document_title: Dissociative identity disorder

question_text: when did multiple personality disorder change to d i d

question_tokens: when did multiple personality disorder change to d i d

text: Dissociative identity disorder

text: Definitions[edit]

text: Dissociation, the term that underlies the dissociative disorders including DID, lacks a precise, empirical, and generally agreed upon definition.[7][17][18] 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. Thus it is unknown if there is a common root underlying all dissociative experiences, or if the range of mild to severe symptoms is a result of different etiologies and biological structures.[7] Other terms used in the literature, including personality, personality state, identity, ego state and amnesia, also have no agreed upon definitions.[15][17] Multiple competing models exist that incorporate some non-dissociative symptoms while excluding dissociative ones.[17] The most widely used model of dissociation conceptualizes DID as at one extreme of a continuum of dissociation, with flow at the other end, though this model is being challenged.[18]

text: Some terms have been proposed regarding dissociation. Psychiatrist Paulette Gillig draws a distinction between an "ego state" (behaviors and experiences possessing permeable boundaries with other such states but united by a common sense of self) and the term "alters" (each of which may have a separate autobiographical memory, independent initiative and a sense of ownership over individual behavior) commonly used in discussions of DID.[19] 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).[20] "Structural dissociation of the personality" is used by Otto 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 hypothesis, primary dissociation involves one ANP and one EP, while secondary dissociation involves one ANP and at least two EPs and tertiary dissociation, which is unique to DID, is described as having at least two ANP and at least two EP.[7] Others have suggested dissociation can be separated into two distinct forms, detachment and compartmentalization, 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, but they have not been universally accepted.[7]

text: Signs and symptoms[edit]

text: According to the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5), DID symptoms include "the presence of two or more distinct personality states" accompanied by the inability to recall personal information, beyond what is expected through normal forgetfulness. Other DSM-5 symptoms include a loss of identity as related to individual distinct personality states, and loss referring to time, sense of self and consciousness.[2] In each individual, the clinical presentation varies and the level of functioning can change from severely impaired to adequate.[16][21] The symptoms of dissociative amnesia are subsumed under the DID diagnosis but can be diagnosed separately. 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).[22] The majority of patients with DID report childhood sexual or physical abuse, though the accuracy of these reports is controversial.[3] Identities may be unaware of each other and compartmentalize knowledge and memories, resulting in chaotic personal lives.[21] Individuals with DID may be reluctant to discuss symptoms due to associations with abuse, shame, and fear.[3] DID patients may also frequently and intensely experience time disturbances.[23]

text: Around half of people with DID have less than 10 identities and most have less than 100; as many as 4,500 have been reported.[7]:503 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 compartmentalized memory components.[7] The primary identity, which often has the patient's given name, tends to be "passive, dependent, guilty and depressed" with other personalities being more active, aggressive or hostile, and often containing a current time line that lacks childhood memory. Most identities are of ordinary people, though fictional, mythical, celebrity and animal parts have been reported.[7]:503

text: Comorbid disorders[edit]

text: The psychiatric history frequently contains multiple previous diagnoses of various disorders and treatment failures.[24] The most common presenting complaint of DID is depression, with headaches being a common neurological symptom. Comorbid disorders can include substance abuse, eating disorders, anxiety, posttraumatic stress disorder (PTSD), and personality disorders.[25] A significant percentage of those diagnosed with DID have histories of borderline personality disorder and bipolar disorder.[26] Further, data supports a high level of psychotic symptoms in individuals with DID, and that both individuals diagnosed with schizophrenia and those diagnosed with DID have histories of trauma.[27] 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.[28] Individuals diagnosed with DID demonstrate the highest hypnotizability of any clinical population.[22] The large number of symptoms presented by individuals diagnosed with DID has led some clinicians to suggest that, rather than being a separate disorder, diagnosis of DID is actually an indication of the severity of the other disorders diagnosed in the patient.[7]

text: Borderline personality disorder[edit]

text: The DSM-IV-TR states that acts of self-mutilation, impulsivity, and rapid changes in interpersonal relationships "may warrant a concurrent diagnosis of borderline personality disorder".[2] Steven Lynn and colleagues have suggested that the significant overlap between BPD and DID may be a contributing factor to the development of therapy induced DID, in that the suggestion of hidden alters by therapists who propose a diagnosis of DID provides an explanation to patients for the behavioral instability, self-mutilation, unpredictable mood changes and actions they experience.[8] In 1993 a group of researchers reviewed both DID and borderline personality disorder (BPD), concluding that DID was an epiphenomenon of BPD, with no tests or clinical description capable of distinguishing between the two. Their conclusions about the empirical proof of DID were echoed by a second group, who still believed the diagnosis existed, but while the knowledge to date did not justify DID as a separate diagnosis, it also did not disprove its existence.[19] Reviews of medical records and psychological tests indicated that the majority of DID patients could be diagnosed with BPD instead, though about a third could not, suggesting that DID does exist but may be over-diagnosed.[19] Between 50 and 66% of patients also meet the criteria for BPD, and nearly 75% of patients with BPD also meet the criteria for DID, with considerable overlap between the two conditions in terms of personality traits, cognitive and day-to-day functioning, and ratings by clinicians. Both groups also report higher rates of physical and sexual abuse than the general population, and patients with BPD also score highly on measures of dissociation.[7] Even using strict diagnostic criteria, it can be difficult to distinguish between dissociative disorders and BPD (as well as bipolar disorder and schizophrenia),[17] though the presence of comorbid anxiety disorders may help.[29]

text: Causes[edit]

text: The cause of DID is unknown and widely debated, with debate occurring between supporters of different hypotheses: that DID is a reaction to trauma; that DID is produced by inappropriate psychotherapeutic techniques that cause a patient to enact the role of a patient with DID; and newer hypotheses involving memory processing that allows for the possibility that trauma-causing dissociation can occur after childhood in DID, as it does in PTSD. It has been suggested that all the trauma-based and stress-related disorders be placed in one category that would include both DID and PTSD.[30] 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.[31]

text: Research is needed to determine the prevalence of the disorder in those who have never been in therapy, and the prevalence rates across cultures. These central issues relating to the epidemiology of DID remain largely unaddressed despite several decades of research.[32] The debates over the causes of DID also extend to disagreements over how the disorder is assessed and treated.[7]

text: Developmental trauma[edit]

text: People diagnosed with DID often report that they have experienced severe physical and sexual abuse, especially during early to mid-childhood[33] (although the accuracy of these reports has been disputed[2]), and others report an early loss, serious medical illness or other traumatic event.[21] They also report more historical psychological trauma than those diagnosed with any other mental illness.[34] 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 behavior.[35] DID is attributed to extremes of stress or disorders of attachment. What may be expressed as post-traumatic stress disorder in adults may become DID when occurring in children, possibly due to their greater use of imagination as a form of coping.[19][22] 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.[22] A specific relationship between childhood abuse, disorganized attachment, and lack of social support are thought to be a necessary component of DID.[19] Other suggested explanations include insufficient childhood nurturing combined with the innate ability of children in general to dissociate memories or experiences from consciousness.[21]

text: Delinking early trauma from the etiology 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.[36] 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.[37] 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".[22] It has also been suggested that there may be a genuine but more modest link between trauma and DID, with early trauma causing increased fantasy-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of DID.[8] 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 DID.[38]

text: The suggestion that DID was the result of childhood trauma 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. There is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption.[39]

text: Therapist-induced[edit]

text: The prevailing post-traumatic model of dissociation and dissociative disorders is contested.[8] It has been hypothesized that symptoms of DID 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.[6][15][16][32][40] Referred to as the "sociocognitive model" (SCM), it proposes that DID is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes,[32] with unwitting therapists providing cues through improper therapeutic techniques. This behavior is enhanced by media portrayals of DID.[8]

text: Proponents of the SCM note that the bizarre dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of DID who, through the process of eliciting, conversing with and identifying alters, shape, or possibly create the diagnosis. While proponents note that DID is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are skeptical of the traumatic etiology suggested by proponents.[41] The characteristics of people diagnosed with DID (hypnotizability, suggestibility, frequent fantasization and mental absorption) contributed to these concerns and those regarding the validity of recovered memories of trauma.[42] Skeptics note that a small subset of doctors are responsible for diagnosing the majority of individuals with DID.[6][15][39] Psychologist Nicholas Spanos and others have suggested that in addition to therapy caused cases, DID may be the result of role-playing rather than alternative identities, though others disagree, pointing to a lack of incentive to manufacture or maintain separate identities and point to the claimed histories of abuse.[43] Other arguments that therapy can cause DID, include the lack of children diagnosed with DID, the sudden spike in rates of diagnosis after 1980 (although DID 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[8][15] (as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy.[8]) These various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably borderline personality disorder, which is commonly comorbid with DID.[8] In addition, presentations can vary across cultures, such as Indian patients who only switch alters after a period of sleep — which is commonly how DID is presented by the media within that country.[8]

text: The therapy-caused cases of DID, it is argued, are strongly linked to false memory syndrome, a concept and term coined by members of the False Memory Syndrome Foundation in reaction to memories of abuse they allege were recovered by a range of controversial therapies whose effectiveness is unproven. Such a memory could be used to make a false allegation of child sexual abuse. There is little agreement between those who see therapy as a cause and trauma as a cause.[5] Supporters of therapy as a cause of DID suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position[32] 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 an artificially low recognition of the diagnosis.[16] However, false memory syndrome per se is not regarded by mental health experts as a valid diagnosis,[44] and has been described as "a non-psychological term originated by a private foundation whose stated purpose is to support accused parents",[45] and critics argue that the concept has no empirical support, and furthermore describe the False Memory Syndrome Foundation as an advocacy group that has distorted and misrepresented research into memory.[46][47]

text: Children[edit]

text: DID is rarely diagnosed in children, despite the average age of appearance of the first alter being three years.[15] This fact is cited as a reason to doubt the validity of DID,[15][32] and proponents of both etiologies believe that the discovery of DID in a child that had never undergone treatment would critically undermine the SCM. Conversely, if children are found to only develop DID after undergoing treatment it would challenge the traumagenic model.[32] As of 2011[update], approximately 250 cases of DID in children have been identified, though the data does not offer unequivocal support for either theory. While children have been diagnosed with DID before therapy, several were presented to clinicians by parents who were themselves diagnosed with DID; others were influenced by the appearance of DID in popular culture or due to a diagnosis of psychosis due to hearing voices—a symptom also found in DID. No studies have looked for children with DID in the general population, and the single study that attempted to look for children with DID not already in therapy did so by examining siblings of those already in therapy for DID. 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.[32]

text: The initial theoretical description of DID 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.[8] Proponents of the traumagenic hypothesis claim the high correlation of child sexual and physical abuse reported by adults with DID corroborates the link between trauma and DID.[7][8] However, the DID-maltreatment link 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.[7][8] 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.[7][8] In addition, studies rarely control for the many disorders comorbid with DID, or family maladjustment (which is itself highly correlated with DID).[7][8] The popular association of DID 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.[41]

text: Diagnosis[edit]

text: The fourth, revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnoses DID according to the diagnostic criteria found in section 300.14 (dissociative disorders). It has also been found difficult to diagnose the disorder in the first place, due to there not being a universal agreement of the definition of dissociation.[48] The criteria require that an adult 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.[2] While otherwise similar, the diagnostic criteria for children also specifies symptoms must not be confused with imaginative play.[7] 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.[24] 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.[17] 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".[42][49]

text: 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.[7][15][40] The social cues involved in diagnosis may be instrumental in shaping patient behavior 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.[39] 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).[16] 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 specialize in DID are responsible for the creation of alters through therapy.[7]

text: Screening[edit]

text: 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.[17] Instead, shortly after the publication of the initial SCID a freestanding protocol for dissociative disorders (SCID-D)[50] was published.[17] This interview takes about 30 to 90 minutes depending on the subject's experiences.[51] An alternative diagnostic instrument, the Dissociative Disorders Interview Schedule, also exists but the SCID-D is generally considered superior.[17] 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.[52]

text: 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.[17] The DES[53] is a simple, quick, and validated[54] 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.[55] The reliability of the DES in non-clinical samples has been questioned.[56]

text: Differential diagnoses[edit]

text: People with DID are diagnosed with five to seven comorbid disorders on average—much higher than other mental illnesses.[19] Due to overlapping symptoms, differential diagnosis includes schizophrenia, normal and rapid-cycling bipolar disorder, epilepsy, borderline personality disorder, and Asperger syndrome.[57] Delusions or auditory hallucinations can be mistaken for speech by other personalities.[22] Persistence and consistency of identities and behavior, amnesia, measures of dissociation or hypnotizability 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.[2] 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.[19] Those with DID generally have adequate reality testing; they may have positive Schneiderian symptoms of schizophrenia but lack the negative symptoms.[58] They perceive any voices heard as coming from inside their heads (patients with schizophrenia experience them as external).[7] In addition, individuals with psychosis are much less susceptible to hypnosis than those with DID.[22] Difficulties in differential diagnosis are increased in children.[32]

text: DID must be distinguished from, or determined if comorbid with, a variety of disorders including mood disorders, psychosis, anxiety disorders, posttraumatic stress disorder, personality disorders, cognitive disorders, neurological disorders, epilepsy, somatoform disorder, factitious disorder, malingering, other dissociative disorders, and trance states.[9] 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.[39] 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 DID patients typically exhibit confusion, distress and shame regarding their symptoms and history.[9] The condition may be under-diagnosed due to skepticism 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.[6][59] A specific relationship between DID and borderline personality disorder has been posited several times, with various clinicians noting significant overlap between symptoms and patient 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.[19]

text: Issues affecting diagnosis[edit]

text: The DSM-5 elaborates on cultural background as an influence for some clinical presentations of DID.[60]

text: 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.

text: History of the DSM diagnosis[edit]

text: 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".[61] 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,[16] and renamed it DID.[2] 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[16] and an emphasis on "the identities as centers of information processing".[22] 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 behavior patterns is the personality.[16] 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 personalize alters, they lack an independent, objective existence.[16] 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.[22] Amnesia was replaced when it became clear that the risk of false negative diagnoses was low because amnesia was central to DID.[16]

text: 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.[1]

text: The DSM-IV-TR criteria for DID have been criticized 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, depersonalization, and derealization 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.[22] The DSM-IV-TR criteria have also been criticized[citation needed] 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.

text: The DSM-5 updated the definition of DID in 2013, summarizing the changes as:[62]

text: 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.

text: Controversy[edit]

text: DID is among the most controversial of the dissociative disorders, and among the most controversial disorders found in the DSM-IV-TR.[7] 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,[4][17] 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 patient suffering from DID.[6][40][42][43][58][63] The debate between the two positions is characterized by intense disagreement.[5][6][15][40][43][58] Psychiatrist Joel Best 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.[39]

text: Some psychiatrists believe that DID is caused by health care, i.e. symptoms of DID are created by psychiatrists 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 "The 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.[64]

text: 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.[15] 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)[17] 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.[65]

text: Pathophysiology[edit]

text: 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,[5] though there is evidence of changes in visual parameters[66] and support for amnesia between alters.[5][17] DID patients also appear to show deficiencies in tests of conscious control of attention and memorization (which also showed signs of compartmentalization 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.[19] Experimental tests of memory suggest that patients with DID may have improved memory for certain tasks, which has been used to criticize 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.[8]

text: Treatment[edit]

text: There is a general lack of consensus in the diagnosis and treatment of DID[5] and research on treatment effectiveness focuses mainly on clinical approaches described in case studies. General treatment guidelines exist that suggest a phased, eclectic approach with more concrete guidance and agreement on early stages but no systematic, empirically-supported approach exists and later stages of treatment are not well described and have no consensus. Even highly experienced therapists have few patients that achieve a unified identity.[67] Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive behavioral therapy (CBT),[19] insight-oriented therapies,[17] dialectical behavioral therapy (DBT), hypnotherapy and eye movement desensitization and reprocessing (EMDR). Medications can be used for comorbid disorders or targeted symptom relief.[10][42] 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.[68] 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.[10] Regular contact (weekly or biweekly) is more common, and treatment generally lasts years—not weeks or months.[10][19] 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.[8]

text: Therapy for DID is generally phase oriented.[29] 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 therapists 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.[19] 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 is appropriate and there are clinical opinions both for and against each option with little high-quality evidence for any position.

text: Brandt et al., noting 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 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.[67]

text: The International Society for the Study of Trauma and Dissociation has published guidelines to phase-oriented treatment in adults as well as children and adolescents that are widely used in the field of DID treatment.[non-primary source needed][10] 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 abuse and eating disorders are addressed in this phase of treatment.[10] 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.[10]

text: A study was conducted with the goal of developing an "expertise-based prognostic model for the treatment of complex posttraumatic 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."[69]

text: Prognosis[edit]

text: Little is known about prognosis of untreated DID.[9] It rarely, if ever, goes away without treatment,[3][21] but symptoms may resolve from time to time[3] or wax and wane spontaneously.[21] Patients with mainly dissociative and posttraumatic 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, failed suicide attempts, and self-harm also occur.[21] Duration of treatment can vary depending on patient goals, which can extend from elimination of all alters to merely reducing inter-alter amnesia, but generally takes years.[21]

text: Epidemiology[edit]

text: There is little systematic data on the prevalence of DID.[70] It occurs more commonly in young adults[70] and declines with age.[71] Reported rates in the community vary from 1% to 3% with higher rates among psychiatric patients.[10][16] It is 5 to 9 times more common in females than males during young adulthood, though this may be due to selection bias as males who could be diagnosed with DID may end up in the criminal justice system rather than hospitals.[7] In children rates among females and males are approximately the same (5:4).[3] 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.[32]

text: Though 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.[32]

text: Changing prevalence[edit]

text: Rates of diagnosed DID were increasing, reaching a peak of approximately 40,000 cases by the end of the 20th century, up from less than 200 before 1970.[3][7] Initially DID along with the rest of the dissociative disorders were considered the rarest of psychological conditions, numbering less than 100 by 1944, with only one further case added in the next two decades.[17] In the late 1970s and 80s, the number of diagnoses rose sharply.[17] An estimate from the 1980s places the incidence at 0.01%.[3] 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 skepticism regarding the diagnosis).[17] Others explain the increase as being due to the use of inappropriate therapeutic techniques in highly suggestible individuals, though this is itself controversial[6][43] while proponents of DID claim the increase in incidence is due to increased recognition of and ability to recognize the disorder.[7] Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries.[72]

text: North America[edit]

text: The DSM does not provide an estimate of incidence for DID and dissociative disorders were excluded from the Epidemiological Catchment Area Project. As a result, there are no national statistics for prevalence and incidence of DID in the United States.[17]

text: DID is 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[40][73] though research has appeared discussing the appearance of DID in other countries and cultures.[74] A 1996 review offered three possible causes for the sudden increase in people diagnosed with DID:[11]

text:
The result of therapist suggestions to suggestible people, much as Charcot's hysterics acted in accordance with his expectations.
Psychiatrists' past failure to recognize 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".

tag: ol

text: Paris believes that the first possible cause is the most likely. Etzel Cardena and David Gleaves believe the over-representation of DID in North America is the result of increased awareness and training about the condition which had formerly been missing.[16]

text: History[edit]

text: The first case of DID was thought to be described by Paracelsus in 1646.[12] 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".[31]

text: An intense interest in spiritualism, parapsychology and hypnosis continued throughout the 19th and early 20th centuries,[73] 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.[75] 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.[73]

text: In the 19th century there were a number of reported cases of multiple personalities which Rieber[75] estimated would be close to 100. Epilepsy was seen as a factor in some cases,[75] and discussion of this connection continues into the present era.[76][77]

text: 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.[78] 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 suffered 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.

text: Between 1880 and 1920, various international medical conferences devoted time to sessions on dissociation.[79] 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.[80] 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.[80][81]

text: In the early 20th century, interest in dissociation and multiple personalities waned for a number of 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.[73] Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.[73]

text: In 1908, Eugen Bleuler introduced the term schizophrenia to represent a revised disease concept for Emil Kraepelin's dementia praecox.[82] 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.[83] 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.[84] A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.[79]

text: 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.[79] 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.[82] It was argued in the 1980s that DID patients were often misdiagnosed as suffering from schizophrenia.[79]

text: 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.[75] 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.[85] 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 behavior of individuals and the judgement of therapists.[85] During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.[79]

text: 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."[61] 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.[17]

text: 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",[86] it presented a detailed discussion of the problems of treatment of "Sybil", a pseudonym for Shirley Ardell Mason. Though the book and subsequent films helped popularize the diagnosis and trigger an epidemic of the diagnosis,[39] later analysis of the case suggested different interpretations, ranging from Mason's problems being caused by the therapeutic methods used by her psychiatrist, Cornelia B. Wilbur or an inadvertent hoax due in part to the lucrative publishing rights,[86][87] though this conclusion has itself been challenged.[88] Dr. 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 Dr. Wilbur tended to pressure her to exaggerate on the dissociation she already had."[89] As media attention on DID increased, so too did the controversy surrounding the diagnosis.[12]

text: With the publication of the DSM-III, which omitted the terms "hysteria" and "neurosis" (and thus the former categories for dissociative disorders), dissociative diagnoses became "orphans" with their own categories[90] with dissociative identity disorder appearing as "multiple personality disorder".[17] 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),[91] became "an artifact of bad (or naïve) psychotherapy" as patients capable of dissociating were accidentally encouraged to express their symptoms by "overly fascinated" therapists.[90]

text: 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.[92] Hacking revisited his concept of "making up people" in an article published in the London Review of Books on 17 August 2006.[93]

text: "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.[17] There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990.[94] Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.[95] Scientific publications regarding DID peaked in the mid-1990s then rapidly declined.[96]

text: 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.[97] 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"[98] of Satanic ritual abuse that was linked to the rise of MPD reports. In an effort to distance itself from the increasing skepticism regarding the clinical validity of MPD, the organization 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.

text: 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, but the condition retains an inherent subjectivity due to difficulty in defining terms such as personality, identity, ego-state and even amnesia.[17] The ICD-10 still classifies DID as a "Dissociative [conversion] disorder" and retains the name "multiple personality disorder" with the classification number of F44.8.81.[1]

text: A 2006 study compared scholarly research and publications on DID and dissociative amnesia to other mental health conditions, such as anorexia nervosa, alcohol abuse 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-90's "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".[96]

text: Society and culture[edit]

text: Despite its rareness, DID is portrayed with remarkable frequency in popular culture, producing or appearing in numerous books, films, and television shows.[43]

text: Psychiatrist Colin A. Ross has stated that based on documents obtained through freedom of information legislation, psychiatrists linked to Project MKULTRA claimed to be able to deliberately induce dissociative identity disorder using a variety of aversive techniques.[100]

text: Surveys of the attitudes of Canadian and American psychiatrists towards dissociative disorders completed in 1999[63] and 2001[101] found considerable skepticism and disagreement regarding the research base of dissociative disorders in general and DID in specific, as well as whether the inclusion of DID in the DSM was appropriate.

text: NFL player Herschel Walker published an autobiography in 2008 discussing his life and diagnosis of DID.[102]

text: Legal issues[edit]

text: Within legal circles, DID has been described as one of the most disputed psychiatric diagnoses and forensic assessments.[5] The number of court cases involving DID has increased substantially since the 1990s[14] and the diagnosis presents a variety of challenges for legal systems. Courts must distinguish individuals who mimic symptoms of DID for legal or social reasons. Within jurisprudence there are three significant problems:[5]

text:
Individuals diagnosed with DID may accuse others of abuse, but lack objective evidence and base their accusations solely on regular or recovered memories.
There are questions regarding the civil and political rights of alters, particularly which alter can legally represent the person, sign a contract or vote.
Finally, individuals diagnosed with DID who are accused of crimes may deny culpability on the grounds that the crime was committed by a different identity-state.

text: In cases where not guilty by reason of insanity (NGRI) is used as a defence in a court, it is normally accompanied by one of three legal approaches—claiming a specific alter was in control when the crime was committed (and if that alter is considered insane), deciding whether all (or which) alters may be insane, or whether only the dominant personality meets the insanity standard.[12] NGRI is rarely successful for individuals with DID accused of committing crimes while in a dissociated state.[13]

text: There is no agreement within the legal and mental health fields whether an individual can be acquitted due to a diagnosis of DID. It has been argued that any individual with DID is a single person with a serious mental illness and therefore exhibits diminished responsibility and this was first recognized in an American court in 1978 (State v. Milligan). However, public reaction to the result of the case was strongly negative and since that time the few cases claiming insanity have found that the altered consciousness found in DID is either irrelevant or the diagnosis was not admissible evidence.[12] The self-reported nature of the symptoms used to reach a diagnosis makes it difficult to determine their credibility, although objective measuring of brain activation and structural patterns are a promising direction for future scientific research into distinguishing malingered from genuine DID in forensic settings.[5] Forensic experts called on to conduct forensic examinations for DID must use a multidisciplinary approach including multiple screening instruments.[12]


document_title: NBA playoffs

question_text: when did nba go to 7 game first round

question_tokens: when did nba go to 7 game first round

root

text: NBA playoffs

text: Format[edit]

text: In September 2015, the NBA announced changes to the formula used to determine the format of the 2016 NBA Playoffs. The top eight teams in each conference (East and West), ranked in order by win-loss records, qualify for the playoffs. The tie-break criteria for playoff seeding and home-court advantage have also changed; head-to-head results between the tied teams is the first tie-breaker, and whether a team won its division championship is the second tie-breaker.[1]

tag: p

text: These seedings are used to create a bracket that determines the match-ups throughout the series. Once the playoffs start, the bracket is fixed; teams are never "reseeded", unlike in the National Football League (NFL) and Major League Soccer (MLS) where the strongest remaining teams face the weakest teams in subsequent rounds. The first round of the NBA playoffs, or conference quarterfinals, consists of four match-ups in each conference based on the seedings (1–8, 2–7, 3–6, and 4–5). The four winners advance to the second round, or conference semifinals, with a match-up between the 1–8 and 4–5 winners and a match-up between the 2–7 and 3–6 winners. The two winners advance to the third round, or conference finals. The winner from each conference will advance to the final round, or the NBA Finals.

text: All rounds are best-of-seven series. Series are played in a 2–2–1–1–1 format, meaning the team with home-court advantage hosts games 1, 2, 5, and 7, while their opponent hosts games 3, 4, and 6, with games 5–7 being played if needed. This format has been used since 2014, after NBA team owners unanimously voted to change from a 2–3–2 format on October 23, 2013.[2]

text: The most common criticism of the current structure is related to parity of conferences. On numerous occasions, Eastern Conference teams with losing records qualified for the playoffs, while Western Conference teams with winning records ended up missing them, including the 2011, 2013 and the 2015 NBA Playoffs.

text: History[edit]

text: The National Basketball Association was established in 1949 by merger of the Basketball Association of America (BAA) and National Basketball League but it recognizes the three BAA seasons as part of its own history. In all of its three years the BAA champion was finally determined in a best-of-seven series but its first two tournaments, the 1947 and 1948 BAA Playoffs, were otherwise quite different from the third, which 21st-century NBA playoffs nearly match. In 1947 and 1948, the Eastern and Western Division champions were matched in a best-of-seven series following the regular season, whose winner advanced to the championship round. Meanwhile, four runners-up played best-of-three series to determine the other finalist: the two second-place teams were matched in one short series and the two third-place teams in another; the winners of those two series played another one. In 1947 the Philadelphia Warriors won the runners-up bracket and beat the Western champion Chicago Stags four games to one, which the NBA recognizes as its first championship; in 1948 Baltimore won the runners-up and beat Eastern champion Philadelphia in the final. Both tournaments generated one finalist from the Eastern and one from the Western Division, but only by chance.[3]

text: In 1949 the third and last BAA tournament matched Eastern teams exclusively and Western teams exclusively, necessarily generating Eastern and Western playoff champions to meet in the final. At the same time, the number of playoff teams was increased from three to four from each Division; two rounds of best-of-three series were played, followed by a best-of-seven championship. The main idea was retained by the NBA. Even the 1950 tournament, following a transitional season with three divisions rather than two, initially determined one playoff champion from each division. The Central champion Minneapolis Lakers became the first league champion under the NBA name by defeating Anderson from the West in a best-of-three, with Syracuse from the East idle, and then knocking off the Syracuse Nationals in six games.[4]

text: The 1951 through 1953 playoffs changed the division finals into a best-of-five playoff. With only nine league members in 1953–54, the NBA cut its postseason tournament field from eight teams to six (from 1954 through 1966, the period of eight to nine league members). Round robins were played in 1954, uniquely in NBA history—a three-team round robin among the three playoff teams in each division. From 1955 to 1966, the first-place team in each division was idle while its two runners-up faced played a best-of-three. Division finals were expanded to best-of-seven in 1958 and division semifinals to best-of-five in 1961.

text: With ten league members again for the 1966–67 season, eight teams were again admitted to the tournament, providing a simple three-round knockout (8-team bracket). A year later, the division semifinals were changed to best-of-seven playoff. Then, in 1975 and 1977, respectively, a fifth and sixth team were added to each Division, necessitating an additional first round of best-of-three series.

text: Finally in 1984, the tournament expanded to its present 16-team, four-round knockout, and the now-complete set of first-round series were expanded to a best-of-five. In 2003 the first round was changed to also be best-of-seven. (Thus all playoff teams from 2003 to present, same as the two Division champions in 1947 and 1948, continue to play at the close of the regular season without idle team ("bye") and may be certain of four playoff games including two at home.)

text: Beginning with the 2004 season, with the addition of the thirtieth NBA franchise, the Charlotte Bobcats, the NBA realigned its divisions. The result was that each conference would have three divisions of five teams each, and the winner of each division was guaranteed a top-three playoff seed. This would change slightly after the 2005–06 season; while division winners still receive automatic playoff berths, they are guaranteed a top-four seed, as described below.

text: 2006 NBA playoffs controversy[edit]

text: The previous playoff format, in place for the 2004–05 and 2005–06 NBA playoffs, after the NBA was re-aligned into six divisions, created controversy during the 2005–06 season and playoffs, and would be changed prior to the 2006–07 NBA season.[5]

text: Prior to 2005, NBA division champions were seeded higher than the other teams in their conference, regardless of their record. Prior to 2004, when the NBA was aligned into two conferences with two divisions each, the division champions were guaranteed the top two seeds. This meant that top two teams in a conference (by record) would be seeded either first and second (if they were in opposite divisions) or first and third (if they were in the same division). Because of the NBA playoffs' preset matchups in the second round, this meant that the top two teams in a conference could never meet until the conference finals, assuming they both made it to that round.

text: After the NBA realigned its two conferences into three divisions each, the seeding rules remained largely unchanged. The top three seeds would now be reserved for division champions. However, this meant that if the top two teams (by record) in a conference were in the same division, they would be seeded first and fourth. Assuming no first-round upsets, this raised the prospect that the top two teams in the conference would face each other in the conference semifinals, instead of the conference finals.

text: In the second year of this format, the 2005–06 NBA season, the two teams with the best records in the Western Conference, the San Antonio Spurs and Dallas Mavericks of the Southwest Division, did just that. The Mavericks had the second-best record in the Western Conference and the third-best record in the entire league, behind the Detroit Pistons and San Antonio. However, they were seeded fourth because they finished second in the Southwest behind the Spurs. This turn of events led to the playoff format being criticized by many. Besides the prospect of a team losing earlier in the playoffs than its regular-season record or seeding would suggest, critics claimed that it also created an unfair advantage for teams in the 2-7/3-6 half of the Western Conference playoff bracket, who could advance to the conference finals without playing either of the two best teams in the conference in an earlier round.

text: The Phoenix Suns, winners of the Pacific Division and possessors of the third best record, were seeded second, while the Denver Nuggets, winners of the Northwest Division and tied for only the seventh-best record in the conference, were seeded third.

text: The Memphis Grizzlies and Los Angeles Clippers met in the second-to-last game of the regular season, after the top four seeds had been clinched. The two teams were already determined to be the fifth and sixth seeds, and had only to determine which rank higher. The fifth seed would likely need to defeat the best two teams in the conference without home-court advantage to advance to the conference finals, as it would face fourth-seeded Dallas in the first round and likely face first-seeded San Antonio if it managed to defeat Dallas. The sixth seed would play third-seeded Denver in the first round, but would have home-court advantage (since the Grizzlies had the fourth-best record in the conference and the Clippers had the fifth-best), and would not have to face either San Antonio or Dallas until the conference finals at the earliest.

text: This led to speculation about whether the Grizzlies or the Clippers would have much commitment to winning their match-up in the second-to-last game of the season, since it was clearly most advantageous to lose the game in order to obtain the 6th seed. The Clippers eventually lost to Memphis without much evidence to support the speculation that the Clippers had lost intentionally.[6] In the first round of the playoffs, the Clippers defeated the Nuggets in five games, while Memphis was swept by Dallas. Ultimately, Dallas and San Antonio did meet in the second round, with Dallas winning in seven games and advancing all the way to the NBA finals.

text: Timeline[edit]

text: 1947: The playoffs were instituted with a three-stage tournament, similar to the Stanley Cup playoffs of the 1930s; the two first-place teams qualified directly to one semifinal where they played each other in a best-of-7 series. Teams finishing second & third qualified for the best-of-3 quarterfinals, where the two second-placed teams were paired in one quarterfinal, as were the two third-placed teams, and the two quarterfinal winners played each other in a best-of-three semifinal. The two semifinal winners played each other in the Basketball Association of America (BAA) best-of-7 final series.

tag: ul

text:
Quarterfinals
Best-of-3

Semifinals
Best-of-3 (one series)
Best-of-7 (one series)

BAA finals
Best-of-7

E3

W3

E3

E2

W2

E2

E2

W1

W1

E1

tag: table

text: There were no byes, or idle time, for the division champions – as there would be for higher-seeded playoff teams 1955–66 and 1975–83. All six 1947 participants played their first tournament games on Wednesday, April 2; in 1948 the two Eastern runners-up (E2, E3 in the figure) were idle for a few days only because there was a three-way Western tie to break. Both winners of the runners-up bracket, Philadelphia in 1947 and Baltimore in 1948, reached the final series having played fewer tournament games than their final opponents, Chicago in 1947 and Philadelphia in 1948, had played in the best-of-7 pairings of division champions. And both winners of the runners-up bracket won the final series. The "postseason" actually comprised 11 games played in a span of 21 days for the 1947 Chicago Stags and 13 games in 30 days for 1948 Philadelphia Warriors, the finalists who emerged from the pairing of division champions.[3]

text: 1949: The playoffs were reorganized to match Eastern Division teams exclusively, and Western Division teams exclusively – in two halves of the bracket, so to speak. Thus the BAA tournament generated a playoff champion in each Division. (So did the NBA in each of three 1950 divisions, and so it has done in each half of the league since then.) The top four teams from each of the two divisions qualified. The quarterfinals and semifinals were renamed division semifinals and division finals, respectively, and both rounds were best-of-3. Thus any playoff team might be eliminated in two games, one home game. The best-of-7 final was unchanged.

text:
Division semifinals
Best-of-3

Division finals
Best-of-3

BAA finals
Best-of-7

E1

E4

E1

Eastern Division

E2

E2

E3

E1

W2

W1

W4

W1

Western Division

W2

W2

W3

text:
1950: The BAA was renamed as the National Basketball Association (NBA). With a three-division setup, 12 teams now qualified for the playoffs, with the top four teams from each division meeting in the best-of-3 division semifinals. The winners met in the best-of-3 division finals. With three teams remaining, the surviving team with the best regular season record qualified directly for the finals while the other two teams met in a best-of-3 NBA semifinals.
1951: With the NBA reverting to a two-division setup; the division semifinals reverted to its original 1949 format with only eight teams qualifying. The division finals was extended to a best-of-5 format.

text:
Division semifinals
Best-of-3

Division finals
Best-of-5

NBA finals
Best-of-7

E1

E4

E4

Eastern Division

E2

E2

E3

E2

W3

W1

W4

W1

Western Division

W3

W2

W3

text:
1954: With only nine league members (soon to be eight), the number of playoff teams was cut down to six. The division semifinals was changed to a double round-robin format within the division, with the top three teams from each division qualifying (each team played four games). Following the round-robin games, the top two teams qualified for the best-of-three division finals, followed by the best-of-seven finals.
1955: The number of playoff teams remained at six, but the initial round-robin was dropped after one year in favor of giving the first-place team in each division a bye to the best-of-five division finals. Teams which placed second and third played a best-of-three division semifinal. In 1955 the byes provided five and six extra days idle for the first-place teams.[7]
1958: The division finals was extended to a best-of-seven format.
1961: The division semifinals were extended to a best-of-five format.

text:
Division semifinals
Best-of-3 (1955–1960),
Best-of-5 (1961–1966)

Division finals
Best-of-5 (1955–1957),
Best-of-7 (1958–1966)

NBA finals
Best-of-7

E1

Eastern Division

E3

E2

E3

E3

W1

W1

Western Division

W2

W2

W3

text: The 1961 to 1966 tournaments alone combined initial byes for seeded teams with best-of-five initial series for unseeded teams. The 1961 byes provided five and seven extra days idle for the first-place teams. By 1966 the schedule provided more rest for the first-round participants with byes of 11 and eight extra days idle.[8]

text:
1967: The number of playoff teams was expanded to eight once more. The division semifinals now included the fourth-best team in each conference. The first-placed teams no longer received a bye. They were matched against the fourth-placed teams in the best-of-5 division semifinals.
1968: The division semifinals was extended to a best-of-seven format.

text:
Division semifinals
Best-of-5 (1967),
Best-of-7 (1968–1970)

Division finals
Best-of-7 (1968–1970)

NBA finals
Best-of-7

E1

E4

Eastern Division

E2

E3

W1

W4

Western Division

W2

W3

text: 1970: With an increased number of teams, the divisions were upgraded into conferences, which were then split into two divisions. Eight teams still qualified, four from each conference. The two division winners were guaranteed at least a #2 seed, and the two best non-division winners from each conference qualified as third and fourth seeds. Hence, the division semifinals and division finals came to be known as conference semifinals and conference finals, respectively.

text:
Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E4

Eastern Conference

E2*

E3

W1*

W4

Western Conference

W2*

W3

text: 1975: The number of playoff teams was expanded from eight to ten. A first round was introduced which matched the fourth and fifth seeds in each conference in a best-of-3 first round series, while the top three seeds received a bye. This is similar to the system used in the NFL from 1978 to 1989.

text:
First Round
Best-of-3

Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E4

E4

E5

Eastern Conference

E2*

E3

W1*

W4

W4

W5

Western Conference

W2*

W3

text: 1977: The number of playoff teams was expanded from 10 to 12. The first round now included the sixth best team in each conference, which was matched against the third seed. Only the division winners received byes to the next round. This is similar to the format currently used by the NFL.

text:
First Round
Best-of-3

Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E4

E5

Eastern Conference

E3

E6

E2*

W1*

W4

W5

Western Conference

W3

W6

W2*

text: The 1983 tournament is the latest to incorporate first-round byes for seeded teams. The first-round best-of-three series tapped off on Tuesday and Wednesday, April 19 and 20; the second-round best-of-sevens on Sunday to the following Wednesday, April 27. Counting from Tuesday the byes provided five to eight extra days idle.[9]

text: 1984: The playoffs were expanded from 12 teams to 16 teams. All teams now participated in the first round, which was extended to a best-of-five series.

text:
Conference quarterfinals
Best-of-5

Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E8

E4

E5

Eastern Conference

E3

E6

E2*

E7

W1*

W8

W4

W5

Western Conference

W3

W6

W2*

W7

text: 2003: The first round was extended to a best-of-seven series. This change arguably benefitted the higher seeds as it reduced the likelihood of an upset by a lower seed. It also meant that a team that swept their series 4–0 might have to wait up to two weeks to play their next series against a team that had won 4–3.

text:
Conference quarterfinals
Best-of-7

Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E8

E4

E5

Eastern Conference

E3

E6

E2*

E7

W1*

W8

W4

W5

Western Conference

W3

W6

W2*

W7

text: 2005: Each conference was realigned into three divisions with each division winner qualifying for a top-three seed regardless of record. The next best five teams from each conference also qualify for the playoffs.

text:
Conference quarterfinals
Best-of-7

Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E8

E4

E5

Eastern Conference

E3*

E6

E2*

E7

W1*

W8

W4

W5

Western Conference

W3*

W6

W2*

W7

text:
2007: To address the criticisms of having each division champion guaranteed a top-three seed, regardless of record, the rules were changed such that the division winners are now only guaranteed a top-four seed. The team with the second-best record in the conference is now guaranteed the second seed, even if it finishes second in its own division. This ensures that the two best teams in the conference cannot meet until the conference finals at the earliest. The previous system raised the prospect of the two best teams in the conference being seeded 1 and 4 if they play in the same division, thus forcing them to play each other in the second round (given no upsets).

Note: In the example below, the East's #2 seed is not a division champion.

text:
Conference quarterfinals
Best-of-7

Conference semifinals
Best-of-7

Conference finals
Best-of-7

NBA finals
Best-of-7

E1*

E8

E5

E4*

Eastern Conference

E3*

E6

E2

E7

W1*

W8

W5

W4

Western Conference

W3*

W6

W2*

W7

text: 2016: While the playoff bracketing did not change, qualification criteria were changed. The teams with the eight best records in each conference receive playoff berths, with no automatic berths nor guaranteed top-four seed placement for division champions.

text: Team roster[edit]

text: Playoff teams must identify their postseason roster before the playoffs begin. They are allowed up to 15 players and can designate two as inactive for each game.[10] Players are eligible to be on a team's playoff roster provided they were on the team for at least one regular season game, and were not on another NBA team's roster after March 1.[11] Previously[when?], playoff rosters were limited to 12 players who were named before the playoffs began.[10]

text: Records and statistics[edit]

text:
Only five 8th seeded teams have managed to win a series versus the number 1 seeded team: The Denver Nuggets eliminated the Seattle SuperSonics 3–2 in 1994. The New York Knicks eliminated the Miami Heat 3–2 in 1999. The Golden State Warriors defeated the Dallas Mavericks 4–2 in the 2007 Western Conference First Round (becoming the first 8 seed to beat a 1 seed in the best of 7 format). In 2011, the Memphis Grizzlies beat the San Antonio Spurs, 4–2 and in 2012, the Philadelphia 76ers beat the Chicago Bulls 4–2.
The 1999 Knicks are the only 8th seeded team ever to reach the NBA finals. No 8th seeded team has won the NBA finals.
The 1956–57 St. Louis Hawks, 1958–59 Minneapolis Lakers and the 1980–81 Houston Rockets are the only teams with losing records (34-38, 33–39 and 40–42, respectively) to make it to the NBA finals. In 1981 the Houston Rockets' opponent in the Western Conference Finals, the Kansas City Kings, also had a losing record (40–42).
The 1994–95 Houston Rockets, a sixth seed with a record of 47–35, were the lowest seeded team to win the NBA finals. In the NBA finals, the Rockets swept the Orlando Magic (57–25) in four games. In doing so, the Rockets defeated four teams that had won 50 or more games during the regular season (Utah Jazz at 60–22, Phoenix Suns at 59–23, San Antonio Spurs at 62–20 and Orlando at 57–25), which had never been done before. They are also the only team to have won an NBA title without having home-court advantage during any round of the playoffs.
The Golden State Warriors own the longest NBA playoff winning streak for a single postseason with 15 straight wins in the 2017 playoffs.
Of all the teams with multiple NBA finals appearances, the Chicago Bulls are the only team to have never lost in the finals, winning 6.
The Boston Celtics possess the most overall NBA finals series wins with an overall record of 17–4. The Los Angeles/Minneapolis Lakers have played in the most NBA finals series (31) with an overall record of 16–15.
The longest active playoff appearance streak currently belongs to the San Antonio Spurs with 21 consecutive appearances in the playoffs, beginning in the 1997–98 NBA season. The longest ever streak of playoffs appearances in a row belongs to the Syracuse Nationals/Philadelphia 76ers, who made the playoffs 22 straight years from the 1949–50 season to the 1970–71 season.
In 1983, under the bye-7-7-7 system, the Philadelphia 76ers attained the best record of 12-1, having only lost in Game 4 of the Eastern Conference Finals against the Milwaukee Bucks.
In 2001, under the best of 5-7-7-7 system, the Los Angeles Lakers attained the best record of 15-1, having only lost in Game 1 of the Finals against the Philadelphia 76ers.
In 2017, under the best of 7-7-7-7 system, the Golden State Warriors attained the best record of 16-1, having only lost in Game 4 of the Finals against the Cleveland Cavaliers. The Warriors and Cavaliers came into the Finals with a combined record of 24-1, with the Cavaliers having only lost in Game 3 of the Eastern Conference Finals against the Boston Celtics.

text: Playoff appearances[edit]

text: Current as of 2018 NBA Playoffs

text: Appearances by active teams[edit]

text:
Team
Appearances[12]

Los Angeles Lakers
60 [A]

Boston Celtics
55

Philadelphia 76ers
48 [B]

Atlanta Hawks
46 [C]

Detroit Pistons
41 [D]

New York Knicks
41

San Antonio Spurs
38 [E]

Chicago Bulls
35

Golden State Warriors
34 [F]

Portland Trail Blazers
34

Houston Rockets
32 [G]

Milwaukee Bucks
30

Oklahoma City Thunder
30 [H]

Phoenix Suns
29

Sacramento Kings
29 [I]

Washington Wizards
29 [J]

Utah Jazz
27 [K]

Indiana Pacers
25 [E]

Denver Nuggets
24 [E]

Cleveland Cavaliers
22

Dallas Mavericks
21

Miami Heat
20

Brooklyn Nets
19 [E][L]

Orlando Magic
14

Los Angeles Clippers
13 [M]

Charlotte Hornets
10 [N]

Memphis Grizzlies
10

Toronto Raptors
10

Minnesota Timberwolves
9

New Orleans Pelicans
7 [N]

text:
Jump up ^ Includes appearances as the Minneapolis Lakers (1947–1960).
Jump up ^ Includes appearances as the Syracuse Nationals (1946–1963).
Jump up ^ Includes appearances as the Tri-Cities Blackhawks (1946–1951), the Milwaukee Hawks (1951–1955), and the St. Louis Hawks (1955–1968).
Jump up ^ Includes appearances as the Fort Wayne Pistons (1949–1957).
^ Jump up to: a b c d Does not include appearances in the American Basketball Association (ABA) playoffs. Per the conditions of the ABA–NBA merger, the NBA does not officially recognize the ABA history, playoffs and records.
Jump up ^ Includes appearances as the Philadelphia Warriors (1946–1962) and the San Francisco Warriors (1962–1971).
Jump up ^ Includes appearances as the San Diego Rockets (1967–1971).
Jump up ^ As part of the 2008 relocation settlement with the City of Seattle, the Thunder officially shares its history with that of the Seattle SuperSonics (1967–2008).[13]
Jump up ^ Includes appearances as the Rochester Royals (1948–1957), the Cincinnati Royals (1957–1972), the Kansas City-Omaha Kings (1972–1975), and the Kansas City Kings (1975–1985).
Jump up ^ Includes appearances as the Chicago Packers (1961–1962), the Chicago Zephyrs (1962–1963), the Baltimore Bullets (1963–1973), the Capital Bullets (1973–1974), and the Washington Bullets (1974–1997).
Jump up ^ Includes appearances as the New Orleans Jazz (1974–1979).
Jump up ^ Includes appearances as the New Jersey Nets (1977–2012).
Jump up ^ Includes appearances as the Buffalo Braves (1970–1978).
^ Jump up to: a b The New Orleans Pelicans were originally named the Charlotte Hornets, and moved to New Orleans in 2002. A new team, the Charlotte Bobcats, was then established in 2004. When the Charlotte team reclaimed the Hornets name in a 2014 agreement, the Charlotte team also reclaimed the history of the original Hornets; as such, the New Orleans Pelicans were established in 2002, and the Bobcats/Hornets rejoined the NBA in 2004.[14]


document_title: Flag of Georgia (U.S. state)

question_text: which group was instrumental in getting the 1956 georgia state flag changed

text: Flag of Georgia (U.S. state)

text: History[edit]

text: I pledge allegiance to the Georgia Flag and to the principles for which it stands: Wisdom, Justice, and Moderation.

text:
Georgia state flags

  Before 1879 (unofficial)

  1879–1902

  1902–1906

  1906–1920

  1920–1956

  1956–2001

  2001–2003

  2003–present

text: 1879 flag[edit]

text: The 1879 flag was introduced by Georgia state senator Herman H. Perry and was adopted to memorialize Confederate soldiers during the American Civil War.[4] Perry was a former colonel in the Confederate army during the war, and based the design of the flag on the first national flag of the Confederacy, also known as the "Stars and Bars".[4]  Over the following decades, the flag was changed by adding, and then changing the "charge" on the flag.

text: 1956 flag[edit]

text: The Georgia state flag that was used from 1956 to 2001 featured a prominent Confederate battle flag and was designed by Southern Democrat John Sammons Bell, a World War II veteran and an attorney who was an outspoken supporter of segregation.[4]

text: The 1956 flag was adopted in an era when the Georgia General Assembly "was entirely devoted to passing legislation that would preserve segregation and white supremacy", according to a 2000 research report by the Georgia Senate.  There are few, if any, written records of what was said on the Georgia House and Senate floors when the 1956 flag bill was being introduced and passed by the Georgia legislature, nor does Georgia law provide for a statement of legislative intent when a bill is introduced, although former U.S. Congressman James Mackay, one of the 32 House members who opposed the change, later stated, "There was only one reason for putting the flag on there: like the gun rack in the back of a pickup truck, it telegraphs a message."[4] Additionally, the 2000 report concluded that the "1956 General Assembly changed the state flag" during "an atmosphere of preserving segregation and resentment" to the U.S. government's rulings on integration.[4]

text: The 2000 report states that the people who had supported the flag's change in the 1950s said, in recalling the event years later, that "the change was made in preparation for the Civil War centennial, which was five years away; or that the change was made to commemorate and pay tribute to the Confederate veterans of the Civil War."[4] Bell, who designed the 1956 flag and supported its adoption during the 1950s as a defense of the state's "institutions", which at the time included segregation, claimed years later that he did so to honor Confederate soldiers.[4] The 2000 report states that the claims that the flag was ostensibly changed in 1956 to honor Confederate soldiers came much later after the flag's adoption, in an attempt by the change's supporters to backtrack from prior support of segregationism in an era where it was no longer fashionable, saying that the "argument that the flag was changed in 1956 in preparation for the approaching Civil War centennial appears to be a retrospective or after-the-fact argument" and that "no one in 1956, including the flag’s sponsors, claimed that the change was in anticipation of the coming anniversary".[4]

text: At the time, opposition to changing the flag came from various sides, including from Confederate historical groups like the United Daughters of the Confederacy (UDC). Opponents to a change of the flag stated that incorporating the Confederate battle flag into the design would be too sectionalist, counterproductive, and divisive, saying that people should show patriotism towards the United States rather than the defunct Confederacy, referring to the U.S. Pledge of Allegiance, which states that the U.S. was "one nation" and "indivisible".[4] Opponents to the flag's change also said that there was nothing wrong with the 1920 flag and that people were content with it.[4] Others opposed changing the flag out of the burden it would place on those who would have to purchase a new flag to replace the outdated one.[4]

text: The 2000 Georgia senate report and other critics have interpreted the adoption of the 1956 flag as a symbol of racist protest, citing legislation passed in 1956 which included bills rejecting Brown v. Board of Education and pro-segregationist comments by then-Governor Marvin Griffin, such as "The rest of the nation is looking to Georgia for the lead in segregation."[4][5][6]

text: Political pressure for a change in the official state flag increased during the 1990s, in particular during the run-up to the 1996 Olympic Games that were held in Atlanta. The National Association for the Advancement of Colored People (NAACP) focused on the Georgia flag as a major issue and some business leaders in Georgia felt that the perceptions of the flag were causing economic harm to the state. In 1992, Governor Zell Miller announced his intention to get the battle flag element removed, but the state legislature refused to pass any flag-modifying legislation. The matter was dropped after the 1993 legislative session.[citation needed] Many Atlanta residents and some Georgia politicians refused to fly the 1956 flag and flew the pre-1956 flag instead.[citation needed]

text: 2001 flag[edit]

text: Miller's successor as governor, Roy Barnes, responded to the increasing calls for a new state flag, and in 2001 hurried a replacement through the Georgia General Assembly. His new flag, designed by architect Cecil Alexander, sought a compromise, by featuring small versions of some (but not all) of Georgia's former flags, including the controversial 1956 flag, under the words "Georgia's History."  Those flags are a thirteen-star U.S. flag of the "Betsy Ross" design; the first Georgia flag (before 1879); the 1920–1956 Georgia flag; the previous state flag (1956–2001); and the current fifty-star U.S. flag.

text: In a 2001 survey on state and provincial flags in North America conducted by the North American Vexillological Association, the redesigned Georgia flag was ranked the worst by a wide margin.  The group stated that the flag "violates all the principles of good flag design."[7]  After the 1956 state flag was replaced in 2001, the Georgia city of Trenton adopted a modified version as its official city flag, to protest its discontinuation.[8]

text: Current flag[edit]

text: In 2002, Sonny Perdue was elected Governor of Georgia, partially on a platform of allowing Georgians to choose their own flag in a state referendum. He authorized the Georgia legislature to draft a new flag in 2003.[9]

text: The Georgia General Assembly's proposed flag combined elements of Georgia's previous flags, creating a composition that was inspired by the Confederate First National flag, the Stars and Bars, rather than the Confederate Battle Flag. Perdue signed the legislation into law on May 8, 2003.[10]

text: The 2003 flag legislation also authorized a public referendum on which of the two most recent flags (the 2001 and 2003 versions) would be adopted as the flag of the state.  The referendum took place during the state's March 2, 2004 presidential primary election. If the 2003 flag was rejected, the pre-2001 design would have been put to a vote.[11] The 2003 design won 73.1% of the vote in the referendum.[12]