Books on Parts Work and Dissociative Identity Disorder

Someone recently asked for a list of the books that inform how I work with trauma, dissociation, and dissociative identity disorder, so here is that list. I thought I might share it here for those who work with these clients or those who suffer with these symptoms.

The books with an * are books I endorse as excellent resources.


Best Readings in Trauma and Dissociation:

• Healing Developmental Trauma: How Early Trauma Affects Self-Regulation, Self-Image, and Capacity for Relationship - Laurence Heller and Aline LaPierre *
• Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists - Suzette Boon, Kathy Steele, and Onno van der hart *
• The Inner World of Trauma: Archetypal Defences of the Personal Spirit - Donald Kalsched *
• Trauma and the Soul: A psycho-spiritual approach to human development and its interruption - Donald Kalsched *
• In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness - Peter Levine and Gabor Mate *
• The Trauma Spectrum: Hidden Wounds and Human Resiliency - Robert Scaer *

Psychosynthesis:

• Multiple Mind: Healing the Split in Psyche and World - Gretchen Silker
• Unfolding Self: The Practice of Psychosynthesis - Molly Young Brown
• The Primal Wound: A Transpersonal View of Trauma, Addiction, and Growth - John Firman and Ann Gila *

Subpersonalities, Ego States, and Parts:

• Subpersonalities: The People Inside Us - John Rowan (basic reference to existing models)
• Parts Psychology: A Trauma-Based Self-State Therapy for Emotional Healing - Jay Noricks
• Embracing Our Selves: The Voice Dialogue Manual - Hal and Sidra Stone *
• Ego States: Theory and Therapy - John G and Helen H Watkins *

Internal Family Systems Therapy:

• Internal Family Systems Therapy - Richard C. Schwartz *
• Parts Work: An Illustrated Guide to Your Inner Life - Tom Holmes (for clients)
• Self-Therapy: A Step-by-Step Guide to Creating Wholeness and Healing Your Inner Child Using IFS, a New, Cutting-Edge Psychotherapy - Jay Earley (for clients)

Dissociative Disorders:

• The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization by Onno van der Hart, Ellert R.S. Nijenhuis, and Kathy Steele *
• Structural Dissociation: A Proposed Modification of the Theory - Colin Ross *
• Trauma Model Therapy: A Treatment Approach for Trauma Dissociation and Complex Comorbidity - Colin Ross *
• The Dissociative Mind - Elizabeth F Howell *
• The Wandering Mind: Understanding Dissociation from Daydreams to Disorders - John A Biever and Maryann Karinch
• The Body Bears the Burden: Trauma, Dissociation, and Disease - Robert Scaer *

Dissociative Identity Disorder:

• Attachment, Trauma and Multiplicity: Working with Dissociative Identity Disorder - Valerie Sinason *
• Treating Dissociative Identity Disorder - James L Spira, editor
• Dissociative Identity Disorder Sourcebook - Deborah Bray Haddock
• Understanding and Treating Dissociative Identity Disorder: A Relational Approach - Elizabeth F Howell *
• Diagnosis and Treatment of Multiple Personality Disorder - Frank W Putnam *
• Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality - Colin Ross

For Clients or By Clients:

• Amongst Ourselves: A Self-Help Guide to Living with Dissociative Identity Disorder - Tracy Alderman and Karen Marshall
• Got Parts? An Insider's Guide to Managing Life Successfully with Dissociative Identity Disorder - A.T.W. 
• Multiple Personality Disorder from the Inside Out - Barry Cohen, Esther Giller, and Lynn W., editors

Documentary - Helen: The Woman with 7 Personalities (and more)

This first documentary is a look at the life of Helen, a woman with seven identified parts, or ego states, or alters. She is a woman with dissociative identity disorder (sometimes known as structural dissociation). Her reported history includes satanic and sexual abuse as a child (the only common denominator in most DID diagnoses is severe and on-going childhood abuse and neglect).

Seven parts is a relatively small number for most reported DID cases - many reports have documented more than 10 and as many as 100 (although some of the parts in cases with such high numbers are little more than fragments of emotions belonging to one or more other parts).

Helen: The Woman with 7 Personalities

The Woman With Seven Personalities - Multiple Personality Disorder: Helen and Ruth were best friends at school. Helen, according to Ruth, was one of the prettiest and cleverest girls in the class. Whenever Ruth thinks of school she thinks of the fun times she shared with Helen. Soon after leaving school, however, they lost contact. Fourteen years later Helen and Ruth bumped into each other by chance on a train. As they sat together on the train, Helen told Ruth that she had Multiple Personality Disorder, claimed she had been satanically and sexually abused as a child and had tried to take her own life on a number of occasions. Since that meeting six years ago Ruth and Helen have begun to rekindle their old friendship. Helen wanted to make this documentary to raise awareness of Multiple Personality Disorder, now known as Dissociative Identity Disorder

This film follows Ruth on her journey of discovery into Helen's world. We accompany her as she gets to know her friend again, as she tries to find out what happened to Helen in the fourteen years they were apart and to understand what it means for Helen to live with Multiple Personality Disorder (MPD), which is now known as Dissociative Identity Disorder (DID).

Here is the list of Helen's inner family:

• Alex, A five year old boy who loves shooting toy guns.
• William, A six year old boy who loves the Mr. Men.
• Adam, A lovable ten year old boy who is not allowed to play outside.
• Brenda, An outspoken, feisty 13 year old girl
• Karl, A sixteen year old boy with an attitude and a temper.
• Jamie
• Elizabeth

Helen will switch from her self personality to one of the alter personalities at a moment’s notice and have no recollection of the time spent in the other personality. Under the personalities of Karl and Brenda, Helen would drink and take drugs. She became an alcoholic and overdosed over 100 times. She has since recovered from the alcoholism and the overdoses, were clearly not fatal.

Ruth was determined to discover what may have caused these personalities to form and was horrified when Helen confided in her that she had been extensively abused as a child and had created the first personalities to distance herself from the horrors. Karl and Brenda provide escape by causing physical pain by means of self-harm to block the emotional trauma, while the younger personalities allow escape to various ages of her childhood.

But wait, there's more . . . if you simply scroll down there is another documentary on dissociative identity disorder (multiple personalities to most folks). This is an old HBO documentary from the 1990s and, while our understanding of DID has increased considering, this one-hour show provides a basic introduction to the experience and development of DID.

Oh, and just in case you think we have moved beyond the idea that dissociative identities are demon possession (an idea raised in the film below), I have worked with people with DID who were told they were possessed by demons by their church pastors, and who tried an exorcism to pray the demons away. Needless to say, it did not work.

Multiple Personalities

Film by: HBO / Michael Mierendorf / Gloria Steinem
Year: 1993

In early times, evil spirits were thought to possess people and make them act in strange and frightening ways. By the 1800’s, the study of this hysteria led some doctors to believe one person could have separately functioning personalities.

In a rare research film from the 1920’s, a woman has different personalities who believes they are separate people. One is a male that is not comfortable in women’s clothes. Another is a small child. The affliction has been known by different names, but recognized for centuries. Today it is called multiple personality disorder.

Why have they become tormented and broken into different personalities? What is the childhood pain that lies buried in the unknown depths of their mind? How can they search for the deadly memories that holds the secrets of their paths and the promise of their healing?

Possession Trance Disorder - Who Knew?

I found this fascinating article at The Neurocritic, a very cool blog "deconstructing the most sensationalistic recent findings in Human Brain Imaging, Cognitive Neuroscience, and Psychopharmacology." The blog is posted with a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License, so here is the whole very interesting article.

The post begins with a small discussion of exorcism based on an episode of American Horror Story: Asylum, a series on FX. From there, however, he goes into a discussion of the available information Possession Trance Disorder, which I am saddened to see will not be in the DSM-5 (yet another of its flaws).

I am a little saddened, seriously, as a rational person who does not believe in spirit possession, to see this piece of cultural sensitivity removed from the DSM. I have actually had a client (Latina/Mexican/Catholic) who was "exorcised" by a woman working in a thrift store (not on the sale floor). The client was borderline DID at the time, with one very destructive (self-harm, suicide attempts) and the "exorcism" silenced the voices for several weeks, although they did eventually return.

As a therapist, it seems important to honor some aspects of other cultures and other belief systems. We do not have to believe them, but we can work within their worldview employing interventions we feel address the core issue(s).

Possession Trance Disorder in DSM-5

American Horror Story: Asylum takes place in 1964 at Briarcliff Manor, a terrifying mental institution for the criminally insane. The show uses every over-the-top stereotype in the book — straightjackets, isolation cells, shock treatment, the chronic masturbator, the nymphomaniac, the sadistic nun, the evil mad doctor, unethical experimentation, wrongful commitment, alien abduction, demonic possession, you name it — yet it still manages to be scary and stylish and suspenseful.

The episode about a poor soul possessed by the devil naturally includes an exorcism by Catholic priests. The afflicted boy becomes ugly and deformed by the demon, who spews out lewd words and exerts its supernatural telekinetic powers by throwing objects (and priests) across the room.

Regarding exorcism, the Catholic Encyclopedia says:

Exorcism is (1) the act of driving out, or warding off, demons, or evil spirits, from persons, places, or things, which are believed to be possessed or infested by them, or are liable to become victims or instruments of their malice; (2) the means employed for this purpose, especially the solemn and authoritative adjuration of the demon, in the name of God, or any of the higher power in which he is subject.

Religious belief in the existence of demons is a sincere part of the Catholic faith, so demonic possession can be a particularly frightening Hollywood trope for devout Catholics (and former Catholics). Walking out of the theater into the dark parking lot and entering your empty apartment after a midnight showing of The Exorcist can be creepy for the believer and the agnostic alike. Even if Satan isn't lurking in your shower, a serial killer like "Bloody Face" could be under your bed. Indoctrination into a belief system where devils are real can haunt a young child into adulthood.

In contrast, the rationalist perspective presents historical and medically-based views of possession phenomena in terms of epilepsy, schizophrenia, and possession trance disorder (PTD), a possible variant of dissociative identity disorder. Nothing evil or supernatural takes over the identity of the person with PTD. Nonetheless, exorcisms performed on mentally ill people continue to this day.

For example, Tajima-Pozo and colleagues (2011) reported on the case of a 28 yr old woman in Spain who had been diagnosed with paranoid schizophrenia. Over the course of 5 yrs she had been treated with the antipsychotic drugs clozapine, risperidone, ziprasidone and onlanzapine, without complete remission. She was an inpatient on a psychosis ward, and yet some diabolical priests managed to get in and convince her that she was possessed by demons. Some of the priests had knowledge of the patient's psychiatric history and should have known better. But they performed multiple exorcisms anyway, which disrupted her clinical treatment (1).

In DSM-IV, spirit possession falls under the category of Dissociative Disorder Not Otherwise Specified, with more specific research criteria (but not an official diagnosis) fitting Dissociative Trance Disorder (possession trance):

This category [DDNOS] is included for disorders in which the predominant feature is a dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific dissociative disorder.
. . . 

Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one's control. Possession trance involves replacement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person and associated with stereotyped involuntary movements or amnesia, and is perhaps the most common dissociative disorder in Asia. Examples include amok (Indonesia), bebainan (Indonesia), latah (Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious practice.

Note the culture-specific aspect of the disorder, which shows substantial heterogeneity in its expression. Dr. Romeo Vitelli at the blog Providentia has written about some of these phenomena. For instance, Amok is an aggressive trance-like state in Malay culture, whereas Pibloktoq is an acute dissociative reaction in the Inuit tradition, caused by evil spirits possessing the living. In two previousposts here at The Neurocritic, we also learned about cen in Uganda, ghosts that replace the identity of the afflicted individual.

Dissociative Disorders in DSM-5

Will there be changes for Dissociative Trance Disorder (DTD) in DSM-5? The new (and already reviled) psychiatric manual makes its debut in May 2013 (2). A 2011 paper by Spiegel et al. described some of the proposed changes to the dissociative disorders. The Pathological Possession Trance (PPT) component of DTD is claimed to be be similar to dissociative identity disorder (DID, or the diagnosis formerly known as "multiple personality disorder"):

It is a disorder of identity alteration that occurs during an altered state of consciousness. Of course, unlike DID, the alternate identity or identities in PPT are attributed to possession (by an external spirit, power, deity, or other person) rather than to internal personality states. Associated symptoms of PPT include stereotyped or culturally determined behaviors or movements that are experienced as being controlled by the possessing agent and/or full or partial amnesia for the event.So pathological possession trance would be included under DID, while dissociative trance without possession would remain under dissociative disorders NOS. Or...

Alternatively, DSM-5 could (a) retain all of DTD in DDNOS (and an appendix), or (b) incorporate DTD (or only PPT) as a new disorder.

“Possession” is a broader construct than PPT because it may be used as a nonspecific attribution for explaining events (e.g. illness, misfortune) that go beyond pathological identity alteration. By contrast, in PPT we focus only on the subset of possession experiences–(1) an alteration of consciousness wherein the person experiences his/her the identity as being replaced by an ancestor, spirit, or other entity (i.e. possession trance), and (2) these alterations are involuntary, distressing, uncontrollable, often chronic, and involve conflict between the individual and his/her surrounding social or work milieu (i.e. the possession trance is a pathological one).

Ultimately, the recommendation was to include PPT under the DID umbrella. The phrase “an experience of possession” would be added to Criterion A of DID.

Kibuuka Kigaanira (R) with a priestly assistant.

Photo Courtesy of Euginia Bonabana, from The Sunday Monitor [Uganda]

Alternate activism: From Kibuuka Kigaanira in the mid-19th century to Kalondoozi in the present, possession practices provide important political space for citizens to negotiate power and authority, while appointed leaders are held to account. 

-from Spirit possession and power play since pre-colonial times

Pathological Possession Trance: Perspectives from Uganda

Previously, I wrote about Spirit Possession as a Trauma-Related Disorder in Uganda and quoted from a personal narrative of spirit possession from Christine, a former child soldier. How well will the new DSM-5 criteria fit cen phenomena in Northern Uganda? The diagnosis for possession trance would now be DID. However, a recent paper by van Duijl et al. (2012) suggests this might be a nosological disaster for the classification of spirit possession in Uganda.

In their study, the authors collected narratives from 119 spirit possessed individuals. They also developed a checklist for locally relevant dissociative and possession symptoms.

The CDS-Ug is a locally designed checklist based on information obtained in focus group discussions with traditional healers, religious leaders, health professionals, and people of the community. It covers common and typical symptoms of dissociation and spirit possession, including:

• Okukangarana: described as being shocked by a situation in such a way that later on one cannot remember the situation (amnesia)

• Okurogwa: described as talking in a different voice, which others recognize as the voice of an (ancestral) spirit (possession trance)

• Eibugane: feeling influenced by unidentified forcescausing behavior different from one’s usual behavior

• Okukyekyera: traveling outside one’s home without remembering (fugues or ‘night dances’)

• Okusharara: feeling as if something from outside holds one’s body or mind so that one cannot move, think, or speak, which is attributed to an outer force (feeling paralyzed)

• Okugwa: shaking of the head or body, seen as an expression of spirits (involuntary repetitive movements)

• Okugamba endimi: speaking in tongues (glossolalia)

• Okwehindura: making sounds and movements as if one has become an animal, for example, a cock, monkey, or goat, without remembering this behavior afterward (possession by animal)Spirit possessed patients were asked whether and how these eight features applied to themselves.

The data were analyzed to examine possible clusters of symptoms, merged with a checklist developed from the personal narratives, and then compared to the old DSM-IV DTD criteria and the new DSM-5 DID criteria.

Two distinctive clusters emerged (3). One cluster included shaking, stereotyped movements, and speaking in voices of spirits ("active symptoms"). The second cluster included amnesia, fugues, and feeling paralyzed ("passive symptoms"). The passive symptoms were a better fit with DID, but the active symptoms were more like DTD. Furthermore, many symptoms fell outside either diagnosis:

...experiences such as hearing voices (e.g., of spirits or deceased), strange dreams, feeling influenced or held by powers from outside, feeling paralyzed, or moving around in fugue-like states are not explicitly covered by the experimental DSM-IV research criteria nor by proposed criteria for DID in DSM-5.

Overall, the authors felt the DSM-IV experimental criteria for dissociative trance and possession trance disorders encompassed the experience of spirit possession to a greater extent than the DSM-5 DID criteria. They do not think possession trance disorder should be subsumed under dissociative identity disorder, nor do they think dissociative trance and possession trance should be separate categories, as they occurred on a continuum in this Ugandan population. Instead, a more culturally-inclusive mindset might have prevented some of the DSM-5 changes from moving forward.

Although the presentation of DID and PTD considerably overlaps and both are covered by the criteria outlined in Table 3, we are not in full support of this approach. Ranking PTD (described in over 360 societies) under DID (described in considerably fewer societies) expresses a Western ethnocentric approach. Ranking characteristic symptoms of PTD such as stereotyped uncontrolled movements as ‘non-epileptic seizures or other sensory-motor (functional neurological) symptoms’ in DSM-5 also heavily imposes a medical descriptive framework and disregards emic attributions. In addition to this, DID is strongly associated with early childhood sexual abuse and neglect, whereas stressors associated with PTD are more broadly framed and require a culturally sensitive approach. 

In DSM-5, Possession Trance Disorder no longer exists.

Footnotes

1 Besides being backwards and barbaric, exorcisms can be deadly, as this case of Fatal Hypernatraemia from Excessive Salt Ingestion During Exorcism shows. Ingestion of salt or salt water is part of the ritual.

2 If you want to know why it's already reviled, start here and follow links. Or Google DSM-5 controversy. I don't feel a need to offer my opinion at the present time.

3 These two clusters could account for ~46 % of the variance.

References

Duijl, M., Kleijn, W., & Jong, J. (2012). Are symptoms of spirit possessed patients covered by the DSM-IV or DSM-5 criteria for possession trance disorder? A mixed-method explorative study in Uganda. Social Psychiatry and Psychiatric Epidemiology DOI:10.1007/s00127-012-0635-1

Spiegel, D., Loewenstein, R., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., Cardeña, E., & Dell, P. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28 (9), 824-852 DOI:10.1002/da.20874

Tajima-Pozo, K., Zambrano-Enriquez, D., de Anta, L., Moron, M., Carrasco, J., Lopez-Ibor, J., & Diaz-Marsa, M. (2011). Practicing exorcism in schizophrenia Case Reports, 2011 (feb15 1) DOI:10.1136/bcr.10.2009.2350

One of the experiential aspects of post-traumatic stress for those who have Complex PTSD (often associated with repeated childhood or adult sexual trauma) is the experience of depersonalization (feeling that one’s body is unfamiliar or strange) and/or derealization (feeling that one’s surroundings are unreal or unfamiliar), both of which are types of dissociation.

A third experience, known as structural dissociation, is the experience of different "selves" taking over the personality. This can range from the experience of one's wounded "inner child" acting out all the way to distinct personalities with names and characterological differences (dissociative identity disorder). Often the experience is somewhere in the middle - the primary self experiences lost time, "absent mindedness," and may told s/he acts like different people sometimes. This is usually the experience of different "stuck" parts of the self taking over, but it can also be specific subpersonalities or parts [mangers] whose job it is to manage stress and anxiety.

This recent study form the Archives of General Psychiatry identified a subgroup of highly dissociative survivors (about 12% of individuals with a current diagnosis of PTSD), as well as a low-severity group and high-severity group. 

The [dissociative] 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.

The researchers suggest that this finding may be sufficient for a dissociative PTSD subtype in the DSM-5, but that is hardly what is needed, in my opinion.

Rather, in my opinion we need:

(1) A developmental trauma criteria, since the experience of trauma during development creates whole different kind of wounding than later trauma [which may also be seen in those who develop structural dissociation];

(2) A Complex PTSD criteria for those who experience repeated and/or on-going trauma, which, again, creates a different collection of symptoms when the wounding manifests in the personality; and

(3) A single-episode PTSD criteria for those who experience a unique traumatic event (natural disaster, terrorist attack, etc.) and experience some of the various symptoms of PTSD, such as hyper-vigilance, hyperarousal, acute anxiety, depression, and nightmares/flashbacks. This final category is unlikely to experience the dissociation with which survivors in the first two categories generally have to deal.

In fact, in my opinion, nearly all "mental illness" is the result of physical, emotional, and/or psychological trauma - i.e., it's all relational (aside from the very few organic issues). This should be the basis for our "diagnostic manual."

But for now, at least psychiatrists believe dissociation is real (for a while, the majority opinion was that patients were only seeking secondary gain).

New ‘Unreal’ Subtype of PTSD Proposed

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on July 4, 2012 

 

A provocative new study suggests that dissociation is associated with one form of post-traumatic stress disorder (PTSD).

Dissociation typically reflects problems in consciousness and awareness. Understanding that the course of PTSD may take alternative paths is an important discovery for treatment of the disorder.

Researchers discovered dissociation is often associated with unique PTSD symptoms of derealization, the feeling that one’s surroundings are unreal or unfamiliar, and depersonalization, or the feeling that one’s body is unfamiliar or strange.

Researchers studied PTSD and dissociative symptoms in 492 veterans and their intimate partners, all of whom had histories 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.

Clinicians interviewed participants with the Clinician Administered PTSD Scale (CAPS), a diagnostic instrument that measures the frequency and severity of PTSD and dissociation symptoms.

Analysis revealed a small but distinct subset of participants characterized by high symptoms of dissociation and PTSD along with high rates of sexual assault history.

Researchers believe the findings contribute to a growing body of research, which could provide a basis for adding the new dissociative subtype distinction to the PTSD diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The study was led by Erika J. Wolf, Ph.D., and Mark W. Miller, Ph.D., both from the National Center for PTSD at the VA Boston Healthcare System and Department of Psychiatry at Boston University School of Medicine.

“This study helps to identify a small group of individuals who show a unique pattern of post-traumatic symptoms marked by derealization, or feeling that one’s surroundings are unreal or unfamiliar, and depersonalization, or feeling that one’s body is unfamiliar or strange,” said Wolf.

“The results clarify that these symptoms are not a core part of PTSD for most people with the disorder. However, identification of this group of individuals is important for maximizing PTSD treatment effectiveness.”

The study findings are published in the journal Archives of General Psychiatry.

Source: Boston University Medical Center

Full Citation:
Wolf EJ, Miller MW, Reardon AF, Ryabchenko KA, Castillo D, Freund R. (2012, Jul). 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.

Here is the abstract for the study:

ABSTRACT

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.

New Research Supports Diagnosis of Dissociative Identity Disorder in Some Survivors of Trauma

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:

Fact or Factitious? A Psychobiological Study of Authentic and Simulated Dissociative Identity States

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).

A Latent Class Analysis of Dissociation and Posttraumatic Stress DisorderEvidence for a Dissociative Subtype

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.