Controversy Regarding and Validity of DID

Dissociative identity disorder (DID), though now validated by more research than ever before, is still considered by some to be controversial, extremely rare, or even iatrogenic or sociocognitive in origin. The most common reasons for this are as follows:

• It is incorrectly assumed that there are no valid or very few valid examples of DID in children.
• It is incorrectly assumed that DID is an American or Western phenomena.
• It is incorrectly assumed that DID that is iatrogenic or sociocognitive could match genuine DID.

Each of the above assumptions are individually refuted within the following pages. Other concerns that have been expressed include:

• It is incorrectly believed that alters have not been clearly defined.

This was true for older literature, but alters are very clearly defined in the theory of structural dissociation, the most current model of dissociative conditions and DID. Within this theory, alters are defined as sufficiently developed and differentiated apparently normal or emotional parts. These apparently normal parts (ANP) and emotional parts (EP) are present in conditions ranging from posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) to other specified dissociative disorder subtype 1 (OSDD-1) and DID, but the alters of DID are definably different from those of less complex dissociative conditions. The EP of PTSD is a simple traumatic container that holds memories, perceptions, emotions, or reactions associated with trauma while the EP that are with associated with DID can hold more of a unique perception of self and are more aware that the trauma is not continuing in the present. Unlike the one ANP of PTSD, the multiple ANP of DID each handle unique aspects of daily life, experience some degree of personal amnesia with each and EP, and engage in avoidance of EP in order to avoid traumatic intrusions.

• It is incorrectly believed that symptoms of DID start only after diagnosis and treatment.

Some of the symptoms of DID might become visible after diagnosis or treatment, but many are present before this point. One study reports corroboration of DID patients’ symptoms prior to diagnosis at 73% and prior to therapy at 67% (Gleaves, Hernandez, & Warner, 1999).¹

Appropriate DID treatment is unlikely to cause additional or worsened dissociative symptoms as it measurably leads to patient improvement. It lowers self-injurious behaviors, leads to fewer hospitalizations, and increases adaptive functioning. As well, self reports of DID patients in the later stages of treatment indicate lower levels of dissociation, PTSD, and distress (Brand et al., 2009).² Another study examines 135 patients with DID after two years of treatment, and it shows that treatment leads to improvement on Schneiderian first rank symptoms, mood and anxiety disorder symptoms, dissociative symptoms, and somatization as well as to less psychiatric medication being prescribed. Integration is associated with more signification improvement (Ellason & Ross, 1997).³ Yet another study validates these results with self reports of decreased levels of dissociation, posttraumatic stress disorder symptoms, general distress, drug use, physical pain, and depression after 30 months of treatment in addition to increased socializing, attending school or volunteering, and feeling good. The patient reports were confirmed by therapist reports of less self-injurious behavior, fewer hospitalizations, and increased global assessment of functioning scores and adaptive capacities over time (Brand et al., 2012).⁴

• Because DID has not been uniformly studied throughout history, it is incorrectly believed that DID was almost nonexistent before the 1970s.

This is addressed in DID in History.

• It is incorrectly believed that it has not been proven that DID results from child abuse.

The theory of Structural Dissociation relies on the assumption of childhood abuse, and the neurological differences between ANP and EP support this assumption as do the neurological similarities between those with DID and those with PTSD. DID patients have smaller hippocampal and amygdalar glands, something seen in those who were abused as children and have PTSD (Vermetten, Schmahl, Linder, Loewenstein, & Bremme, 2006).⁵ As well, one study confirmed childhood abuse in eight out of nine cases of DID and all twelve cases of DDNOS (OSDD-1) examined (Coons, 1994).⁶ At least 79% of those with DID meet the criteria for PTSD (Ellason, Ross, & Fuchs, 1996)⁷, though other studies place the number at 89% (Brand et al., 2009)². Another study found that 98.1% of individuals with DID experienced child abuse (Ross, 1997).³

• It is incorrectly believed that DID is rare, occurring in only .01% of the population.

This is addressed in Prevalence.

• It is incorrectly believed that the majority of professionals do not believe in DID.

In a study completed in 1998, a survey of 425 doctoral-level clinical and counseling psychologists assessed beliefs about the existence and prevalence of DID as well as the clinician's familiarity with the research and how many individuals the clinicians had encountered who either had or had feigned DID. It was found that 79% of clinicians surveyed believed that DID is a valid diagnosis, and only 8% believed that DID is not a valid diagnosis. 59% of respondents indicated belief that DID affects between 0.1-0.5% of the population, and 65% believed that DID occurs cross-culturally. 85% attributed DID to child abuse, and 55%, 51%, and 76% respectively rejected the notion that it can be created through hypnosis, iatrogenically, or sociocognitively. All of this was despite the majority of respondents being only somewhat, slightly, or not at all familiar with research about DID; familiarity with the research was negatively correlated with skepticism. 38% of respondents had had a patient with DID, and contrary to popular belief, the mean number of such patients was 2.06 with a standard deviation of 6.16; it was not a select group treating all cases of DID (Cormier & Thelen, 1998).⁸ Similar response rates were produced at the time from the Netherlands, in which 18.8% of 1,452 psychiatrists indicated having made at least one diagnosis of DID (Sno & Schalken, 1999).⁹ The number of professionals who believe in DID has only increased since then as more evidence has been produced to support the existence of the disorder, and known prevalence of the disorder and its existence in other countries have also increased with additional research.

• It thought that because the FMSF petitioned to have DID removed from the DSM-5, DID is not a valid disorder.

That DID is still in the DSM-5 should be answer enough. The American Psychiatric Association only removes disorders from the DSM if enough reason is empirical reason is given for them to do so. That DID was not removed indicates that attempts to prove it invalid or even iatrogenic have not been successful. The DSM-5 still associates DID with childhood trauma and does not mention any concerns about the diagnosis not being legitimate. Regardless, the many unscientific and sometimes shady practices of the False Memory Syndrome Foundation are addressed here.

• It is incorrectly believed that because cultural influences and therapists can have an impact on alter presentation, alters are created by cultural influences or therapists.

A journal oriented towards both psychiatry and law addressed this in 1999. The decision was that suggestive influences in therapy have not been proven to any satisfactory degree to be capable of creating DID. While the frequency and type of alter behavior can be influenced in patients who already have DID, this is not the same as alters being created where there were none before. The same article addresses recantations of DID, attributing some of these accusations of iatrogenesis to influences of false memory syndrome proponents after the end of treatment and others to factitious behaviors on the part of the patient (Daniel, Edward, & Alan, 1999).¹⁰

Additionally, it should be remembered that it is common for culture to impact how "individuals display and communicate their symptoms, how such symptoms are interpreted, and what type of care is sought" (Dorahy et al., 2014).¹¹ This is not unique to DID but has also been found to be true for eating disorders, personality disorders, depression, schizophrenia, and anxiety disorders (Dorahy et al., 2014).¹¹

• Some particularly tactless individuals insist that because DID was not found in Holocaust survivors, DID must not be genuinely created by trauma.

While Holocaust survivors certainly experienced the severe, repeated trauma that is necessary for the formation of DID, that alone is not enough to cause the disorder. The trauma must be something that the child (DID can only form before the personality has completely solidified, and this event is generally placed around six years of age) can’t integrate into their psyche, and this usually occurs when the child is trapped in a situation in which it’s more dangerous for them to be aware of the trauma than to be ignorant of large portions of their life. In contrast, it would have been deadly for a victim of the Holocaust to be unaware of the horrors around them while they were still trapped within them. Many Holocaust survivors developed Dissociative Amnesia or repressed memories of the Holocaust after it was over (Hart & Brom, 2000),¹² but it would have been unproductive for them to have had separate awareness of the Holocaust while they were still being victimized. Survivors were tasked with survival at all times and at no time had to deny this need to survive in order to survive. Additionally, those who survived the Holocaust were under no consistent outside pressure to deny their reality. In general, everyone around them was aware of the Holocaust (save for those few who manage to ignore all evidence in favor of advancing their own agenda), and the survivors could rely on each other for support. Those who were forced into ghettos and concentration camps were, at least originally, still connected with the family, friends, and community that was forced in beside them. Even when isolated and moved elsewhere, the victims learned to form new connections in order to survive. Upon their release, they weren’t isolated and silenced. While parts of the world may have wished to ignore their stories, the world as a whole made a promise never to forget what happened to them. Israel was formed for the Jewish survivors, and many memorials were erected as a testament to what the Holocaust survivors had been through. Even if individual survivors were left without adequate support, they would not have had to dissociate their awareness of the Holocaust in order to survive in a world that refused to acknowledge their existence. While what survivors of the Holocaust or any other such tragedy experienced was undeniably traumatic, trauma of that sort doesn’t provide all of the aspects necessary for the formation of DID.

¹ Gleaves, D., Hernandez, E., Warner, M. (1999). Corroborating premorbid dissociative symptomatology in dissociative identity disorder [Abstract]. Professional Psychology: Research and Practice, 30(4), 341-345. doi: /10.1037/0735-7028.30.4.341

² Brand, B., Classen, C., Lanins, R., Loewenstein, R., McNary, S., Pain, C., Putnam, F. (2009). A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specific patients treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 153-171. doi: 10.1037/a0016210

³ Ellason, J., & Ross, C. (1997). Two-year follow-up of inpatients with Dissociative Identity Disorder. American Journal of Psychiatry, 154(6), 832-839. Retrieved from http://www.rossinst.com/treatment_outcome.html

⁴ Brand, B. L., McNary, S. W., Myrick, A. C., Classen, C. C., Lanius, R., Loewenstein, R. J., Pain, C., & Putnam, F. W. (2012). A longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 5(4),301-308. doi: 10.1037/a0027654

⁵ Vermetten, E., Schmahl, C., Lindner, S., Loewenstein, R., & Bremner, J. (2006). Hippocampal and amygdalar volumes in Dissociative Identity Disorder. American Journal of Psychiatry, 163(4), 630-636. doi: 10.1176/appi.ajp.163.4.630

⁶ Coons, P. (1994). Confirmation of childhood abuse in child and adolescent cases of multiple personality disorder and dissociative disorder not otherwise specified [Abstract]. The Journal of Nervous and Mental Disease, 182(8), 461-4. doi: 10.1097/00005053-199408000-00007

⁷ Ellason, J., Ross, C., & Fuchs, D. (1996). Lifetime Axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry: Interpersonal and Biological Processes, 59(3), 255-266.

⁸ Cormier, J. F., & Thelen, M. H. (1998). Professional skepticism of multiple personality disorder. Professional Psychology: Research and Practice, 29(2), 163-167. doi:10.1037//0735-7028.29.2.163

⁹ Sno, H., & Schalken, H.F.A. (1999). Dissociative identity disorder: Diagnosis and treatment in the Netherlands [Abstract]. European Psychiatry, 14(5), 270-277. doi:10.1016/S0924-9338(99)00171-6

¹⁰ Daniel, B., Edward, F. J., & Alan, S. W. (1999). Iatrogenic dissociative identity disorder—An evaluation of the scientific evidence. Journal of Psychiatry & Law, 27(3-4), 549-637.

¹¹ Dorahy, M., Brand., B, Sar, V., Kruger., C, Stavropoulos, P., Martinez, A., ... Lewis-Fernandez, R. (2014). Dissociative identity disorder: An empirical overview. Australian and New Zealand Journal of Psychiatry, 48(5), 402-417. doi: 10.1177/0004867414527523

¹² Hart, O., & Brom, D. (2000). When the victim forgets: Trauma-induced amnesia and its assessment in Holocaust survivors. In R. Yehuda, A. C. McFarlane, & A. Y. Shalev (Authors), International handbook of human response to trauma (pp. 233-248). New York: Kluwer Academic/Plenum Press.