DID is one of the most controversial psychiatric disorders with no clear consensus regarding its diagnosis or treatment.[3] Research on treatment effectiveness still focuses mainly on clinical approaches and case studies. Dissociative symptoms range from common lapses in attention, becoming distracted by something else, and daydreaming, to pathological dissociative disorders.[4] No systematic, empirically-supported definition of "dissociation" exists.[5][6]
Although neither epidemiological surveys nor longitudinal studies have been done, it is thought DID rarely resolves spontaneously. Symptoms are said to vary over time.[4] In general, the prognosis is poor, especially for those with co-morbid disorders. There is little systematic data on the prevalence of DID.[7] The International Society for the Study of Trauma and Dissociation states that the prevalence is between 1 and 3% in the general population, and between 1 and 5% in inpatient groups in Europe and North America.[8][dead link] DID is diagnosed more frequently in North America than in the rest of the world, and is three to nine times more common in females than in males.[5][7][9] The prevalence of DID increased greatly in the latter half of the 20th century, along with the number of identities (often referred to as "alters") claimed by patients (increasing from an average of two or three to approximately 16).[5]
Dissociative disorders including DID have been attributed to disruptions in memory caused by trauma and other forms of stress, but research on this hypothesis has been characterized by poor methodology. So far, scientific studies, usually focusing on memory, have been few and the results have been inconclusive.[10] An alternative hypothesis for the etiology of DID is as a product of techniques employed by some therapists, especially those using hypnosis, and disagreement between the two positions is characterized by intense debate.[3][11] DID became a popular diagnosis in the 1970s, 80s and 90s but it is unclear if the actual incidence of the disorder increased, if it was more recognized by clinicians, or if sociocultural factors caused an increase in iatrogenic presentations. The unusual number of diagnoses after 1980, clustered around a small number of clinicians and the suggestibility characteristic of those with DID, support the hypothesis that DID is therapist-induced.[12] The unusual clustering of diagnoses has also been explained as due to a lack of awareness and training among clinicians to recognize cases of DID.[13]
DID is among the most controversial of the dissociative disorders, and among the most controversial disorders found in the DSM-IV-TR.[5] The primary dispute is between those who believe DID is caused by traumatic stresses forcing the mind to split into multiple identities, each with a separate set of memories,[10][14] and the belief that the symptoms of DID are produced artificially by certain psychotherapeutic practices or patients playing a role they believe appropriate for a patient suffering from DID.[11][13][33][35][36][48] The debate between the two positions is characterized by intense disagreement.[3][11][12][13][33][36]
Psychiatrists August Piper and Harold Merskey have challenged the trauma hypothesis, arguing that correlation does not imply causation - the fact that people with DID report childhood trauma does not mean trauma causes DID — and point to the rareness of the diagnosis before 1980 as well as a failure to find DID as an outcome in longitudinal studies of traumatized children. They assert that DID cannot be accurately diagnosed because of vague and unclear diagnostic criteria in the DSM and undefined concepts such as "personality state" and "identities", and question the evidence for childhood abuse beyond self-reports, the lack of definition of what would indicate a threshold of abuse sufficient to induce DID and the extremely small number of cases of children diagnosed with DID despite an average age of appearance of the first alter of three years.[12] Psychiatrist Colin Ross 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)[14] that are in the internal validity range of widely accepted mental illnesses such as schizophrenia and major depressive disorder. In his opinion, Piper and Merskey are setting the standard of proof higher than they are for other diagnoses. He 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.[49]
Richard J. McNally has explained in his 2005 book how he sees child abuse being politicized.[34]#
The cause of DID is controversial, with debate occurring between supporters of different hypotheses: that DID is a reaction to trauma; that DID is produced iatrogenically by inappropriate psychotherapeutic techniques that cause a patient to enact the role of a patient with DID; and newer hypotheses involving memory processing that allows for the possibility that trauma-causing dissociation can occur after childhood in DID, as it does in PTSD. It has been suggested that all the trauma-based and stress-related disorders be placed in one category that would include both DID and PTSD.[25] Disturbed and altered sleep has also been suggested as having a role in dissociative disorders in general and specifically in DID.[26]
Research is needed to determine the prevalence of the disorder in those who have never been in therapy, and the prevalence rates across cultures. These central issues relating to the epidemiology of DID remain largely unaddressed despite several decades of research.[27] The debates over the causes of DID also extend to disagreements over how the disorder is assessed and treated.[5]
Developmental trauma
Main article: Trauma model of mental disorders
People diagnosed with DID often report that they have experienced severe physical and sexual abuse, especially during early to mid-childhood,[28] (although the accuracy of these reports has been disputed[2]) and others report an early loss, serious medical illness or other traumatic event.[18] They also report more historical psychological trauma than those diagnosed with any other mental illness.[not in citation given][29] Severe sexual, physical, or psychological trauma in childhood has been proposed as an explanation for its development; awareness, memories and emotions of harmful actions or events caused by the trauma are removed from consciousness, and alternate personalities or subpersonalities form with differing memories, emotions and behavior.[30] DID is attributed to extremes of stress or disorders of attachment. What may be expressed as post-traumatic stress disorder in adults may become DID when occurring in children, possibly due to their greater use of imagination as a form of coping.[16][19] Possibly due to developmental changes and a more coherent sense of self past the age of six, the experience of extreme trauma may result in different, though also complex, dissociative symptoms and identity disturbances.[19] A specific relationship between childhood abuse, disorganized attachment, and lack of social support are thought to be a necessary component of DID.[16] Other suggested explanations include insufficient childhood nurturing combined with the innate ability of children in general to dissociate memories or experiences from consciousness.[18]Delinking early trauma from the etiology of dissociation has been explicitly rejected by those supporting the early trauma model. However, a 2012 review article supports the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states.[31] Giesbrecht et al. have suggested there is no actual empirical evidence linking early trauma to dissociation, and instead suggest that problems with neuropsychological functioning, such as increased distractibility in response to certain emotions and contexts, account for dissociative features.[32] A middle position hypothesizes that trauma, in some situations, alters neuronal mechanisms related to memory. Evidence is increasing that dissociative disorders are related both to a trauma history and to "specific neural mechanisms".[19] It has also been suggested that there may be a genuine but more modest link between trauma and DID, with early trauma causing increased fantasy-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of DID.[6]
Therapist induced
The prevailing post-traumatic model of dissociation and dissociative disorders is contested.[6] It has been hypothesized that symptoms of DID may be created by therapists using techniques to "recover" memories (such as the use of hypnosis to "access" alter identities, facilitate age regression or retrieve memories) on suggestible individuals.[11][12][13][27][33] Referred to as the "sociocognitive model" (SCM), it proposes that DID is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes,[27] with unwitting therapists providing cues through improper therapeutic techniques. This behavior is enhanced by media portrayals of DID.[6]Proponents of the SCM note that the bizarre dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of DID who, through the process of eliciting, conversing with and identifying alters, shape, or possibly create the diagnosis. While proponents note that DID is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are skeptical of the traumatic etiology suggested by proponents.[34] The characteristics of people diagnosed with DID (hypnotizability, suggestibility, frequent fantasization and mental absorption) contributed to these concerns and those regarding the validity of recovered memories of trauma.[35] Skeptics note that a small subset of doctors are responsible for diagnosing the majority of individuals with DID.[11][12] Psychologist Nicholas Spanos Others have suggested that in addition to iatrogenesis, DID may be the result of role-playing rather than alternative identities, though others disagree, pointing to a lack of incentive to manufacture or maintain separate identities and point to the claimed histories of abuse.[36] Other arguments for the iatrogenic position, include the lack of children diagnosed with DID, the sudden spike in incidence after 1980 (although DID was not a diagnosis until DSM-IV, published in 1994), the absence of evidence of increased rates of child abuse, the appearance of the disorder almost exclusively in individuals undergoing psychotherapy, particularly involving hypnosis, the presences of bizarre alternate identities (such as those claiming to be animals or mythological creatures) and an increase in the number of alternate identities over time[6][12] (as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy.[6]) These various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably borderline personality disorder, which is commonly co-morbid with DID.[6] In addition, presentations can vary across cultures, such as Indian patients who only switch alters after a period of sleep — which is commonly how DID is presented by the media within that country.[6]
The iatrogenic position is strongly linked to the false memory syndrome, coined by the False Memory Syndrome Foundation in reaction to memories recovered by a range of controversial therapies whose effectiveness is unproven. Such a memory could be used to make a false allegation of child sexual abuse. There is little consensus between the iatrogenic and traumagenic positions regarding DID.[3] Proponents of the iatrogenic position suggest a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position[27] though it has also been claimed that higher rates of diagnosis in specific countries like the United States, may be due to greater awareness of DID. Lower rates in other countries may be due to an artificially low recognition of the diagnosis.[13]
In children
DID is rarely diagnosed in children, despite the average age of appearance of the first alter being three years.[12] This fact is cited as a reason to doubt the validity of DID,[12][27] and proponents of both etiologies believe that the discovery of DID in a child that had never undergone treatment would critically undermine the SCM. Conversely, if children are found to only develop DID after undergoing treatment it would challenge the traumagenic model.[27] As of 2011[update] approximately 250 cases of DID in children have been identified, though the data does not offer unequivocal support for either theory. While children have been diagnosed with DID before therapy, several were presented to clinicians by parents who were themselves diagnosed with DID; others were influenced by the appearance of DID in popular culture or due to a diagnosis of psychosis due to hearing voices — a symptom also found in DID. No studies have looked for children with DID in the general population, and the single study that attempted to look for children with DID not already in therapy did so by examining siblings of those already in therapy for DID. An analysis of diagnosis of children reported in scientific publications, 44 case studies of single patients were found to be evenly distributed (i.e. each case study was reported by a different author) but in articles regarding groups of patients, four researchers were responsible for the majority of the reports.[27]The initial theoretical description of DID was that dissociative symptoms were a means of coping with extreme stress (particularly childhood sexual and physical abuse), but this belief has been challenged by the data of multiple research studies.[6] Proponents of the traumagenic hypothesis claim the high correlation of child sexual and physical abuse reported by adults with DID corroborates the link between trauma and DID.[5][6] However, the DID-maltreatment link has been questioned for several reasons. The studies reporting the links often rely on self-report rather than independent corroborations, and these results may be worsened by selection and referral bias.[5][6] Most studies of trauma and dissociation are cross-sectional rather than longitudinal, which means researchers can not attribute causation, and studies avoiding recall bias have failed to corroborate such a causal link.[5][6] In addition, studies rarely control for the many disorders comorbid with DID, or family maladjustment (which is itself highly correlated with DID).[5][6] The popular association of DID with childhood abuse is relatively recent, occurring only after the publication of Sybil in 1973. Most previous examples of "multiples" such as Chris Costner Sizemore, whose life was depicted in the book and film The Three Faces of Eve, disclosed no history of child abuse.[34]
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