And it's just different aspects of self that have been disowned by a child and personified internally. But it is just not this big, dramatic, full on production. I mean, that just has very little to do with what DID is.
Kaufman:
DID is someone who grew up with intolerable circumstances and real conflicts. “How can I get up the next day and function?” And so, difficult thoughts and feelings and memories are compartmentalized, so you can just get up and move forward. So the way that it is depicted in popular media, movies and books, I think therapists got the wrong…mental health professionals had the wrong idea. People had the wrong idea. And so I think that that was very problematic. But we've come a long way in our understanding and public awareness, I think professional awareness, to some extent, but we still need to educate people. It's just not what it looks like in the popular media. And were there people, who probably didn't have DID, may have been traumatized, but were sort of acting out in these ways, or therapists that may have pushed too hard for this type of scenario. That may in fact happen, but there's also been a lot of folks that have had this disorder and did not recognize themselves in these popular portrayals, therapists, who for many years, have been doing good work, good research, and understanding what is the typical manifestation. Which is, again, very different than what popular and fictional media portrayals present.
Puder:
Maybe we can go back a little bit. You mentioned that there's a certain personality type that is more, maybe prone to dissociation. What do we know about that? Even before the trauma exists? Right?
Biological Capacity for Dissociation: Absorption, Highway Hypnosis & "Not Me" Adaptation (15:25)
Kaufman:
I think I wouldn't so much call it a personality type. It's a sort of a capacity to dissociate. And really, what is meant by that is sort of born with the capacity to become highly…it's absorption. And many people have this. The typical sort of portrayal, this is like “highway hypnosis,” where you're driving home, you got the radio on, and you miss your exit. You don't even realize for four stops. Or, you become incredibly absorbed in a movie, and you're surprised when the lights go back on, that you weren't fully in the movie. That's just incredible. That's absorption. And people are born with this, different capacities. Some people don't become absorbed at all. Some people become highly absorbed. And I think in order to be someone that is highly dissociative, you have to have this capacity to become very internally absorbed. And that's why it is sort of an internal disorder. It's a way of being able to absorb internally, which also is inability to not attend emotionally, or think in way to sort of compartmentalize that away. So it's both being able to absorb internally, inside, and sort of shut out what's going on. And that's, again, just normally distributed except for this high tail at the end.
Robinson:
And you can, I would just,
Kaufman:
Oh, go ahead, Matt.
Robinson:
I was just going to add that part of the reason the diagnosis was changed from multiple personality disorder to DID is to recognize that this really isn't about personality or having multiple personalities. It's about not developing a cohesive sense of self at a certain developmental time because the child's creative capacity was able to have this adaptation that made the abuse that was happening, “not me,” it was happening to someone else, or it was “that other boy or girl, not me.” And as Melissa mentioned earlier, that allows them to leave what happened the night before with that boy or that girl and the boy or girl can go to school and listen and pay attention and be social without being bedraggled by the reality of what went on the day before. So it's not a personality disorder, it's not multiple personalities. It's not enough of one because of early life experiences.
Kaufman:
Right. And there's not different people inside. There's not really a different little person that goes to school. There's not really a different little person who is, you know, dealing with whatever's happening at home, but it feels very much like that to the person, and that's how they cope. It's not conscious. This is just something that they sort of arrive at because during early childhood, there's this this sort of, this time, and you may remember this yourself when you personify things where your stuffed animal, if you don't want to go to school but your mom's saying you have to go to school, you say, “Well, I'll go, but my stuffed animal is mad at you. He doesn't want to go to school.” It's this natural developmental way that kids have of just kind of disavowing feelings or thoughts and then personifying them.
Kaufman:
And if you have that ability to do that as a kid, and lots of little children do, and again, really difficult things are happening, you're going to make use of that ability to disavow and personify externally. And that becomes the “not me” adaptation. So instead of a little child who says, “Oh, my stuffed animal's mad at you. It's not me. I love you, but he's mad at you,” as a way to figure out how to deal with conflicting feelings that are hard to manage. And at that age, you don't know that your stuffed animal isn't real. Right? Santa Claus is real. Superman is real. So that's sort of the developmental ground that that children are walking on at that age. And again, if they're being, you know, have really tremendous challenges, relational trauma, they're going to use that ability. And again, it's not really conscious. Children don't think to themselves, “Oh, I'm going to pretend that I'm mad that my stuffed animal's mad. I'm gonna just say that because I don't want my mom to be mad at me.” They don't know that they really feel that that's happening. So that's when DID develops. And that's the sort of disavowal and personification that happens and then just continues because the child is highly dissociative and they just keep doing this and doing this. And so it feels internally as if these things are real.
Trauma Requirements for DID: Repeated, Inescapable Childhood Maltreatment & Gene-Environment Interaction (20:33)
Puder:
I'm curious, kind of going to early childhood development, for example, something like disorganized attachment style. There's research on kids with disorganized attachment style later have higher degrees of dissociation (Carlson, E. A. (1998)) [see episodes 87, 88, and 192]. Is that part of this pathway in your mind, or is this something different?
Kaufman:
I think it hasn't been shown. They haven't done, you're thinking of Ruth…. I can't remember her last name. Lyons [Dr. Karlen Lyons-Ruth]. She's at, she was at…
Kaufman:
Yes. Thank you.
Puder:
And Beatrice Beebe, as well. Yes. Really impressive research from them showed that Beatrice Beebe, at four months, was able to predict, right, based off of the video of a mother infant diad, if a kid would develop disorganized attachment style. Right? At the age of one and one and a half years of age.
Kaufman:
And what Lyons-Ruth did was to use the adult attachment inventory that was developed and then follow it along and look at the kids who were predicted using the adult attachment inventory who may go on to have disorganized attachments, later followed them longitudinally and saw that they had higher scores of dissociation. What I don't think has been done yet, but there's a lot of theory about it, is there hasn't been the longitudinal study that goes on to show that people actually developed DID, but theoretically, it makes a lot of sense. And I think there's been some really elegant conceptual papers hypothesizing that children who grew up to have DID have disorganized attachments. It's something that we would actually love to do in the lab, to do an adult attachment inventory on folks with DID and see. But it is very hard to do those longitudinal studies for long enough to see if someone ends up developing DID. But I think it makes a lot of sense.
Puder:
One thing I've seen, when I've looked at DID in the past, is that the trauma and the horrific nature of the trauma seems so much higher than PTSD or it's not a singular event. Can you speak to this? Can you speak to the extent, what research you've seen, you have a lot in your group, you follow some lived experienced patients, as well. And I know IOP partial kind of attracts a lot of the most horrific trauma. So I imagine you've seen a lot of this stuff.
Kaufman:
Matt, you want to take that?
Robinson:
Sure. So yeah, I think the type of trauma that we're talking about that most often results in someone later developing DID are situations that are really inescapable and repeated. That's where we get the repeated nature. Because if it happens once, and the coping doesn't require the same level of dissociation that it does, if it's happening repeatedly. And it doesn't mean that it has to be… I hate to categorize or rank trauma. It doesn't have to be the worst things ever. I think for some people it's the combination of this prolonged persistent experience that's confusing and harmful, in some way neglectful that can be, quote, “enough” because the child needs to escape to survive. And so really, I think it's about that need for escape ability as opposed to the specific type of trauma. I think correlation, I've seen in my work, at least people that experienced repeated childhood sexual or physical abuse will often and develop DID with all the other criteria that we've already discussed. But that's not the only, doesn't have to be those things per se.
Lebois:
I think another interesting piece is thinking about a gene by environment interaction as well. That, which would be true of any psychiatric condition. You could have someone who has a very high genetic loading for, like Melissa was saying, the capacity just to dissociate, and for that to turn into DID would need less severe—again, it's weird, like you're saying, that to rank traumas—but would need less of a stress to push them down the path of coping using DID versus someone else who had a genetic loading for, I don’t know, bipolar disorder. Would that stress push them down that road? Someone who had less of a genetic loading for DID, but had a lot more trauma, that would get them down the DID road. But, I think it's all interacting in that way that makes it kind of complex.
Kaufman:
I think we're thinking about it in more sophisticated ways as time goes on. There were a number of quite a few early studies in the eighties, nineties, that did show that patients with DID reported more severe childhood maltreatment across, and it typically wasn't one form. Right? If you're being sexually abused, odds are, you're probably being emotionally abused, as well. You may be being neglected. But people with DID in these early studies were reporting more severe levels of childhood trauma across different types of traumatic events at the hands of caretakers. But I also agree with what you're saying, Lauren and Matt, that I think there's also more complexity there as well. I've certainly met people who have DID and certainly were raised in very challenging environments, but only had this or only had that, but it was over a long course of time. And if you think about it as someone's being sexually abused over a long course of time, or physically abused, or emotionally abused, coping skills are probably going to be pretty scarce because that's where we learn how to cope, is from our parents. So that's part of it, as well. It's not just the abuse or just the biological capacity, it's that there's no other way to cope. The child is left to their own defenses because they're not learning from their parents how to cope.
How to Spot & Diagnose DID in Clinic: Dissociation Symptoms, Questions to Ask & Therapist Mirror Neuron Response (26:46)
Puder:
I know that it could present a number of ways, but what are some of the typical presentations that make you think this is more DID versus other things like borderline personality disorder, or what are the things, how are you actually diagnosing this in your clinics, in the IOP partial?
Kaufman:
Yes. It's not typically that someone comes in and says, “I think I have DID. Can you do an hour-long assessment?” And that's it. More typically, but, let's say it's someone that's presenting in outpatient treatment. It’s maybe someone who comes in for treatment and they may be complaining of longstanding depression or longstanding anxiety. And you start to take a history and what you may notice is a couple things. One, is that it's hard for people with DID to really create a linear narrative. They can be very high functioning, for example, in their lives, and be very sophisticated thinkers, but when you start to ask them about their childhood, suddenly their narrative becomes difficult to follow. And you may notice that they may say, “I'm kind of getting foggy. This is hard to talk about.” And there are some subtle physical types of manifestation that make it look like people are suddenly really focused internally. Blinking. Sort of blinking, closing their eyes, just having kind of a glazed expression on their face or their eyes. And they're just suddenly way more focused internally than they were. And that is something a person who can say, “I had a tough time growing up,” but really can't give me details; and when they start to give details, they start to look like they're dissociative. That can be a sign. People with DID always have post-traumatic symptoms. So, you know, you're looking at someone who's having nightmares or clearly avoidant of certain kinds of situations, has a heightened startle response.
Kaufman:
And then they're telling you that “things were tough when I was growing up.” I wouldn't know at that point if they have DID or not. But I would want to start to inquire and ask them about symptoms of dissociation. And often, what we find is someone comes in and maybe they have a past diagnosis of PTSD, but when we start to ask them about dissociation symptoms of depersonalization, derealization, symptoms that don't make a lot of sense, that sometimes thoughts and feelings don't feel so much like they belong to them, even though they know that's not possible because this is not psychosis. And they say, “No one's ever asked me that before. How do you know this?” And we're simply inquiring about symptoms of dissociation a lot of times.
Puder:
So, walk me through that. Give me the actual questions that you would ask for dissociation. What are the…rattle off the ones that you normally….
Kaufman:
Well, there's certainly reliable and validated self-report measures and clinical interviews. But if I'm not doing that at a meeting with someone for the first time, I start to notice these things I might ask, “You know, do you ever have periods of time, do you ever feel that you're a little bit detached from your own thoughts or feelings? Do you feel detached from your body sometimes? Do you ever have experiences where things start to feel dreamlike around you?” I mean, there's many, many different ways to ask about dissociation. Maybe you guys can pop in with some other ones.
Robinson:
I mean, one of the most common is the experience of feeling like you're watching yourself from another perspective, or that you're on autopilot, sort of like you're riding around in your body and going about your daily life, but watching, not really feeling that you're controlling. You're washing the dishes, you're doing this or that, but not really thinking about it. A lot of people will report that sounds or sight feel louder or quieter than they actually are, or further away, or closer than they actually are. That dreamlike thing that Melissa mentioned, where it's kind of cloudy and fuzzy and….
Puder:
Do you guys start to feel it? Because I know when I'm with someone who's starting to dissociate, they don't have to say anything. I'm just starting, I can start to feel it. And sometimes I'm like, “Okay, is this me? Is this them?”
Kaufman:
I didn't want to say that, because that sounds, I mean, unless you've experienced it, it sounds a little weird. But yeah, sometimes you may. Your own understanding of it, is because you start to feel a little fuzzy or foggy and you become aware that you're sort of thinking about something else, and then you're sort of, things can start to feel a little dreamlike, a little foggy. But again, I didn't want to say that because if you haven't really experienced it, it sounds odd.
Robinson:
It's like our mirror neurons. Right? We see it happening, or we kind of perceive it, and we start to experience it too.
Puder:
I think if you're an empathic human being, you can't not feel that, or just like anytime you're with someone when they're talking about something traumatic, you may feel a little bit like that. You may feel a little bit more numb, a little bit more disconnected. You may feel like this sleepy haze come upon you. Absolutely. I find myself sometimes needing to feel my focus on the sensation of my butt on the chair.
Kaufman:
Ground yourself.
Puder:
Ground myself. Right? Yeah.
DID vs. Borderline Personality Disorder (BPD): Internal Fullness vs. Emptiness & Adaptive Compartmentalization (32:52)
Kaufman:
I think you're exactly right. If you've ever seen someone have a trauma related flashback, the hair on the back of your neck goes up and it feels very much like you're watching something terrible happen in the moment.
Puder:
Yes. I remember….
Kaufman:
If you haven't felt that. If you haven't seen that before, it's hard to understand.
Puder:
Yes. I mean, I don't want to dissociate everyone that's listening to this podcast, but I remember this one story, this horrific trauma that one of my patients, was delivered by their mother, that involved a near drowning type of situation. And it was very purposeful, very sadistic from the mother, too. It wasn't like an accident. Right? And when the patient described this for me, it was like, the room just started, jerking. And I had to remind myself of when I used to play, I used to do sports, and during a wrestling match when I was about to lose, or I was almost about to get pinned. And there was this moment where I would start to go hazy, and then I would have to try to fight out of it to win. So I think this is kind of like that experience. Right? But when you're with a patient like this, it could be kind of chronic, like you could go, every session feels like this slightly. Right? For months I had one patient who was very dissociative. It was like two years of trying to come out of the dissociation, to varying degrees. Right?
Robinson:
Yeah. I'm glad we're talking about how this manifests in a treatment room. I would say though, for your audience and a lot of mental health providers who are really encountering people for one or two times in an emergency room setting, you may not get that sense from people because they are often more guarded. And some of the other, maybe not clinical things in the room, things that I would look for are multiple past diagnoses. Often bipolar disorder, borderline personality disorder, mood related psychotic disorder, and you have all three of those and none of them really fit or hold water fully. Because they didn't have a full manic episode and they never really lost reality testing, and maybe they have some somatic symptoms. And you see this sort of concoction of diagnoses that follow people, and no one's been able to make sense of it.
Robinson:
That's always sort of a “ding, ding, ding” for me. And, you know, remembering that DID’s prevalence is on par with schizophrenia. So you are seeing these people all the time whether you know it or not, probably people with DID. So looking for multiple past diagnoses that don't stick is another common sign. And you asked about distinguishing between something like BPD and DID. There's lots we could say about that, but Melissa, Lauren and I will often share, I think others in the field would agree, that people with DID have a very full, like, overly full, overly loud internal experience when you get to know them. Whereas, people with BPD will often describe feeling empty or having a lack of sense of self, not having enough of a self to really ground themselves or attach to. And that's, you can kind of feel that too, when you're working with someone, when you meet someone with BPD versus DID.
Puder:
Say that again. I didn't hear which one was. So the BPD is a lack of internal self, like an emptiness. Is that what you said?
Robinson:
Yes. Like difficulty with identity fragmentation, sense of self, but in an empty way. Whereas, people with DID are often conflicted and confused and overwhelmed with how much they have internally to grapple with and make sense of, and that's kind of what keeps them quiet, hidden and confused, because it's too much to make sense of.
Kaufman:
Completely agree with that.
Puder:
I think the way that I understand personality, I think that BPD has been stigmatized. I'm more of the psychodynamic where we have neurotic level of functioning, borderline level of functioning, psychotic level of functioning. We have defense mechanisms. Everyone has a personality style, whether they're the highest functioning person in the world, could be a narcissistic personality style and enjoy the acclaim and very focused on image protection. Right? But very high functioning, you know, maybe some world leaders may have that. Or you could have a schizoid level where it's like there's a rich fantasy life and you have this fear of being consumed. So I'm wondering, is it more one personality style or another? Like could they just as easily be a little bit maybe narcissistic or a little bit schizoid or a little bit histrionic or a little bit dependent personality, depressive personality, hypomanic personality? Or do you guys not think in those categories in your sort of day to day?
Kaufman:
Okay, I do. And I'm thinking about that Nancy McWilliams book [Psychoanalytic Diagnosis
Second Edition: Understanding Personality Structure in the Clinical Process] that…
Puder:
Love it. Yep.
Kaufman:
Exactly what I'm talking about. And I was trained somewhat dynamically. And certainly, in that book she describes the dissociative identity as its own (McWilliams, 2011). Right? It's a chapter at the end of that great book that she described. So I definitely hear you. I think a lot of people aren't trained that way anymore, which is too bad. That's a very interesting way to think about it. But I think there's a dissociative structuring of the mind that happens that involves compartmentalization of thoughts, feelings, affects, memories. And if we're going along, you know, that sort of line in what you're thinking, there's like horizontal splitting versus vertical splitting. And I think that's an interesting way of thinking about it. So it's not repression, it's not, you know, sort of this horizontal divide. It's a vertical divide. And where any of these thoughts and memories and feelings can be accessed at any time, but they're shut off by these vertical walls until they're triggered or there's some unconscious motivation that happens. And so there's the change. But I hear what you're saying. I think it's a rich and fascinating way of describing things. It's just not the way we tend to think about things in the clinic, but I do like that.
Robinson:
Well, and now that you're saying that, Melissa, it makes me think that people with DID who are out in the world do have a character style and kind of adult defenses. Like they might have a more narcissistic or whatever way of dealing with their world around them. And DID, the DID tends to be more hidden in operating the background. And they have this other sort of style of being in the world that allows them, just like all of us, to function. They're organized in a certain way.
Kaufman:
And it actually can be quite adaptive, because if you think about it, by compartmentalizing these very difficult–I keep saying the same thing–but thoughts and feelings and memories by compartmentalizing that there is still then the chance to feel humor, feel connection, feel empathy as opposed to someone that doesn't sort of compartmentalize away. It's so overwhelming. And I've seen people with PTSD who are, in the moment, their symptoms are so much worse because they don't have the capacity to compartmentalize away. And that's not easy to live with, you know, rampant dissociation and DID in any way. And people with DID have terrible PTSD, at times, but they have this ability to compartmentalize things away so they can be feeling horrible and then get up and go to work. Get up, take care of their children. There is this capacity that is defensive in structure, but is quite adaptive.
Robinson:
And just to say one more thing, we're talking about all of these ways of seeing DID, as there's a diverse presentation and experience of DID. So there are people who really struggle with the symptoms and have a hard time functioning all the way up to people who you would never know, and they may never tell you they have DID, but they've had it all along. And everything in between. So it's not like there is a prototypical, you know, DID person, person with DID, obviously.
Kaufman:
But I do think there is that adaptability piece.
Neuroscience of DID: Brain Findings, Symptom Provocation, Hyperarousal vs. Shutdown (Ruth Lanius & Simone Reinders Studies) (42:10)
Puder:
Maybe I can get Lauren to weigh in on some of the brain findings, some of the scans, this kind of lowering of the heart rate that can sometimes happen when someone gets under this kind of stress, but it's not like, you know, normally we'd expect their heart rate to go up, but their heart rate actually drops. So what are some of those different findings?
Lebois:
Yes. Thanks, David. I think the neuroscience of DID has been evolving in exciting ways, but you're right, it kind of lays on the foundation of some of those early PTSD studies. And so, I think that's a great place to start in the neuroscience to help understand what's going on in DID, as well. But to go back to what you were saying there are some really great, they're called symptom provocations studies in PTSD. And how they work is that they ask folks with PTSD to come into the lab and they narrate a traumatic experience that's happened to them personally in the past. They record that, play it back to them while they're in a neuroimaging scan. That idea being that they can capture what's happening in the brain while someone is feeling triggered and actively symptomatic with their PTSD symptoms because they're back in that traumatic memory (Lanius, 2002).
Lebois:
And what they find in classic PTSD, with more that kind of dominance of not hyperarousal symptoms, feeling emotionally flooded, is that you have rapid activation of the amygdala, which is involved in orienting you to potential salient information in your environment. An example would be potential threats. And so, in someone without PTSD, that would happen, but then, very quickly, the ventral medial prefrontal cortex would come online to help regulate that bodily stress response that the amygdala is helping to mount. And they found, in classic PTSD that fails to occur. So the ventral medial prefrontal cortex is not coming online to help regulate the amygdala. And a metaphor we can use to think about is that if the ventral medial prefrontal cortex is kind of like the breaks, the breaking mechanism isn't there, and so you're getting this continuous stress response being mounted, even though that threat is no longer there.
Lebois:
They're just listening to a recording of what's happening to them in the past, what Ruth Lanius and her team have done, they've built on these findings looking at folks who have the dissociative subtype of PTSD, so all the regular PTSD symptoms, but in addition, symptoms of depersonalization or derealization, feeling detached from your sense of self and your environment. And she's found that the opposite thing actually occurs in the dissociative subtype of PTSD, where it's like the breaks are on too tightly. There's actually less amygdala activation and more activation in regions like the ventral medial prefrontal cortex. And then, Simone Reinders and her team have also done symptom provocation studies in folks with DID, and she finds that depending on what– the jargon in the field we use for this is dissociative self states. So, depending on what state someone's experiencing at any moment, they'll either show the classic PTSD pattern or the dissociative subtype PTSD pattern. [Four of Reinders’ articles linked below].
Lebois:
So, an example of a prototypical self state that someone with DID might experience is one that feels kind of more hyperaroused and activated. They have a sense, when they're listening to that trauma memory, that it did happen to them personally. And that's where we see the breaks are off in the brain. There's more amygdala activation, less ventral medial prefrontal cortex activation. But when someone with DID is in another prototypical state, which is one that's more numb and detached, has lost a sense of agency and ownership over that trauma memory. So it kind of feels like it happened to somebody else. It's not them. That's where we see that the breaks are on too tightly. There's increased ventral medial prefrontal cortex activation and less activity in regions like the amygdala. So, I think that's a key set of findings in DID that help place it on a continuum as a post-traumatic adaptation. We're seeing these different types of PTSD brain patterns in the patterns of activation in DID.
Puder:
I don't know if you guys saw recently, the polyvagal theory [see episodes 23 and 48]. There was a big paper [Grossman, et al 2026] that came out with like 50 or so people that co-signed it saying, “This thing is not a thing.” And, I've always seen it as the three stages, you know, rest and relaxation, fight and flight, and more of that dissociation. And I think a lot of this stuff kind of makes sense in that context. Right? Where it's not just one nerve in the body, like the dorsal vagal, as the polyvagal theory says. But it's like this whole brain system that is dissociation. Right? Do you guys have any comments on that?
Lebois:
I haven't seen the paper.
Polyvagal Theory, False Memory Debate & Believing Survivors in the Epstein Era (47:36)
Kaufman:
I think it's an eloquent or elegant theory. I agree, it's not one single nerve, and in that way it always seemed a bit simplistic. But I think, theoretically, in thinking about the symptom cascades in that way that there is a hypoaroused, there is a more shut down kind of a response that some patients have. So, I mean, that makes sense to me clinically.
Kaufman:
But I will look up that paper. What journal was in?
Puder:
I don't recall off the top of my head. Oh, the other thing I was thinking was, what do you guys think of false memory syndrome or this idea? Because like 20 years or 10 years ago, if someone said, “I was sexually assaulted by this congressman and this president and this billionaire,” we'd be like, “Oh, is this person crazy?” You know, but now post-Epstein files, we'd be like, “Oh, wait, like some of this stuff matches up. You know, this might have happened.” Right? But then there's also this whole genre of “there are false memories.” Right? And there are people that don't remember things maybe, or they're all false. There's the capacity for people to create memories that didn't exist. So how do you differentiate this in your mind? What are your thoughts?
Kaufman:
I mean, I think you just summed it up pretty well. I mean, there are all sorts of studies on both camps and we could sort of debate you know, is dissociation false memories, are there false memories? Do sometimes people have false memories? I suspect so. Are some memories true? Yep. Is it possible to dissociate childhood maltreatment? It is. Are people who grew up to have post-traumatic symptoms and dissociation, have there been documented cases where they go back and look through the records and, in fact, they were abused? Yes. Were there therapists at times who may have pushed too hard or had their own agenda, or whatever, and there were people who ended up having symptoms that perhaps they didn't walk in with?
Kaufman:
Probably. I tend not to be black and white about it. But if someone comes in and reports a history of childhood abuse, and they have all the symptoms of it, I'm not a detective, and I'm not going to go back and make sure that the records are documented. I know enough that it does happen. I know that PTSD is a real thing. I know that DID is a real thing. I know that child abuse does happen. At the same time, you want to be really careful as a treater not to… it's your patient's story, and there's nothing, you don't get any points for having this, you know, diagnosing someone with this or that. You have an ethical obligation to practice according to standards of care. Has that happened? Has that not happened? At times, yes. Do I believe my patients when they tell me things and the symptoms are there, and I go with what I'm shown. Have I had also, I mean, people can malinger, people can have factitious disorders. I mean, there's all, it's just so gray. There's no black white about any of this.
Lebois:
But I think that maybe an important thing to hold onto is just because there may be one person who was factitious or malingering, or something, doesn't mean that the majority cases are like that,
Protector Parts, Anger in DID & Why Most Are Not Violent Outwardly (51:16)
Kaufman:
Yes. Right. There's a great paper, 2012, by Linberg and colleagues. And I would just, if you haven't read it, it's great. I would suggest that anyone who's interested, who's listening to the podcast read that article where it goes through very, very carefully and addresses these types of issues about false memory syndrome. And it's really a classic in the field.
Puder:
Yes. One thing I had, there's a couple patients that come to mind that could not remember the abuse until the parent that committed the abuse passed away. And I'm curious if you've seen this at all. What do you think might be going on there?
Kaufman:
I have seen that; and I've even seen it a couple times, very dramatic. Like they literally had no memory of it. However, most often there are, it's just sort of a central memory, maybe missing. But as the patient talks to you more, there are symptoms that they're expressing that are post-traumatic. And they may not remember like one thing in particular, but their siblings have talked about other things, that it's usually not just like a complete, “I didn't remember one thing about it, and I'm shocked that this happened.” Sorry, your question was about when a parent dies. So yes, I have seen that, because I think the sort of motivation to not remember, or to not know, really has eased in that kind of situation.
Robinson:
Similarly, I think when a parent's adult children move out of the house, we might see someone's symptoms get worse. Or when a major life event that changes their need to stay hidden or to keep things so compartmentalized goes away, that we see people often start to become symptomatic later in life, whatever that point is.
Kaufman:
The kids have gone off to college, and so they're less distracted, if you will, by child rearing or going to school, or going out and becoming excellent at your job. I mean, those things, I've seen a lot of people in retirement age who are slowing down and all of a sudden that's what they're left with.
Puder:
I've also seen people, when they stop drinking alcohol heavily, that's when they start to remember, or…. Yeah, you're all nodding your heads.
Kaufman:
I mean, in a way it's just just another way to, I don't want to say distract, but the way of someone who has been busy their whole life raising children or going to school, I mean, all of this stuff has been probably a wonderful distraction. In the same way that drinking sort of is. You know, you cope by overworking or taking care of others, you cope by drinking. So I think it's sort of similar in that way. They stopped drinking, that coping, that way of coping with the traumatic thoughts and feelings has gone. So, yeah, I agree.
Puder:
Speak a little bit about, it seems like people with DID have like a part of themself that's more of the protector. It could be more, maybe even angry or violent if necessary. Is this common? Is this something you look for?
Robinson:
I would say it's not in my clinical work. I don't go looking for anything in particular when having self states.
Puder:
I appreciate that. I appreciate that. Yeah.
Robinson:
And you're right that I think if you think about what a kid would need to survive or the different ways a kid would need to be in the world to stay hidden, having someone who can be protective and bold, or set boundaries, might be a state. Having someone who holds anger or fear, or like really overwhelming emotion, whatever that is, could be a state. Someone who is soothing and reassuring could be a state. Having a critical sort of you know, overly critical voice or anger towards the self voice could be a state.
Kaufman:
Agreed.
Robinson:
And those are, I think those are, not everyone has those, but those are commonly reported in a person's own words, in a way.
Kaufman:
Yes. Lots of people with DID are pretty allergic to anger. When you're a little kid and you're being harmed it would be very natural to become angry, but it's not very adaptive when you're very small to show anger. So that's a huge conflict for a kid. What do they do with it? So it becomes dissociated. So I would say that having an angry self state, I often see that. Are they able to become violent? I would say that folks with DID that I have treated that have DID were not violent people. If anything, they were allergic to violence.
Kaufman:
Despite, you know, there have been some cases that have been quite sensationalized in the media about, you know folks who had committed murder, and then said, “It wasn't me. It was him.” And I think a lot of those aren't DID, but some of them are. But on the whole, I would say that folks with DID are probably less outwardly violent because there's an internal solution. And it's not adaptable to be violent if you're a young child or a woman, in many ways. So, yeah.
Key Neuroimaging Evidence: Simulators vs. Authentic DID & Treatability of the Condition (57:16)
Puder:
Lauren, I know you have to do some childcare stuff coming up here. Are there other big areas that we haven't even started to talk about that you could maybe take us through?
Lebois:
Yes, that's a great question. I feel like just kind of sticking with the neuroscience a little bit. There are some other key findings there that might be helpful to hold in mind as a clinician or when you're talking to insurance companies or when you're encountering folks who are giving you a little bit of pushback about what DID is or does it really exist or something. So another big, big line of work that Simone Reinders has taken on is comparing folks with DID to people who simulate having DID and comparing their brain activity. The idea being that, okay, so maybe the fantasy model of people are making this up or role playing in some way, or it's iatrogenic or something. That's captured by this control condition of someone asked and trained to simulate the symptoms of DID and they go through pretty elaborate trainings and lots of manipulation checks to make sure someone really gets this, and they ask them, for example, to do the symptom provocation study of remembering their own past traumatic reimmersing in their own past traumatic memories in one state versus another.
Lebois:
And then they compare that to someone who's genuinely diagnosed with DID. What does it look like for them in one state versus another in these different memory conditions? And they, in all studies that have done that to date, they've never been able to, the simulating control has never been able to replicate the brain activation that we see in folks with DID. So that helps to kind of dispel that particular theory about genuine DID. I think that's really important. Also a lot of the neuroscience of DID has focused on comparing one dissociative self state to another. And they, I think, that's helpful in that it shows that these are, while it's not as we've been talking about this caricature of actual different people, they are internally experiencing very, what feels like, very distinct states. And we see that in the brain activation across paradigms, across different neuroimaging modalities.
Lebois:
There's different activity in the brain when someone's in one dissociative self state versus another. And what that specific brain activation is just kind of depends on what you're asking them to do in the scanner. So I think that's helpful to hold onto, that these are real states that people are experiencing. And then, I think, let's see, maybe, I know we haven't, this takes us a little bit out of the neuroscience, but I think another important thing to talk about is that DID is treatable. You can recover from DID. I think that's an important point to hold on to hope-wise for people who are experiencing this or have loved ones who have this condition, that it is treatable.
Puder:
Yes. And Melissa Kaufman, I know you shared publicly that this is something that you have struggled with historically. Maybe you could mention a little bit about your road to recovery. Or what you would like to mention about this?
Melissa Kaufman's Personal Recovery Story: From DID & PTSD to Full Integration (01:00:52)
Kaufman:
Yes. I'm happy to do that. I have spoken publicly about the fact that I grew up having DID. I did receive treatment, you know, luckily enough to find a really excellent treater when I was actually a resident, a psychiatry resident; and fully recovered. I no longer have PTSD or DID; and it's very important to me. That's one of, really one of the big reasons that I chose to self disclose. So, later in life, I really wanted to get the message out that these things, you can feel much better. And it is treatable. I was treated by a psychiatrist who did have some background in treating people that had dealt with childhood abuse and neglect.
Kaufman:
She actually was a psychodynamic psychotherapist. And I think, broadly speaking, was sort of phasic in the way she treated it. It took me a long time to feel comfortable with her. And I think a large part of my treatment was sort of building trust and being able to feel like I could talk about these things that have been hitting me for so long. I would say she didn't do any sort of trauma focused treatment, like prolonged exposure or cognitive processing. Really, because in DID the trauma is always sort of there. And really what she taught me was more so how to become less symptomatic, and how to, if I were starting to feel dissociative or starting to feel like I was having a flashback, how to manage it. She would help me manage it.
Kaufman:
And then I began to be able to manage it myself. And the more that I could do that, the more it felt, I felt very gradually able to go from a sense of, “That didn't happen to me.” I know, I always felt like that sounded crazy. I never wanted to say that, but I did have this internal sense of having different, you know, people inside me, even though I knew that, intellectually, that's not really possible. It was, I was so conflicted about it. But over time, as she taught me, and then I was able to take it in myself that I had control. I could stop flashbacks. I could stop dissociating. I didn't have to talk about anything I didn't want to. But if I felt like I could tolerate it, I would talk about it.
Kaufman:
And gradually, over time, there was just this diminishment of sense that “it's not me.” And then it's like, “Oh my God, that was me. No, it couldn't have been. Well, my God, it was me.” And then eventually, it's like, “Oh my gosh, it was me all along.” There's this sort of gradual dawning of awareness, if you will. And that was it. It wasn't super dramatic. And it's like, you know in, I'm thinking about in the movie Sybil, there was this one, I mean, it was like an amazing, it was an amazing sort of piece of art in terms of drama. But, you know, I can't remember exactly what it was, but she remembered something and collapsed, and then it seemed like she didn't have DID anymore. It's just like that, it's just a gradual, more and more able to integrate within oneself, the huge conflicts about being dependent, huge conflicts about saying things about people in your life that you don't want to say bad things about. You know, those kinds of conflicts that people have when they've grown up in challenging situations.
Kaufman:
So that was my treatment. And I feel very fortunate, and I very much want people to understand. I mean, not everyone wants that either. I mean, not everyone wants to be integrated. Some people with DID don't like that word. And there's some people that it may not make sense to sort of reach that point. It may make more sense to arrive at a place where the sort of internal “not me” states get along better. There's not so much conflict anymore, and some people are okay reaching that state and that's okay.
Puder:
Do you still find there are moments where you can dissociate, maybe more than the average person? Or is that mostly resolved, as well?
Kaufman:
Yes, it's interesting. I suspect I'm still like an absent-minded professor. I can get very immersed in books and movies and but not like I used to
Puder:
But not like spacing out for….
Kaufman:
Not as much as I used to. I'm way more in the outside world than I was before. And in some ways, I miss it. But, you know, I say that, but, you know, it's not easy having DID. It's not easy having post-traumatic symptoms. But I've changed a little bit. I'm just not as internally focused as I used to be.
Treatment Pearls: Building Trust, Grounding Skills, Boundaries & Consistency in Therapy (1:06:22)
Puder:
Thank you for sharing.
Kaufman:
Thanks for asking.
Puder:
Thank you for sharing. Matthew, do you have any treatment pearls?
Robinson:
Yes. Well, I mean, first I want to say that treatment and access to treatment for DID is woefully under… there's a huge access problem. And so the more people that can learn about DID the better. As Melissa described, I think the biggest focus of treatment is relationship building and development and helping a person develop the language to understand their mind. So, it is a very relational, I think, psychodynamic approach, in many cases. And treatments, like finding solid ground, which is a new treatment, by Bethany Brand, Ruth Lanius, and colleagues that can help teach people skills for grounding and managing the sort of active symptoms of dissociation. It's a great adjunct to the work that goes on to help a person feel more whole and in control. But I would say a lot of people want to find a DID specialist, and I often have to tell people, “Find a good therapist. Find a good therapist who wants to build a strong relationship. And a lot of the work will happen that needs to happen because they know how to do therapy.”
Kaufman:
And they know how to do therapy. And one thing that's really important is to find a therapist that's really boundaried. That was actually something I learned as a psychiatrist. I also learned in my own treatment how important that is. I think it can sometimes, with folks that have been through very difficult circumstances, there may be a wish to help more, or show more, or be more to a person. And I think having a very boundaried therapist, for many, many reasons that's one of the most important things.
Robinson:
That's actually the pearl. So Melissa's one of the people that trained and mentored me as a person who feels moderately comfortable treating DID. I've learned a lot from her. And I have her voice in my head, about “just be consistent,” “be consistent,” “be boundaried and pace.” And so I've held that in the background as I'm trying to work with someone with DID. That, and also, I always remember that it's one person. The person I'm working with can describe their experience in lots of ways. And whether or not, you know, I don't always challenge that or ask about that, but I'm always holding onto the notion, the reality that this is one whole person who experiences themself in the world in this way. And so my job is to hold that frame and the ability to hold that frame for themselves over time.
Kaufman:
Actually. You definitely can empathize. And, you know, you're not going to challenge and say that's not possible to have. I mean, that you absolutely can empathize with the fact that subjectively that is absolutely how it feels. And as Matt is saying, you also hold onto both. That is subjectively how people feel. And you may, in treatment, speak to them in a way that they can subjectively understand. But also keep reminding yourself, “This is one person, this is one person.”
Puder:
That's good. Kind of wrapping up our time. I have to go to my own childcare adventures here. Coaching my son's basketball team. So, yeah, I'm curious if there's anything else kind of floating around in your mind that you really wanted to say. I want to give you the chance to do it.
Final Thoughts: Advocacy, Justice for Survivors & Call for Better Access to DID Care (01:10:22)
Kaufman:
I guess I just want to thank you for this opportunity. I think it's important for people to understand that…. This is what I want to say, I do get tired of saying DID is real. We don't have to really do that with other psychiatric conditions. So I hope, you know, educational forms like this we can keep doing this; and thank you for allowing us to do this. Because at some point, we're going to have to, we can just stop saying that and people can just get on with what needs to be done. And that is getting access and care for folks that have dissociative disorders.
Puder:
And I hope you don't feel like me putting out the conflicts too early because I think I even mentalize that when I'm thinking about how people think about it, you know? So I think it's good to put out kind of the conflict that is in our space. Right? We have to talk about it. We don't, like Freud, we don't want to think that horrific traumas happen to children. We don't want to think, you know, it would be a nice fantasy to believe it's all fantasy. Right? And also dissociation is alive and well. It's very adaptive. It's absolutely adaptive. I'll probably go play some Minecraft tonight, with my kids, and dissociate from all of the worries of work, for half an hour.
Kaufman:
I appreciate you bringing up the controversies, because if you didn't, people would wonder why that would be. Like, pretending as if there is still no controversy. There's still controversy, but we've made great strides. And again, you know exactly what you're doing, allowing this space to speak about these things. I could not be more grateful.
Puder:
Matthew, any final thoughts?
Robinson:
Just referencing back to a couple things you actually said. Thank you. Yes, I agree, I'm very glad to have this space. Even though we're talking more about childhood abuse and maltreatment of people and human rights violations, it's in the news more, I still think there's this collective willfulness around action and taking it seriously. And so I would implore anyone listening, to when you notice yourself or people around you doing that, “It's not happening to me, it's somewhere else. It can't be as bad as it sounds.” A lot of my patients right now are horrified about what's in the news and the lack of accountability. And they say to me, “This is why I didn't talk about it for so long. There's evidence. There's millions of pages of evidence of something and nothing's happening.” So I think as mental health providers, we are here to provide treatment, but we're also here to be advocates and a voice for people who can't voice things for themselves.
Puder:
All of a sudden I have this patient who really likes Punisher comic books, and I decided to get a series of Punisher comic books, which are about the child sex trade and the Punisher going after the abusers. And then I was like, I became conscious all of a sudden, like, “Oh, I bought this for a reason, at this point in history, at this point in time.” Right? And we do want justice. Right? We do. It's like, I'm not going to become a vigilante, but we do want justice. Right? And we do need to speak out and we can go back through the early survivors that did speak out about Epstein and how they were publicly shunned. I was just talking to a therapist today. She said there was a person that she treated that had been horrifically abused by someone in the film industry early on in her career. And she never spoke out about it because she knew it would be the end of her career. It would be the absolute end of her career. And you know, so we collectively need to start to believe, “Yes, this could happen.” It could absolutely happen. And if there's good documentation that it has happened, then these people should be brought to some sense of justice. Right? Yes, absolutely.
Kaufman:
Agreed.
Robinson:
Thank you.
Puder:
All right guys, we'll leave it there for today. Okay. take care. Part two will probably focus on treatment. Because I feel like we could really go into, I mean, you run an IOP partial. There's so much collective wisdom that you guys have for this. So we'll, we'll do that at another time.
Robinson:
Thank you. Sounds good. Thanks, David. Okay.
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