According to the American Psychiatric Association (APA) (2013), Dissociative Identity Disorder is characterized by “disruption of identity characterized by two or more distinct personality states,” “recurrent gaps in the recall of…events,” along with the existence of significant distress and the absence of any cultural, religious, and substance-induced alternate explanation (p. 292). Although it is clearly listed in the DSM-5 as a disorder, a large amount of controversy still remains. Two main theories have considerable support: the Post Traumatic Model (PTM) and the Sociocognitive Model (SCM). The Post Traumatic Model centers around the belief that a majority of DID patients underwent extreme trauma in their childhoods. Under this assumption, alternate personalities (“alters”) develop as a coping strategy in which individuals respond to the emotional pain of trauma by compartmentalizing their experiences (Lilienfeld, 1999, p. 507).
Neurobiological theories complement the PTM well, and the PTM is overall much more common in the literature. In her neurodevelopmental-approach-based paper, Forrest (2001) breaks down DID etiology into four factors: the orbitofrontal cortex’s role in behavior, emotional regulation development, the development of the self, and experience-dependent processes. All of these factors essentially hypothesize that a discontinuous childhood, as a result of trauma and discontinuous parenting, creates the development of a discontinuous self; these experiences thus make these children vulnerable to the creation of alters as a way to cope with their disorganized brain functioning and themes they’ve built for themselves (p. 259). In other words, the orbitofrontral cortex, in charge of organizing behavior and developing emotion regulation (Forrest, 2001, p. 266), cannot perform as it should under traumatic stress. The child fails to develop a coherent sense of self because he is given mixed responses from his disorganized home life; in extremely simplified terms, he cannot decide whether he is good or bad, worthy or unworthy, to the extent that he cannot even form a solidified idea of himself.
The Sociocognitive Model states otherwise. This model states DID is a purely iatrogenic syndrome, emerging as “multiple role enactments that have been created, legitimized, and maintained by social reinforcement” (Lilienfeld, 1999, p. 507). In this model, sociocultural influences have played a monumental role in the development of DID (Lilienfeld, 1999, p. 508). Through unintentional prompting from therapists, social influences, media portrayals, etcetera, those prone to creating fantasies are likely to partake in role enactment and create these “alters” in response to the sociocultural influences condoning this (Lilienfeld, 1999, p. 509). Many renowned authors in the DID literature agree that few DID patients exhibit many unambiguous signs of their condition prior to their involvement in therapy (Lilienfeld, 1999, p. 511). This could mean patients are simply not aware of their symptoms until further exploration, or this could further support the SCM arguing therapists are unconsciously ushering the creation of multiple roles. Despite this social hypothesis gaining momentum, evidence of trauma in DID patients reinforces a trauma-based model like the PTM. According to the DSM-5, Diagnostic Statistical Manual of Mental Disorders (APA, 2013), “the prevalence of childhood abuse and neglect in the United States, Canada, and Europe among those with the disorder is about 90%” (p. 295). With the DSM-5 being the resource most trusted in the field at this time, the community holds firm in its support of the PTM, trauma-based etiology.
Expectedly, this controversial etiological debate has spawned further controversy regarding both diagnosis and treatment. Regarding diagnosis, DID is known to be difficult to assess. This is largely due to the fact that very few patients show signs of the disorder at the time of assessment. It is even argued that close family cannot see clear manifestations of symptoms early on (Coons, 2005, p. 679). Without these overt signs existing at the time of an intake assessment, proper diagnosis of Dissociative Identity Disorder remains challenging. Those with DID could be presenting with symptoms associated with common differentials, such as Major Depressive Disorder, Posttraumatic Stress Disorder, or a range of personality disorders (APA, 2013, p. 296-297). Even if patients did hypothetically present with overt DID symptoms according to the DSM-5, there is argument that the DSM-5 is far too lax in its diagnostic criteria in the first place. The terms and concepts such as, “personality states,” “identities,” and “take control” are ambiguous and no clarification is evidently given in the manual. As a result, clinicians cannot be extremely certain whether a patient’s alter is “taking control” or if they are simply in a heightened emotional state (Coons, 2005, p. 679).
As for treatment, there have been problems with methods that are too generic. Academics in the field have considered the possibility that treatment for DID could do more harm than help. If treatment is not adapted to the patient’s specific problems, they may be more vulnerable to worsening of these symptoms. It is expected that this occurs due to high levels of comorbidity and dissociation tendencies in these patients (Brand, 2014, p. 170). Although most research has proved these worries to be moot, the controversy does still exist in the literature; academia has now come to the conclusion that, for the most part, clinicians can only do harm to DID patients if they are not properly trained in the detailed, phasic treatment model (Brand, 2014, p. 184). This treatment standard is described in the International Society for the Study of Trauma & Dissociation’s Treatment Guidelines for Dissociative Identity Disorder in Adults (ISSTD) (Brand, 2014, pg. 171). Thus, carefully staged psychotherapy treatment— like the tri-phasic ISSTD guidelines — that both focuses on the previous trauma and targets the dissociative symptoms is shown to be most successful (Brand, 2014, p. 170).
The social controversies surrounding diagnosis of Dissociative Identity Disorder essentially engendered the creation of Spanos’ aforementioned Sociocognitive Model. While the SCM does not argue that DID doesn’t exist, it does argue that many features of DID patients “derive from culturally based scripts and expectations regarding the typical manifestations of multiple role enactments in Western culture” (Lilienfeld, 1999, pg. 510). Proponents of the SCM also make a solid argument in stating they have found no other disorder whose main feature is rarely observable at intake and usually becomes more prominent during treatment (Lilienfeld, 1999, pg. 512). These arguments force one to take a hard look at Western society and the possible repercussions it has had on mental health.
A related social issue involving DID comes from the media and how it has portrayed this specific disorder. According to The Trauma and Mental Health Report, while television shows and films have some accuracy regarding DID, most programs programs involve characters who develop a different identity in order to release their darkest impulses, a detail clearly exaggerated for the thrill (Garzon, 2013). Traub (2009) argues media influences have participated in the over-diagnosis of DID, especially in regards to the number of alters per person. One can assume this is a large portion of what Lilienfield is discussing when referring to Western culture and the Sociocognitive Model. While the Posttraumatic Model remains prominent in the literature, it would be naive to ignore the societal effects in regards to any disorder, especially one so unique in its presentation.
The multi-phasic treatment previously mentioned and outlined by the ISSTD seems to be a common and successful form of DID treatment. It is, in essence, a form of Dialectic Behavioral Therapy (DBT), in its organized phases. The DID literature emphasizes how critical a staged approach is, starting with creating a safe space before acknowledging trauma; Marsha Linehan’s Dialectic Behavior Therapy involves a staged approach where behavior and safety issues are addressed first, and followed by any trauma work in the next stage (Foote, 2016, pg. 1). According to the ISSTD, “adaptations of DBT to Phase 1 of the treatment of DID are currently being developed in several countries” (International Society for the Study of Trauma and Dissociation , 2011, pg. 139). The phase-oriented treatment approach usually consists of three phases: (1) establish safety and reduce symptoms, (2) tackle trauma, (3) and integrate identity. In phase 1, DID patients learn impulse regulation, communication and cooperation skills. Phase 2 involves deeper dissection of the trauma, including direct events but also feelings and impulses surrounding the events; safety must still be prioritized during this phase so that they patient remains present and stable. Finally, in phase 3, patients begin to tackle future life, including pursuing healthy relationships and activities once integration is accomplished (Brand, 2014, pg. 171).
The Cognitive Behavioral Therapy approach has also proven to be successful in the DID treatment literature. This approach stands firm in the belief that the more structure therapy is, the more successful it will be in providing safety and consistency for the patient. Thus, a CBT approach gives same treatment repeated across all personalities; it serves as an “anchor” to the patients’s dissociative states and their ideas about reality. Here, it is believed that DID patients and clinicians must acknowledge their cognitive distortions before being able to understand the resulting personalities. From there, these cognitive distortions are challenged and hopefully tackled upon reaching integration (Fine, 1999, pg. 362). Essentially, this approach holds more emphasis on thought-life and realigning cognition with reality. While both CBT and DBT still acknowledge trauma, CBT uses the effects of trauma to understand the patient’s beliefs about the world; DBT works to process the trauma emotionally.
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