Introduction
Dissociative identity disorder (DID) is a recognized mental disorder characterized by the presence of several personality states that can dominate a patient’s behavior. The diagnosis involves assessing subjective experiences and self-reports provided by the patient, which can be a challenging task. Additionally, some symptoms of DID overlap with other mental disorders, such as borderline personality disorder, post-traumatic stress disorder, and bipolar disorder. The validity of this diagnosis is still a topic of debate among mental health professionals.
Researchers agree on the fact that the syndrome exists; however, what is questioned is how the separate identities under DID develop. One approach suggests that a history of severe childhood trauma is the decisive factor. However, there is also another approach that suggests that DID alters are primarily caused by the professionals’ actions and patients’ fantasy proneness. This paper will focus on assessing both approaches and evaluating which one is more supported by evidence, while also arguing that a combined approach is appropriate.
The Trauma Model
Description
The trauma model of dissociative identity disorder suggests that the disorder is a coping mechanism that develops in response to severe traumatic events that usually take place in childhood. According to this model, dissociation is a natural response to trauma and serves as a way to protect the individual from the full impact of the experience (Lynn et al, 2019a). In this case, it is suggested that the mechanisms of trauma reactions in DID are similar to those in post-traumatic stress disorder (PTSD). Most research is dedicated to finding the link between brain responses in dissociative PTSD and dissociative identity disorder.
Evidence
Understanding brain activity in relation to trauma is the most critical aspect of proving trauma causation of DID. Reinders & Veltman (2020) provide an example of a 2003 study that “revealed personality-state-dependent processing of neutral and trauma-related autobiographical memory scripts”. The following study, also discussed by Reinders & Veltman(2020), was focused on the differences in the brain processing of people diagnosed with DID and those who showed different levels of fantasy proneness.
The study’s results demonstrated significant differences in brain activity responses. Finally, brain activity responses of patients diagnosed with DID were compared with those diagnosed with dissociative PTSD, showing similar patterns between the two (Reinders & Veltman, 2020). All these studies serve as proof of DID developing as a trauma response.
There is also neurostructural evidence for the relation between trauma and DID. A smaller hippocampus has been proven to be caused by childhood trauma. Thus, it was hypothesized and later proven in a study that people with dissociative identity disorder and PTSD have smaller hippocampal volume (Reinders & Veltman, 2020). This demonstrates that DID can be caused by trauma that takes place in childhood, depending on the severity thereof, as well as the relation between DID and PTSD. A study of the cortical volume of patients with DID also demonstrated the influence of environmental factors and trauma on the patients (Reinders & Veltman, 2020). As such, brain activation studies and neurostructural studies have proved that DID is likely to be related to childhood trauma.
Critique
The critics of the trauma model deny the relation between traumatic life events and dissociative identity disorder. Several suggestions support the criticism of the trauma model. First, it has been demonstrated that not all patients diagnosed with DID report experiencing trauma or abuse in childhood (Lynn et al, 2019b).
Another aspect of criticism is the lack of a clear definition of the scale of traumatic events, meaning that it is unclear how traumatic an event has to be to cause DID. Thus, it is hard to interpret the results of the studies objectively. Confirmation bias of the studies and lack of objectivity affect the validity of the trauma model as well.
Some studies have also proved that in many cases, a DID diagnosis is not assigned unless there is information about a traumatic background (Lynn et al, 2019b). In cases where there is no knowledge of such, the patient is diagnosed with other disorders. Thus, the specific character of the trauma-DID relation is questioned.
The Sociocognitive Model
Description
The sociocognitive model of dissociative identity disorder diagnosis suggests that DID is not a genuine disorder produced by childhood trauma, but rather a product of individuals’ suggestibility and social learning. According to the professionals who support this model, highly suggestible patients may develop DID symptoms. This can happen as a result of exposure to media portrayals of the disorder or through work with therapists who encourage them to develop their alters. Trauma and other psychological factors as disorder causes are discarded; instead, it is emphasized that the individual’s belief in the existence of multiple identities contributes to the development of the disorder. These beliefs are reinforced through interactions with others who also believe in the existence of multiple identities, such as therapists who support the trauma model.
Evidence
Studies aiming to support the sociocognitive model address patients’ suggestibility and professionals’ biases. In one study, a group of women who self-diagnosed with DID and were willing to find confirmation of their self-diagnosis worked with therapists who looked for trauma evidence. Even in cases where there were no memories of trauma, the doctors tried to persuade the patients that some traumatic event had taken place. The patients, in turn, were persuading the professionals that they indeed have DID (Pietkiewicz et al, 2021).
In the same study, it was found that these patients had been prone to fantasizing since an early age. Their perception of their psychological state and symptoms also changed after they started learning about DID (Pietkiewicz et al, 2021). Discussing the condition with family members, friends, and others also increased the manifestation of symptoms. If the diagnosis was ruled out, the patients experienced feelings of resentment and disappointment. According to SCM supporters, this study reflects the fantasy and social influence on many patients who are diagnosed with DID.
Another piece of evidence supporting the validity of the SCM models is the statistics showing an increase in DID diagnosis since the beginning of the 21st century (Lilienfield et al., 2015). This data suggests that the increase occurred due to the spread of popular media.
Critique
The sociocognitive model of DID diagnosis remains controversial and is not widely accepted within the mental health community. Critics of the sociocognitive model argue that it fails to account for the significant distress and impairment experienced by individuals with DID. They point out that the fact that many individuals with DID report experiencing traumatic events before the development of their symptoms cannot be disregarded.
The particular reasoning behind the criticism is as follows: first, social influence and suggestibility do not necessarily rule out the importance of trauma (Lynn et al., 2019b). Trauma has been proven to be closely linked with other dissociative disorders, such as dissociative PTSD; thus, it is essential to take it into account. Moreover, it is argued that patients’ fantasy proneness may be related to trauma; thus, the former is exacerbated by the latter, leading to the development of DID symptoms.
The Combination of Approaches
Despite significant differences in the investigated models, some professionals believe that it is possible to reach a consensus and combine both approaches when working with patients reporting DID symptoms. To begin with, it is essential to acknowledge the existence of both trauma influence and fantasy and social influence on the disorder development. For example, an individual who has experienced trauma may be more suggestible, which can lead to the development of dissociative symptoms. Additionally, social and cultural factors may impact the way individuals understand and express their experiences of trauma. A more integrated approach to DID diagnosis can help to address the complex factors that contribute to the development and maintenance of the symptoms.
Conclusion
When it comes to diagnosing patients with dissociative identity disorder, the trauma model focuses primarily on trauma as the primary mechanism leading to the manifestation of the symptoms. The evidence of this approach includes the studies of brain activity and neurostructural evidence. These studies demonstrate that brain activity and the structure of the brain in people with DID are similar to those of people with PTSD, suggesting that trauma is the underlying cause of the condition.
However, the approach is criticized by the supporters of the sociocognitive model, who argue that patients’ suggestibility and clinicians’ bias play the leading role in the development of the condition. This approach is not as supported by evidence as the trauma approach, but there is still evidence suggesting a high fantasy proneness in patients. The concluding idea is that combining the two models could lead to a more comprehensive diagnosis and treatment, as both models can be taken into consideration to address all the influencing factors.
References
Lynn, S. J., Lilienfild, S. O., Merckelbach, H., Maxwell, R., Aksen, D., Baltman, J. & Giesbrecht, T. (2019a). Dissociative disorders (5th ed.). Routledge.
Lynn, S. J., Maxwell, R., Merckelbach, H., Lilienfeld, S. O., van Heugten-van der Kloet, D., & Miskovic, V. (2019b). Dissociation and its disorders: Competing models, future directions, and a way forward. Clinical Psychology Review, 73, 101755.
Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (Eds.). (2015). Science and pseudoscience in clinical psychology (2nd ed.). Guilford Press.
Pietkiewicz, I. J., Banbura-Nowak, A., Tomalski, R. and Boon, S. (2021). Revisiting false-positive and imitated dissociative identity disorder. Frontiers in Psychology, 12.
Reinders, A. A. T. M., Veltman, D. J. (2020). Dissociative identity disorder: out of the shadows at last? The British Journal of Psychiatry, 219(2), 1-2.