Causes of Dissociative Identity Disorder

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The causes of Dissociative Identity Disorder are highly debated, but fall under two models. The first is the Posttraumatic model, which predicts that there is a correlation between the frequency of DID and childhood trauma, and that the incidence of dissociation is a means of coping with the trauma experienced[1] [8] The other is the Sociocognitive model, in which a number of factors, including social cues, influence from psychotherapists and personality type of the individual contribute to the diagnosis of Dissociative Identity Disorder, but does not include the possibility of conscious malingering. It also attributes the level exposure a certain culture receives to the idea of dissociation to incidences of DID (Spanos 1985)[1][8]. The continual revision of these two models is important in the detection and proper treatment of Dissociative Identity Disorder.

Posttraumatic Model

The posttraumatic model, presented by Putnam in 1989 hypothesizes that patients who have experienced chronic sexual or physical abuse as a child react to such trauma with incidences of pathological dissociation, such as dissociative fugue, schizophrenia or dissociative identity disorder1. The premise behind the model is that dissociation provides a means of coping with traumatic life events, a way of spreading the emotional distress around multiple “selves” [9]. This model is fundamentally different from the Sociocognitive model in that trauma leads to dissociation, regardless of cultural factors, or “contamination” (in which people are influenced by portrayals of DID in the media, or taught about it in school). In a study done by Ross et.al in 2008, participants who had experienced similar levels of childhood trauma in separate cultures, one where DID is widely recognized and one with virtually no “contamination”, still reported similar levels of dissociation, which is consistent with the trauma model of dissociation[8].

Causes of DID
A woman diagnosed with DID describes her experience growing up in an
abusive environment and how she used the creation of alters to help her cope.
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Childhood Abuse/Trauma

The bulk of the published research surrounding the trauma model of DID focuses on the role of childhood abuse and trauma. Both emotional and physical abuse in childhood as well as the relationship between the child and the instigator of the abuse are linked to dissociation in adolescence[3][5][7]. In a study conducted in (2009) it was found that dissociation seems to be a middle ground between maltreatment in childhood and borderline personality disorder[7]. The creation of multiple “self-states” helps the child adequately deal with what has happened to them and helps stabilize their emotional instability[5][7][9]. In (2009), the relationship between auditory hallucinations in dissociative disorders and traumatic stress during childhood was studied in 3 groups: schizophrenic patients with and without a history of childhood maltreatment, and DID patients. The authors used structured interviews and the Childhood Trauma Questionnaire (CTQ) and it was found that the highest volume and variety of auditory hallucinations was experienced by individuals suffering from DID. It is noteworthy that the content of these hallucination were either surrounding someone influential in the patient’s life, or replaying a memory of a stressful event[3]. This can be explained by speculating that the severity of the experienced childhood trauma experienced was to such an extent that it initially dissociated from the child’s conscious awareness, and thus when the individual later recalls the incident it feels as though it had never been experienced before i.e. it was a hallucination[3].

Early Childhood Attachment/Parenting

The environment in which a child grows up can also influence incidences of DID. In a study done in 2009, the Dissociative Experiences Scale (DES) was used to draw a link between dissociation in adulthood and negative upbringings as a child (level of parental warmth, conflict between parents, and general neglect that is common in abusive environments). It was found that when parents do not establish a proper support system for their children during stressful life experiences, the proper integration and consolidation of memories being formed is impacted; the child may use dissociation to organize and deal with their distress. Interestingly, it was also found that for similar levels of childhood abuse, those with a more supportive familial environment while growing up were less likely to develop a dissociative disorder[6].

In addition, the individuals own personal security and attachment style, which is determined at birth, can also mark a predisposition for dissociation. Childhood abuse and stress can lead to insecurity in adolescence, which is a risk factor for development of psychological disorders such as dissociation [2].

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The Role of Stress

Stress has been hypothesized as a contributing factor to the diagnosis of DID. In 2003, Williams et al. induced stressful experiences by way of recreation of a stressful memory and compared them to dissociative episodes and neutral emotional events (such as making a pot of coffee) in a woman with diagnosed DID to test the role of stress in dissociation. It was found that when she relived the stressful memory, a decrease in heart rate was found (marking a decrease in arousal; she calmed down) and she recalled having experienced dissociation, as if she was watching the event as an outsider. Thus, dissociation decreased heart rate in stressful situations and it can be extrapolated that dissociation is used by individuals with DID as a defence mechanism to deal with traumatic experiences[4][9].

Sociocognitive Model

The Sociocognitive model as one of the etiologies of Dissociative Identity Disorder, presented by Spanos in 1994, states that individuals can, unknowingly, act as though they have multiple personalities due to a number of factors, including influences from their environment, the media, and psychotherapeutic interventions[13].

Social Contamination

Social contamination is the acknowledgement of any given phenomenon by any given culture and society. DID has been recognized as a disorder in certain societies though media (books, movies, etc.), scientific inquiry and knowledge. DID is taught in medical schools such that therapists are made aware of its existence[1]. Based on the Sociocognitive model, the exposure to the concept of DID can be sufficient to induce DID in some patients[14].

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Role of Social Interaction

The motivation for people with a histrionic personality type to yearn for the diagnosis of DID is motivated by social factors, such as attractive portrayals of DID in the media. DID patients shown in movies or brought on as guests on TV talk shows are glorified as having dramatic switching between alters, the attention of many health care professionals, and a loving support system[11]. In 1994, a hospitalized 17 year old began experiencing symptoms of DID after viewing a movie where the main character had DID[11]. Additionally, while self-help groups and workshops act to offer support to those with genuine DID, they also legitimize the disorder, which worsens the problem for those with malingered or a less severe form of DID[11].

Iatrogenesis

Iatrogenesis and the effectiveness of treatment is a widely debated concept in studying the etiology of DID. In iatrogenesis, psychotherapists unknowingly prompt patients to reveal dissociative symptoms that may not actually have priorly existed[13]. DID can sometimes be a “hidden” disorder, where patients might not be aware of alternate “selves” or do not display outward symptoms of the disorder until provoked in treatment. Upon discovering that the patient does not remember any childhood maltreatment or abuse, therapists often use suggestive methods, attempting to uncover abusive memories that may or may not be genuine[11]. Extrapolating from this, there is a tendancy for the patients to desire conforming to a view of DID from what they have been exposed to in the media. In addition, the therapist’s expectation of the patient’s condition plays a major role in how the patients view themselves. Also, there is a possibility that some clinicians are not adequately trained in the treatment of DID and may act to ignore/suppress the individuals alters, which has been shown to be harmful to the patient. It is the belief of Brand et al. that treatment of DID is not as comprehensive as it should be, and may contribute to iatrogenesis[10].

Personality Type

There is evidence that a histrionic personality type is linked to a diagnosis of factitious/malingered Dissociative Identity Disorder. A study done in 2001 which compared cases of malingered DID with genuine DID revealed that patients who were malingering tended to score higher on the Dissociative Experiences Scale (DES) due to the fact that they are motivated by wanting a diagnosis of DID. Additionally, malingerers did not experience any dissociative amnesia, which is consistent with genuine DID patients who are unable to integrate memories of different alters, and they did not display other symptoms characteristic of genuine DID (such as discomfort in group settings where disturbing memories can easily be triggered by something that someone says)[12].

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State of Controversy Between the Two Models

The legitimacy of these two models has been continually debated, with new evidence emerging to weaken one or the other. For example, the fact that therapists are able to unveil untrue memories of abuse from patients after some prodding weakens the claims of the trauma model[11], whereas a study done in 2008 refuted the findings of the previous paper. This study compared two groups of patients who experienced similar levels of childhood trauma from different cultures (one where there was a high level of social contamination of DID, and one with virtually no knowledge of the disorder). If the Sociocognitive model is accurate, there should be no incidences of DID in cultures with no contamination, but that is not what was seen. Both groups reported very similar dissociation levels, consistent with the trauma model[8]. The debate over which model is the most accurate is ongoing. It is safe to suggest that further investigation is needed to determine which model is more encompassing of this disorder.

Bibliography
1. Xiao, Z et al. Trauma and Dissociation in China. American Journal of Psychiatry. 163(8): 1388-1391 (2006).
2. Riggs, S et al. Family Environment an Adult Attachment as Predictors of Psychopathology and Personality Dysfunction among Inpatient Abuse Survivors. Violence and Victims. 22(5): 577-601 (2007).
3. Dorahy, M et al. Auditory Hallucinations in Dissociative Identity Disorder and Schizophrenia With and Without a Childhood Trauma History. The Journal of Nervous and Mental Disease.197(12):892-898 (2009).
4. Williams, C et al. Psychophysiological Correlates of Dissociation in a Case of Dissociative Identity Disorder. Journal of Trauma and Dissociation.4(1): 101-118 (2003)
5. Dale, K et al. Testing the Diagnosis of Dissociative Identity Disorder Through Measures of Dissociation, Absorption, Hypnotizability and PTSD: A Norwegian Pilot Study. Journal of Trauma and Dissociation.10: 102-112 (2009)
6. Dutra, L et al. Quality of Early Care and Childhood Trauma: A Prospective Study of Developmental Pathways to Dissociation. Journal of Nervous and Mental Disorders. 197 (6): 383-390 (2009).
7. Sar, V et al. Childhood Emotional Abuse and Dissociation in Patients with Conversion Symptoms. Psychiatry and Clinical Neurosciences.63:670-677 (2009)
8. Ross, C et al. A Cross-Cultural Test of the Trauma Model of Dissociation. Journal of Trauma and Dissociation. 9(1): 35-49 (2008)
9. Gleaves, D. The Sociocognitive Model of Dissociative Identity Disorder: A Re-examination of the Evidence. Psychological Bulletin. 120(1): 42-59 (1996).
10. Brand B, Loewenstein R. Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative? Journal of Trauma and Dissociation.15: 52-65 (2014).
11. Spanos, N.P. Multiple Identity Enactments and Multiple Personality Disorder: A Sociocognitive Perspective. Psychological Bulletin 116(1): 143 – 165 (1994).
12. Thomas, A. Factitious and Malingered Dissociative Identity Disorder: Clinical Features Observed in 18 Cases. Journal of Trauma & Dissociation 2(4): 59 – 77 (2001).
13. Powell, A.P. et al. Dissociative Identity Disorder and the Sociocognitive Model: Recalling the Lessons of the Past. Psychological Bulletin 125(5): 507 – 523 (1999).
14. Mueller-Pfeiffer, C. et al. Global functioning and disability in dissociative disorders. Psychiatry Research 200: 475 – 481. (2012)

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