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New Review on DID and Dissociative Disorders

February 15, 2012

A new review of DID and Dissociative Disorders has just been published in the APS journal, Current Directions in Psychological Science.

Lynn, S.J., Lilienfeld, S.O., Merckelbach, H., Giesbrecht, T., & van der Kloet, D.  (2012).  Dissociation and Dissociative Disorders:  Challenging Conventional Wisdom.  Current Directions in Psychological Science, 21,48-53.

Abstract

Conventional wisdom holds that dissociation is a coping mechanism triggered by exposure to intense stressors. Drawing on recent research from multiple laboratories, we challenge this prevailing posttraumatic model of dissociation and dissociative disorders. Proponents of this model hold that dissociation and dissociative disorders are associated with (a) intense objective stressors (e.g., childhood trauma), (b) serious cognitive deficits that impede processing of emotionally laden information, and (c) an avoidant information-processing style characterized by a tendency to forget painful memories. We review findings that contradict these widely accepted assumptions and argue that a sociocognitive model better accounts for the extant data. We further propose a perspective on dissociation based on a recently established link between a labile sleep-wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality. We conclude that this perspective may help to reconcile the posttraumatic and sociocognitive models of dissociation and dissociative disorders.

The authors compare and contrast two models associated with DID: the Posttraumatic Model and the Sociocognitive Model. Proponents of the Posttraumatic Model have claimed that DID is associated with very high rates of childhood trauma, especially sexual abuse. However, as the authors of this review point out, the studies that show these “high rates”  lack objective corroboration of the abuse and instead rely mainly on uncorroborated self reports. Assessing a person for DID and then asking them if they remember having been abused in childhood is what is known as a retrospective study, a study that relies on participants’ memories of past experiences. In contrast, prospective studies, which follow people after the fact of having undergone documented childhood trauma have failed to substantiate the notion that childhood trauma leads to DID.  Other problems with this model are researchers’ failure to control for overlapping conditions such as eating, anxiety and personality disorders, which are not necessarily unique to people with dissociative disorders. It also may be that people with dissociative disorders who also have childhood abuse issues are more likely to seek treatment, thus the studies reporting high rates that took their subjects from a clinical population are the result of selection and referral bias. Additionally, in studies that have controlled for perception of family pathology, the correlation between abuse and psychopathology has greatly lessened or disappeared entirely. The authors point out that this could mean that the “association is due to global familial maladjustment rather than the abuse itself.”

In contrast, the authors describe the Sociocognitive Model of DID:

This model holds that DID results from inadvertent therapist cueing (e.g., suggestive questioning regarding the existence of possible alters, hypnosis for memory recovery, sodium amytal), media influences (e.g., television and film portrayals of DID), and sociocultural expectations regarding the presumed clinical features of DID. In aggregate, the sociocognitive model posits that these influences can lead predisposed individuals to become convinced that indwelling entities—alters—account for their dramatic mood swings, identity changes, impulsive actions, and other puzzling behaviors (see below). Over time, especially when abetted by suggestive therapeutic procedures, efforts to recover memories, and a propensity to fantasize, they may come to attribute distinctive memories and personality traits to one or more imaginary alters. (Lynn et al., p. 49).

The authors then review a number of research findings that are consistent with the Sociocognitive Model. For example, the number of DID diagnoses and the number of alters diagnosed greatly increased after the book and TV movie, Sybil was released and popularized during the 1970s. Therapy techniques involved in DID therapy can often be suggestive, asking leading questions and naming alters, that reinforce and reifies the alters. Also, the vast majority of DID diagnoses are found among a small minority of therapists who identify themselves as having expertise in treating DID.  Of course, DID therapists, in turn, argue that the diagnosis was missed by previous therapists who were not adequately trained but when the disorder is on such shaky grounds in the first place, this appears to be a circular argument. If DID were a naturally arising condition, it ought to be immediately obvious to therapists who have no such bias.

This review also includes some very recent findings on the association (in both clinical and nonclinical samples) of sleep, memory problems and dissociation. They note:

This link, they contend, is evident across a range of sleep-related phenomena, including waking dreams, nightmares, and hypnagogic (occurring while falling asleep) and hypnopompic (occurring while awakening) hallucinations.

Lynn and his colleagues cited studies that showed that when healthy volunteers are deprived of sleep under experimental conditions, they exhibit dissociative symptoms. This is especially interesting in light of what people who study destructive cults have noted regarding dissociative symptoms displayed by people who are members of such groups, commonly attributed to brainwashing and mind control. Given that sleep deprivation is common in many such groups, the dissociative symptoms might be better explained by sleep deprivation and this would be well worth further study.

Most interesting is that the authors cite a growing body of literature showing that when people with dissociative disorders are treated for sleep problems by learning good sleep hygiene, their dissociative problems markedly improved. In one such study of 266 participants, 24% met the clinical cut-off for dissociative disorders prior to treatment, whereas after treatment (sleep hygiene) at follow up, the percentage dropped to 12%. The authors point out that these studies were missed in meta-analyses conducted by DID proponents such as Bethany Brand and her colleagues who instead, included only eight studies that revolved around treating trauma. The findings of the sleep hygiene intervention fly in the face of those who believe that it is necessary to treat trauma to help people with DID and other dissociative disorders.

Lynn and his colleagues do not entirely rule out trauma playing a role in dissociative disorders, but they do urge people to consider other factors that have come to light through research findings. They conclude their review by noting:

The data we have summarized have received only scant attention in the clinical literature. Nevertheless, they have the potential to reshape the conceptualization and operationalization of dissociative disorders in the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMV, publication scheduled in 2013). In particular, they suggest that sleep disturbances, as well as sociocultural and psychotherapeutic influences, merit greater attention in the conceptualization and perhaps classification of dissociative disorders (Lynn et al., in press). From this perspective, the hypothesis that dissociative disorders can be triggered by (a) a labile sleep cycle that impairs cognitive functioning, combined with (b) highly suggestive psychotherapeutic techniques, warrants empirical investigation. More broadly, the data reviewed point to fruitful directions for our thinking and research regarding dissociation and dissociative disorders in years to come. (p. 51)

 

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10 Comments
  1. Thank You for posting this. It is interesting. I was recently diagnosed (6-7 months ago) however, due to much debate am still not in treatment. This has helped me understand why my diagnosis is in so much trouble and strife and why like 20 Dr’s are all disagreeing and not getting things done or helping me.

  2. I believe that this is best refuted by the following study:

    “Although not intended as such, the present findings refute the sociocognitive model of DID because 15 of the 23 subjective dissociative symptoms that were measured (the criterion A symptoms except for trance and the criterion B symptoms except for self-alteration…) are invisible (ie, completely experiential), unknown to the media, unknown to the general public, and largely unknown to the mental health field. Nevertheless, these 15 subjective dissociative symptoms occurred in 83% to 95% of persons who had DID … . The pervasive presence of these symptoms cannot be explained (away) by the sociocognitive model’s ‘‘usual suspects’’ therapist cueing, media influences, and sociocultural expectations regarding the clinical features of DID. There can be no therapist cueing, media influences, or sociocultural expectations about dissociative symptoms that are invisible, unknown to the media, unknown to the culture, and largely unknown to the
    mental health field.

    The sociocognitive model explains and predicts the classic signs of DID, but the sociocognitive model neither predicts nor can explain (1) most of the empirical literature’s well-replicated dissociative symptoms of DID (Table 1), (2) most of the subjective/phenomenological dissociative symptoms of DID (Box 1), or (3) most of the findings of the present study. In contrast, the subjective/phenomenological model of DID predicts and explains all of the symptoms of classic DID, all 13 of the well-replicated empirical findings about DID (Table 1), all 23 of the subjective/phenomenological dissociative symptoms in Box 1, and all 23 of the dissociative findings of the present study (Table 2).”
    Dell, P F (2006). “A New Model of Dissociative Identity Disorder”. Psychiatric Clinics of North America 29 (1): 1–26.
    http:// www. copingwithdissociation. com/Dell_2006_ANewModelofDID1.pdf

    The study included 220 people who had been diagnosed with Dissociative Identity Disorder. It examined amnesia, conversion symptoms, hearing voices, depersonalization, trance states, self alteration, derealization, awareness of other personalities, identity confusion, flashbacks, psychotic-like dissociative symptoms, auditory hallucinations, visual hallucinations, and Schneiderian first-rank symptoms in regards to Dissociative Identity Disorder. Many of these symptoms, including Schneiderian first-rank symptoms, are completely invisible and subjective, unknown to the public, and even unacknowledged by the DSM. While switching alters is commonly known as a symptom, dissociative intrusions are otherwise ignored.

    The criteria that needed to be met was: “(A) general dissociative symptoms (4 of 6 symptoms are required), (B) partially-dissociated intrusions (6 of 11 symptoms are required), and (C) fully-dissociated actions (2 of 6 symptoms are required).”
    Some of media unacknowledged criteria from (A) are: “Memory problems, Depersonalization, Derealization,” and “Somatoform symptoms.” From (B) they include: “Speech insertion (unintentional or disowned utterances), Thought insertion or withdrawal, ‘Made’ or intrusive feelings and emotions, ‘Made’ or intrusive impulses, ‘Made’ or intrusive actions, Temporary loss of well-rehearsed knowledge or skill,” and “Self-puzzlement.” Only Criteria C is widely known: “Time loss, ‘Coming to’, Fugues, Being told of disremembered actions, Finding objects among one’s possessions,” and “Finding evidence of one’s recent actions.”

    • I have to say, K, that what you just quoted from is the most convoluted response I have heard to date from DID believers. It’s invisible and unknown? If that is the case, then it is not measurable and hence, completely outside the realm of science so thank you for confirming that what this segment of the mental health profession is participating in is pseudoscience. Of course, you then contradict yourself by citing the DSM, which is known and something that anyone can access. DSM is based on consensus and voting among a small number of people, not science. This was confirmed in the case of the Twilight Rapist, who attempted to use his claimed DID to get off. It didn’t work and the ruling confirmed that just because something is in the DSM, that does not mean it is scientific. This is yet another illustration that when the mental health profession persists in colluding with pseudoscientists and those delivering iatrogenic interventions, the law will step in.

      And no, a DID “expert” slapping his labels on 220 unfortunate subjects and engaging in essentially confirmation bias is not scientific evidence. For the author to claim some kind of secret, invisible knowledge is ludicrous and no more valid than advanced Scientologists who do essentially the same thing when they foist the “invisible” symptoms of their secret, advanced levels on others. The only difference is that Scientologists are outsiders to the mental health profession, whereas the flawed studies of DID experts have been allowed in, accompanied by all the damage that they do. It is most unfortunate that the psychiatric profession in all too many instances has gone far afield of science. Another stunning example of this is the 60 Minutes report that aired last Sunday that featured the work of Irving Kirsch and others, showing that antidepressant effects being promoted by psychiatrists, courtesy of Big Pharma are largely placebo. The psychiatric profession has a great deal to answer for and since they have repeatedly jumped into bed with Big Pharma and allowed substandard DID claims into their literature, ultimately the justice system will step in as the casualties continue to come forward. The good news is that more and more people are catching onto this and find valid ways to help themselves, with or without the mental health profession.

      • Brandon Jones permalink

        I stopped reading after you implied that invisible and unknown = unmeasurable= outside of the realm of science. I’ve always thought that science is about figuring out the unknown. Scientists love invisible things.

      • Where did I ever say that? I never said nor implied that. The point is that things that are untestable are, by definition, outside the realm of science, it has nothing to do with invisibility. Science can test what you call “invisible” things (i.e. abstractions) by operationalizing them. See any basic research textbook for details.

      • Brandon Jones permalink

        I pulled the following from your reply directly to K:

        “I have to say, K, that what you just quoted from is the most convoluted response I have heard to date from DID believers. It’s invisible and unknown? If that is the case, then it is not measurable and hence, completely outside the realm of science so thank you for confirming that what this segment of the mental health profession is participating in is pseudoscience.”

        I acknowledge that you were responding to K, but the implication seems to be yours. Unless you are saying did not post this, I think it’s pretty clear that you make an illogical statement… if “it’s invisible and unknown” then “it is not measurable”.

        Thanks for pointing me towards operationalization, though.

        Monica Pignotti’s Response:
        You pulled my remark out of context. Note that I wrote “Invisible AND unknown”. The person was committing the logical fallacy of argument from ignorance and creating a non-falsifiable situation. Most ironic that you would think that I made an “illogical statement” given the extremely convoluted nature of the statement I was responding to in the first place. You then equivocate on the word, “invisible” and conflate it with abstract constructs that researchers operationalize.

        Not all “invisible” things are of the type that can be researched, however and what the commenter was presenting was not testable. He was presenting the results in a poorly done study where the authors jumped to unwarranted conclusions and did not adequate operationalize any of these so-called “invisible” things. Scientists do not study “invisible things” in the sense that K and apparently you are talking about because in order for something to be testable, it must be falsifiable and K set up a situation that is not falsifiable. K made bold, untestable assertions about things that are “invisible and known”. That’s the context that you dropped when you apparently just read three words and reacted to them without even bothering to read the full context. But thank you for your response as it is helping me to understand how people can fall for this kind of pseudoscientific thinking.

      • Brandon Jones permalink

        My understanding of the “invisible” things to which K refers = the six other symptoms (ie conversion symptoms, voices, depersonalizarion, etc) often found in alleged cases of DID that aren’t mentioned in criteria a and b of the current DSMkraft also happen to be relatively unknown to those who haven’t read the literature on DID.

        Do you have a different understanding? I feel like this needs to be hashed out.

        Thanks.

  3. The purge of the psychotherapy field cannot happen fast enough. I am appalled at the number of charlatans who practice under the “therapy” banner and get paid by the healthcare industry to cause harm. The related Castlewood Treatment Center lawsuit discussion is another example of how pseudoscience in psychotherapy has to be addressed. “Parts” therapy whether it be IFS or a DID diagnosis should seriously be questioned by our healthcare industry. Writing books on totally imagined theories and holding weekend workshops where people are “certified” has to stop. To think that people are getting DID diagnosis’ from IFS “experts” who take 6 weekend workshops so they can “get referrals” or complete “at home” courses from people like Colin A. Ross makes me ill. Colin A. Ross recently received a “best paper” honor from the “Journal of Trauma and Dissociation” Google his name along with the term “quack” for some truly frightening facts.

  4. Carr Conway permalink

    CM-psychobabble has been nonsense for many years but at least was relatively benign and worthless. When repressed memory therapy and MPD/MPD came on the scene psychobabble changed from being merely benign and worthless to causing immeasurable harm. I believe these types of therapy should be criminalized similar to yelling fire in a crowded theater. Further, serious questions about these therapies have now existed for so long that continued use can only be described as evil and depraved. Unfortunately the True Believers are fully caught up in this mass hysteria and refuse to even consider the harm they are causing to innocent people. The fires of hell will not burn hot enough for these miscreants!!!

  5. I know I’m a bit late in the day, but I must say this is a very interesting perspective. Now I hate dodgy therapists more than most, I certainly don’t agree with assuming a client must have been abused and then asking the leading questions (or heaven forefend using medication or hypnosis, though I did recently read a paper involving that published this year), but…what about spontaneous memory recovery? No therapist, no leading questions, no known reason for it, just spontaneous memory recovery.

    Maybe the water gets muddied by the number of diagnoses within ‘dissociative disorders’. I’ve certainly seen people in dissociative states (and argued with a junior doctor about why it met none of the criteria for a psychotic episode only for a senior doctor to diagnose a dissociative disorder). Rather obviously, I also believe that dissociative amnesia is a genuine condition (and was amazed how similar someone else found their experience of memory recovery to be). Dissociative Identity Disorder is, however, very controversial. But they are all grouped together and it seems to be rather all or nothing as to whether practitioners believe they exist or believe they don’t.

    Anyway, I’m rambling because it’s late. I’m always interested to hear healthy scientific debate.

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