New Review on DID and Dissociative Disorders
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.
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)