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Etiology of Dissociative Identity Disorder

Aetiology of DID

The nature and, indeed, existence of ‘true’ DID, have been as hotly debated as the existence of recovered memories, and the arguments are very similar (see, for example, Piper and Merskey 2004). Such is the level of debate that even some studies of this disorder remain neutral about its nature and aetiology. Elzinga et al. stated, for example, that they adopted a ‘pragmatic stance  .  .  .  without making a priori claims about the nature of so-called “identities”’. Some contend that its existence is self-evident, and that there are too many people experiencing these symptoms to deny the reality of the problem. Others reject the concept, arguing that the symptoms are invented by the individuals reporting them, or even implanted in their consciousness by over-zealous therapists. The two dominant theories of DID are that it is either the result of childhood trauma or a socially constructed system created by the affected individual and shaped by the therapist.

Childhood trauma

There are relatively few studies of DID – perhaps because of the low prevalence of the condition. However, what evidence there is suggests that it is associated with childhood trauma. Boon and Draijer, for example, reported that 94 per cent of the series of people diagnosed with DID in their sample reported a history of childhood physical and/or sexual abuse. Proponents of the childhood trauma model suggest that the experience of severe trauma during childhood produces a mental ‘splitting’ or dissociation as part of a defensive reaction. The abused child learns to dissociate, or enter a self-induced hypnotic state, placing the memory of the abuse in the subconscious as a means of coping with the trauma. These dissociated parts of the individual ‘split’ into alter personalities that, in adulthood, manifest themselves to help the individual cope with stressful situations and express resentments or other feelings that are unacceptable to the primary personality.

Taking a similar approach, Putnam (1997) proposed a developmental model of these phenomena. He suggested that traumatic environments prevent children from completing the developmental task of consolidating an integrated sense of self from what he termed the ‘discrete behavioural states’ – involving cognitive and emotional functioning – which predominate in infancy. He suggested that normal caregiving environments facilitate integration of these differing states into a single integrated whole. Trauma actively inhibits this integration. Instead, the child develops a series of separate states that are adaptive to their parental behaviours.

Socio-cognitive model

By contrast, socio-cognitive theorists have argued that DID is a set of beliefs and behaviours constructed by the individual in response to personal stress, therapist pressure and societal legitimization of the construct of ‘multiple personality’. They suggest that DID has become a legitimate way for many people to understand and express their failures and frustrations, as well as a tactic for the manipulation of others. According to this account, individuals diagnosed as having DID learn to portray themselves as possessing multiple selves and to reorganize and elaborate on their personal biography to make it consistent with their understanding of what it means to be a ‘multiple’. That is, they actively construct their various selves. They argued that psychotherapists have contributed to the development of this disorder by encouraging clients to construe themselves in this way and by providing offi cial legitimation for the different identities their patients enact.

The battleground of DID

A number of issues have been identified as the ‘battleground’ of evidence in relation to DID: DID and child abuse Findings that people with DID report extremely high rates of repeated and frequent childhood sexual or physical abuse have led some theorists to suggest that dissociation as a result of repeated sexual abuse is a defi ning characteristic of DID. In response to this, Piper and Mersky (2004) noted that many cases were entirely uncorroborated, relying on patient accounts, or when evidence was claimed, this was generally weak. In addition, Spanos (1994) argued that the apparently high level of association between child sexual abuse and the phenomenon of DID may be spurious and the result of therapist and client beliefs about the nature of the phenomenon. He suggested that:

Child sexual abuse is relatively common in the USA, and rates are particularly high among those who seek psychiatric help. High rates among people who develop DID may therefore be indicative of these high background rates rather than risk for DID.

Because some clinicians consider a history of sexual abuse to be a possible sign of DID, they may be more likely to expose abused than non-abused patients to hypnotic interviews and other procedures that result in ‘multiplicity’. Some patients with DID do not remember being abused until their multiplicity is discovered in the course of therapy. Any recovered memories should be treated with some caution.

Therapists may disbelieve DID patients who claim not to have been abused and may probe repeatedly in an attempt to unearth such memories. When patients believe they may be fantasizing, their uncertainty may be presented to them as evidence that they are unwilling to face the fact of their abuse (Bliss 1986). Many patients with DID report not just sexual abuse but also that this was ritualistic and long-term.

These histories are usually identifi ed following a series of leading questions under hypnotic suggestion, and none have been found to be substantiated. Some of the data related to abuse are not in accordance with data on memory recall and typical patterns of abuse. Ross et al. (1991) reported on the age of earliest sexual abuse reported by their patient group. Over a quarter reported being abused before the age of 3 years, and 10 per cent reported being abused before the age of 1 year. These ages are much younger than is typical in cases of sexual abuse and prior to the establishment of neural substrates that permit long-term recall. Problems of prevalence The prevalence of DID has changed over time, increasing substantially since the 1980s. Foote et al. (2006), for example, found that 29 per cent of admissions to one US inner city psychiatric hospital were diagnosed with DID. A number of authors have argued that if DID were a naturally occurring state, this degree of change would not occur, and that it represents an increase in the social construction of the condition by therapists and clients. They noted that among ‘investigators who are sympathetic to DID’, diagnostic rates are extremely high. Modestin’s  survey of Swiss psychiatrists, for example, suggested that about 1 per cent of cases within their psychiatric system were diagnosed as having DID.

In addition, while 90 per cent of the psychiatrists he surveyed had not seen a case of DID, three reported seeing more than 20 people with the disorder: 66 per cent of the cases were reported by less than 0.1 per cent of the psychiatrists surveyed. He suggested that these clinicians may have either misidentifi ed symptoms as evidence of DID or encouraged their clients to construct various manifestations of the disorder. Defenders of DID have responded to this argument by suggesting that it is not surprising there were differences in observation rates among differing clinicians. According to Kluft, this may have resulted from different referral rates, an unwillingness among some clinicians to give a diagnosis of DID, and a reluctance among the same clinicians to ask the questions that would lead to this diagnosis being assigned. He also suggested that the increase in reported prevalence may be a function of previous misdiagnoses as a result of it being a relatively new diagnostic category, increased awareness of the prevalence and problems of child abuse, and increased interest in dissociative states. A further critique of the incidence issue is provided by Piper and Mersky who noted that while there has been a massive rise in the reported prevalence of DID, there has been no corresponding rise in reported levels of child abuse. In addition, Kihlstrom noted that prospective studies of traumatized children have revealed no convincing cases of DID.

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