Dissociative identity disorder (DID) is still one of the most controversial diagnoses in psychology, with many professionals denying its existence. The primary objections are that the "disorder" is iatrogenic (created by the therapist) and that DID is a culture-bound syndrome not found in other cultures.
There is a considerable body of evidence in support of dissociative disorders, including DID. A couple of new studies are presented below - one refuting the iatrogenic model for DID and one supporting a sub-type of PTSD with strong dissociative tendencies.
Wikipedia offers a good summary of the current issues:
What the main debate today concerns is the question - can child abuse causes DID.
Colin A. Ross points out the errors of logic and scholarship that the quite vocal disbelievers of trauma based disorders, Piper and Merskey, have made in their publications concerning DID, but even with the doubt raised by Ross there is still debate today. [33] Ross also 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)
[73] that are in the internal validity range of widely accepted mental illnesses such as schizophrenia and
major depressive disorder. In Ross's opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses. Ross 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 in some patients.
[74]
Initially DID was infrequently diagnosed, numbering less than 100 by 1944, with only one further case added in the next two decades. In the late 1970s and 80s, the number of cases rose sharply. Accompanying this rise was an increase in the number of alters per case, rising from only the primary and one alter personality, in most cases, to an average of 13 in the mid-1980s. Proponents of the trauma model propose that the increase in
incidence and
prevalence of DID over time is that the condition was misdiagnosed as other such disorders in the past; another explanation is that an increase in awareness of DID and child sexual abuse has led to earlier, more accurate diagnosis. Those in the Sociocognitive camp explain the increase as a result of iatrogenic procedures and health care professionals past failure to recognize dissociation is now redressed by new training and knowledge and they claim that dissociative phenomena is actually increasing, but this rise only represents a new form of an old and protean entity: "hysteria". In a 2011 publication, V. Sar postulated other possible causes for the apparent differences in the prevalence of DID, including different preferences in diagnostic instruments, cultural differences in the interpretation of presenting symptoms, differences in mental health care systems and differences in the frequency of overall mental health treatment seeking behavior around the world.
[75]
I have generally been highly skeptical of DID diagnoses, and I still believe there is a serious issue with iatrogenic causation. However, I have seen extreme dissociation in clients (fitting the structural dissociation model - more on this below) in which clients do not necessarily have a different personality, but regress to a much younger and wounded self-state that is totally isolated from the adult self.
A new piece of research recently examined a collection of the complaints against DID, that clients diagnosed with DID exhibit fantasy proneness, suggestibility, suggestion, and role-playing tendencies. One of the researchers,
Ellert Nijenhuis, is a leader is in the understanding of structural dissociation. The research was published in the open access journal (freely available online), PLoS ONE:
A. A. T. Simone Reinders,
Antoon T. M. Willemsen,
Herry P. J. Vos,
Johan A. den Boer,
Ellert R. S. Nijenhuis.
Abstract
Background
Dissociative
identity disorder (DID) is a disputed psychiatric disorder. Research
findings and clinical observations suggest that DID involves an
authentic mental disorder related to factors such as traumatization and
disrupted attachment. A competing view indicates that DID is due to
fantasy proneness, suggestibility, suggestion, and role-playing. Here we
examine whether dissociative identity state-dependent psychobiological
features in DID can be induced in high or low fantasy prone individuals
by instructed and motivated role-playing, and suggestion.
Methodology/Principal Findings
DID
patients, high fantasy prone and low fantasy prone controls were
studied in two different types of identity states (neutral and
trauma-related) in an autobiographical memory script-driven (neutral or
trauma-related) imagery paradigm. The controls were instructed to enact
the two DID identity states. Twenty-nine subjects participated in the
study: 11 patients with DID, 10 high fantasy prone DID simulating
controls, and 8 low fantasy prone DID simulating controls. Autonomic and
subjective reactions were obtained. Differences in psychophysiological
and neural activation patterns were found between the DID patients and
both high and low fantasy prone controls. That is, the identity states
in DID were not convincingly enacted by DID simulating controls. Thus,
important differences regarding regional cerebral bloodflow and
psychophysiological responses for different types of identity states in
patients with DID were upheld after controlling for DID simulation.
Conclusions/Significance
The
findings are at odds with the idea that differences among different
types of dissociative identity states in DID can be explained by high
fantasy proneness, motivated role-enactment, and suggestion. They
indicate that DID does not have a sociocultural (e.g., iatrogenic)
origin.
Full Citation:
Simone
Reinders AAT, Willemsen ATM, Vos HPJ, den Boer JA, Nijenhuis ERS. (2012).
Fact or Factitious? A Psychobiological Study of Authentic and Simulated
Dissociative Identity States.
PLoS ONE, 7(6):
e39279.
doi:
10.1371/journal.pone.0039279
The most recent studies suggest that DID is a form of structural dissociation, as defined by Steele, van der Hart, and Nijenhuis. Again,
Wikipedia offers a brief and coherent overview of the structural model:
Structural Dissociation Model
Steele, K., van der Hart, O., Nijenhuis, E. suggest a distinction
between "apparently normal parts" (ANP) and "emotional parts". ANP, the
part in executive control and who is responsible for daily functioning
is often exhausted and depressed. The part avoids trauma memory and
often has amnesia for many if not all childhood traumatic events. If
those events were grouped close together, entire blocks of early life
will be absent from ANP's memory. ANP avoids the affect and information
held by EP, including nightmares, dreams, somnambulism, intrusive
thoughts, flashbacks and some somatoform symptoms. ANP is not only
avoidant of the list above, but is actually phobic of trauma memory,
related emotions, cognitions and sensory memory that goes with it. ANP
actively or passively suppress triggers to the point that it can become
automatic. [55]
"Emotional parts" (EP) are needed for survival situations involving Fight or Flight,
total submission, reflexes, vivid traumatic memories and strong,
painful emotions. EP remains fixated in traumatic experiences, which it
often reenacts. It is focused on a narrow range of cues that were
relevant to the trauma. “Action systems” direct EP. [56]
Summary of Categories of Structural Dissociation. Primary Structural Dissociation (PSD)
- PSD - Involves one EP and one ANP such as found in simple acute
stress disorder and PTSD. The ANP is detached and numb, characterized by
partial or complete amnesia of the trauma. EP is usually limited in
scope compared to ANP and is hyper-amnesic and re-experiences trauma.
- Secondary Structural Dissociation. (SSD) - Includes trauma based
DDNOS-1, complex PTSD and borderline personality disorder. This is
characterized by dividedness of two or more defensive subsystems. For
example, there may be different EP's who are devoted to flight, fight,
freeze, total submission and so on.
- Tertiary Structural Dissociation (TSD) - This is Dissociative
Identity Disorder. Two or more ANP perform aspects of daily living, such
as work, child-rearing. There must also be 2 or more EP.
This model fits the findings of the Internal Family Systems model of therapy (which is not exclusive to DID, but works with all forms of multiplicity). The ANP are termed managers in the IFS model, while the EP are called exiles. The IFS model also recognizes a third group of parts that fall between the ANP and EP distinctions - firefighters are parts that leap into action when the ANP fail to keep the EP suppressed, and they often take the form of addictive and numbing behaviors.
Colin Ross explains DID through his trauma model of dissociation (see
Epidemiology of Multiple Personality Disorder and Dissociation, which is unfortunately behind a pay wall). A recent study, published in JAMA's
Archive of General Psychiatry, was able to verify the existence of a dissociative subtype in PTSD survivors - the results seem to confirm the links between early trauma, PTSD, and dissociative disorders for some individuals (overwhelmingly, it seems, in those who suffered childhood abuse).
Erika
J. Wolf, PhD; Mark W. Miller, PhD; Annemarie F. Reardon, PhD; Karen A.
Ryabchenko, PhD; Diane Castillo, PhD; Rachel Freund, PhD
Arch Gen Psychiatry. 2012;69(7):698-705.
doi:10.1001/archgenpsychiatry.2011.1574
Context
The nature of the relationship of dissociation to
posttraumatic stress disorder (PTSD) is controversial and of
considerable clinical and nosologic importance.
Objectives
To examine evidence for a dissociative subtype of PTSD
and to examine its association with different types of trauma.
Design
A latent profile analysis of cross-sectional data from structured clinical interviews indexing DSM-IV symptoms of current PTSD and dissociation.
Settings
The VA Boston Healthcare System and the New Mexico VA Health Care System.
Participants
A total of 492 veterans and their intimate partners,
all of whom had a history of trauma. Participants reported exposure to a
variety of traumatic events, including combat, childhood physical and
sexual abuse, partner abuse, motor vehicle accidents, and natural
disasters, with most participants reporting exposure to multiple types
of traumatic events. Forty-two percent of the sample met the criteria
for a current diagnosis of PTSD.
Main Outcome Measures
Item-level scores on the Clinician-Administered PTSD Scale.
Results
A latent profile analysis suggested a 3-class
solution: a low PTSD severity subgroup, a high PTSD severity subgroup
characterized by elevations across the 17 core symptoms of the disorder,
and a small but distinctly dissociative subgroup that composed 12% of
individuals with a current diagnosis of PTSD. The latter group was
characterized by severe PTSD symptoms combined with marked elevations on
items assessing flashbacks, derealization, and depersonalization.
Individuals in this subgroup also endorsed greater exposure to childhood
and adult sexual trauma compared with the other 2 groups, suggesting a
possible etiologic link with the experience of repeated sexual trauma.
Conclusions
These results support the subtype hypothesis of the
association between PTSD and dissociation and suggest that dissociation
is a highly salient facet of posttraumatic psychopathology in a subset
of individuals with the disorder.
Full Citation:
Wolf EJ, Miller MW, Reardon AF, Ryabchenko KA, Castillo D, Freund R. (2012). A Latent Class Analysis of Dissociation and Posttraumatic Stress Disorder: Evidence for a Dissociative Subtype. Arch Gen Psychiatry, 69(7):698-705. doi:10.1001/archgenpsychiatry.2011.1574.
The continued collecting of data on this small subgroup of clients are so crucial in enabling clinicians to understand their experiences and design appropriate interventions.