Editing Dissociative identity disorder (section)

==Causes==
===General===
There are two competing theories on what causes dissociative identity disorder to develop. The trauma-related model suggests that complex trauma or severe adversity in childhood, also known as developmental trauma, increases the risk of someone developing dissociative identity disorder.<ref name="Blihar">{{cite journal |vauthors=Blihar D, Delgado E, Buryak M, Gonzalez M, Waechter R |date=September 2019 |title=A systematic review of the neuroanatomy of dissociative identity disorder |journal=European Journal of Trauma & Dissociation |volume=9 |issue=3 |page=100148 |doi=10.1016/j.ejtd.2020.100148 |doi-access=free}}</ref><ref name="Dalenberg-2012">{{Cite journal |last1=Dalenberg |first1=Constance J. |last2=Brand |first2=Bethany L. |last3=Gleaves |first3=David H. |last4=Dorahy |first4=Martin J. |last5=Loewenstein |first5=Richard J. |last6=Cardeña |first6=Etzel |last7=Frewen |first7=Paul A. |last8=Carlson |first8=Eve B. |last9=Spiegel |first9=David |date=May 2012 |title=Evaluation of the evidence for the trauma and fantasy models of dissociation |journal=Psychological Bulletin |volume=138 |issue=3 |pages=550–588 |doi=10.1037/a0027447 |pmid=22409505 }}</ref><ref name="Vissia-2016">{{Cite journal |last1=Vissia |first1=E. M. |last2=Giesen |first2=M. E. |last3=Chalavi |first3=S. |last4=Nijenhuis |first4=E. R. S. |last5=Draijer |first5=N. |last6=Brand |first6=B. L. |last7=Reinders |first7=A. A. T. S. |title=Is it Trauma- or Fantasy-based? Comparing dissociative identity disorder, post-traumatic stress disorder, simulators, and controls |journal=Acta Psychiatrica Scandinavica |year=2016 |volume=134 |issue=2 |pages=111–128 |doi=10.1111/acps.12590 |pmid=27225185 |s2cid=4188544 |url=https://kclpure.kcl.ac.uk/portal/en/publications/is-it-trauma-or-fantasybased-comparing-dissociative-identity-disorder-posttraumatic-stress-disorder-simulators-and-controls(bd508f35-fe81-4454-9a12-f2eaa904a634).html }}</ref> The non-trauma related model, also referred to as the sociogenic or fantasy model, suggests that dissociative identity disorder is developed through high fantasy-proneness or suggestibility, roleplaying, or sociocultural influences.<ref name="Blihar" /><ref name="Dalenberg-2012" /><ref name="Vissia-2016" />

The DSM-5-TR states that "early life trauma (e.g., neglect and physical, sexual, and emotional abuse, usually before ages 5-6 years) represents a major risk factor for dissociative identity disorder."<ref name="American-Psychiatric-Association-2022" />{{rp|style=ama|p=333}} Other risk factors reported include painful medical procedures, experiences of [[war]], witnessing [[terrorism]], or being trafficked in childhood.<ref name="American-Psychiatric-Association-2022" />{{rp|style=ama|p=333}} <!-- DSM-5-TR p333 Risk and Prognostic Factors-->Dissociative disorders frequently occur after trauma, and the DSM-5-TR places them after the chapter on trauma- and stressor-related disorders to reflect this close relationship between complex trauma and dissociation.<ref name="American-Psychiatric-Association-2022" />{{rp|style=ama|p=329}}

===Traumagenic model===
{{Main|Trauma model of mental disorders}}

Dissociative identity disorder is often conceptualized as "the most severe form of a childhood-onset post-traumatic stress disorder."<ref name="Blihar" /> According to many researchers, the etiology of dissociative identity is multifactorial, involving a complex interaction between developmental trauma, sociocultural influences, and biological factors.<ref name="Dorahy">{{cite journal |vauthors=Dorahy MJ, Brand BL, Şar V, Krüger V, Stavropoulos P, Martínez-Taboas A, Lewis-Fernández R, Middleton W |date=May 1, 2014 |title=Dissociative identity disorder: An empirical overview |journal=[[Australian and New Zealand Journal of Psychiatry]] |volume=48 |issue=5 |pages=402–17 |doi=10.1177/0004867414527523 |pmid=24788904 |s2cid=3609433 |hdl-access=free |hdl=2263/43470}}</ref><ref name="Blihar" /><ref name="Vedat" />

People diagnosed with dissociative identity disorder often report that they have experienced [[physical abuse|physical]] or [[sexual abuse]] during childhood<ref name="Mer2019Pro" /> (although the accuracy of these reports has been disputed<ref name="dsm" />); others report overwhelming stress, serious medical illness, or other traumatic events during childhood.<ref name="Mer2019Pro" /> They also report more historical psychological trauma than those diagnosed with any other mental illness.<ref name="Sar2011">{{cite journal|last1=Sar |first1=V. |title=Epidemiology of Dissociative Disorders: An Overview |journal=Epidemiology Research International |volume=2011 |pages=1–9 |year=2011 |doi=10.1155/2011/404538  |doi-access=free}} See also §5.3, ''Childhood Psychological Trauma'', p.&nbsp;5.</ref>{{efn|Most of the published clinical case series are focused on chronic and complex forms of dissociative disorders. Data collected in diverse geographic locations such as North America [2], Puerto Rico [3], Western Europe [4], Turkey [5], and Australia [6] underline the consistency in clinical symptoms of dissociative disorders. These clinical case series have also documented that dissociative patients report highest frequencies of childhood psychological trauma among all psychiatric disorders. Childhood sexual (57.1%–90.2%), emotional (57.1%), and physical (62.9%–82.4%) abuse and neglect (62.9%) are among them (2–6). — Sar (2011)<ref name = Sar2011/>{{rp|at=§1, ''Introduction'', p.&nbsp;1}}}}

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 sequestered away from consciousness, and alternate parts form with differing memories, emotions, beliefs, temperament and behavior.<ref>{{cite book|author1=Carson, V.B. |author2=Shoemaker, N.C. |author3=Varcarolis, E. |year=2006 |title=Foundations of Psychiatric Mental Health Nursing: A Clinical Approach |edition=5th |location=St. Louis |publisher=[[Elsevier|Saunders Elsevier]] |pages=[https://archive.org/details/foundationsofpsy00eliz/page/266 266–267] |isbn=978-1-4160-0088-4 |url=https://archive.org/details/foundationsofpsy00eliz/page/266}}</ref> Dissociative identity disorder is also attributed to extremes of [[Stress (psychological)|stress]] and disturbances of [[attachment theory|attachment]] to caregivers in early life. What may result in [[complex post-traumatic stress disorder]] (C-PTSD) in adults may become dissociative identity disorder when occurring in children, possibly due to their greater use of [[imagination]] as a form of [[coping (psychology)|coping]] as well as lack of developmental integration in childhood.<ref name=Spiegel>{{cite journal|vauthors=Spiegel D, Loewenstein RJ, Lewis-Fernández R, Sar V, Simeon D, Vermetten E, Cardeña E, Dell PF |title=Dissociative disorders in DSM-5 |journal=Depression and Anxiety |volume=28 |issue=9 |pages=824–852 |year=2011 |pmid=21910187 |doi=10.1002/da.20874 |s2cid=46518635|doi-access=free }}</ref>

Possibly due to developmental changes and a more coherent sense of self past age 6-9 years, the experience of extreme trauma may result in different, though also complex, dissociative symptoms, identity disturbances and trauma-related disorders.<ref name = Spiegel/> Relationships between childhood abuse, [[disorganized attachment]], and lack of social support are thought to be common risk factors leading to dissociative identity disorder.<ref name = Gillig/> Although the role of a child's biological capacity to dissociate remains unclear, some evidence indicates a neurobiological impact of developmental stress. Moreover, the personalities of children are universally born unintegrated, and the various aspects of a child's undeveloped personality gradually integrate as the child's brain grows and develops.<ref name="Vedat"/>

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.<ref name="pmid22423434">{{cite journal|author=Stern DB |title=Witnessing across time: Accessing the present from the past and the past from the present |journal=The Psychoanalytic Quarterly |volume=81 |issue=1 |pages=53–81 |year=2012 |pmid=22423434 |doi=10.1002/j.2167-4086.2012.tb00485.x |s2cid=5728941}}</ref> Giesbrecht et al. have suggested there is no actual [[Empirical research|empirical evidence]] linking early trauma to dissociation, and instead suggest that problems with [[Neuropsychology|neuropsychological functioning]], such as increased distractibility in response to certain emotions and contexts, account for dissociative features.<ref name="pmid18729565">{{cite journal|vauthors=Giesbrecht T, Lynn SJ, Lilienfeld SO, Merckelbach H |title=Cognitive processes in dissociation: An analysis of core theoretical assumptions |journal=Psychological Bulletin |volume=134 |issue=5 |pages=617–647 |year=2008 |pmid=18729565 |doi=10.1037/0033-2909.134.5.617 |citeseerx=10.1.1.489.1520 |s2cid=14335587}}</ref> 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".<ref name = Spiegel/> It has also been suggested that there may be a genuine but more modest link between trauma and dissociative identity disorder, with early trauma causing increased [[Fantasy (psychology)|fantasy]]-proneness, which may in turn render individuals more vulnerable to socio-cognitive influences surrounding the development of dissociative identity disorder.<ref name = Lynn2012/>

Joel Paris states that the trauma model of dissociative identity disorder increased the appeal of the diagnosis among health care providers, patients and the public as it validated the idea that child abuse had lifelong, serious effects. Paris asserts that there is very little experimental evidence supporting the trauma-dissociation hypothesis, and no research showing that dissociation consistently links to long-term memory disruption.<ref name = Paris2012/>

===Sociogenic model===
Symptoms of dissociative identity disorder may be created by therapists using [[recovered-memory therapy|techniques to "recover" memories]] (such as the use of [[hypnosis]] to "access" alter identities, facilitate [[Age regression in therapy|age regression]] or retrieve memories) on suggestible individuals.<ref name="pmid15503730" /><ref name="pmid15560314"/><ref name =Cardena/><ref name = Boysen/><ref name="Blackwell">{{cite book |last=Rubin |first=EH |url=https://books.google.com/books?id=uX4ZwtDKNqMC&pg=PA280 |title=Adult psychiatry: Blackwell's neurology and psychiatry access series |publisher=[[John Wiley & Sons]] |year=2005 |isbn=978-1-4051-1769-2 |editor=Rubin EH |edition=2nd |page=280 |editor2=Zorumski CF}}</ref> Referred to as the non-trauma-related model, or the sociocognitive model or fantasy model, it proposes that dissociative identity disorder is due to a person consciously or unconsciously behaving in certain ways promoted by cultural stereotypes,<ref name = Boysen/> with unwitting therapists providing cues through improper therapeutic techniques. This model posits that behavior is enhanced by media portrayals of dissociative identity disorder.<ref name = Lynn2012/>

Proponents of the non-trauma-related model note that the dissociative symptoms are rarely present before intensive therapy by specialists in the treatment of dissociative identity disorder who, through the process of eliciting, conversing with, and identifying alters, shape or possibly create the diagnosis.<ref>{{cite book |last1=Mitra |first1=Paroma |last2=Jain |first2=Ankit |title=StatPearls |date=2023 |publisher=StatPearls Publishing |url=https://www.ncbi.nlm.nih.gov/books/NBK568768/ |access-date=15 May 2023 |chapter=Dissociative Identity Disorder|pmid=33760527 }}</ref> While proponents note that dissociative identity disorder is accompanied by genuine suffering and the distressing symptoms, and can be diagnosed reliably using the DSM criteria, they are skeptical of the trauma-related etiology suggested by proponents of the trauma-related model.<ref name = McNally2005/> Proponents of non-trauma-related dissociative identity disorder are concerned about the possibility of hypnotizability, suggestibility, frequent fantasization and mental absorption predisposing individuals to dissociation.<ref name="MacDonald">{{cite journal |last1=MacDonald |first1=Kai |title=Dissociative disorders unclear? Think 'rainbows from pain blows' |journal=Current Psychiatry |date=1 May 2008 |volume=7 |issue=5 |pages=73–85 |id={{Gale|A179269544}} |url=https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/0705CP_Article3.pdf}}</ref> They note that a small subset of doctors are responsible for diagnosing the majority of individuals with dissociative identity disorder.<ref name="Blackwell neurology">{{cite book |title=Adult psychiatry: Blackwell's neurology and psychiatry access series |last=Rubin |first=EH |editor=Rubin EH |editor2=Zorumski CF |edition=2nd |publisher=[[John Wiley & Sons]] |year=2005 |isbn=978-1-4051-1769-2 |page=280 |url=https://books.google.com/books?id=uX4ZwtDKNqMC&pg=PA280}}</ref><ref name="pmid15560314"/><ref name = Paris2012/>

Psychologist [[Nicholas Spanos]] and others have suggested that, besides cases caused by therapy, dissociative identity disorder might result from [[role-playing]]. However, others disagree, arguing that there is no strong incentive for people to fabricate or maintain separate identities. They also cite reported histories of abuse as evidence.<ref>{{cite book |title=Psychology: Themes and Variations |last=Weiten |first=W |edition=8 |year=2010 |publisher=[[Cengage Learning]] |isbn=978-0-495-81310-1 |pages=[https://books.google.com/books?id=Wnr7vEjB7NAC&pg=PA461 461]}}</ref> Other arguments that therapy can cause dissociative identity disorder include the lack of children diagnosed with DID, the sudden spike in [[incidence (epidemiology)|rates of diagnosis]] after 1980 (although dissociative identity disorder 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<ref name="Lynn2012" /><ref name="pmid15560314" /> (as well as an initial increase in their number as psychotherapy begins in DID-oriented therapy<ref name="Lynn2012" />). These various cultural and therapeutic causes occur within a context of pre-existing psychopathology, notably [[borderline personality disorder]], which is commonly comorbid with dissociative identity disorder.<ref name="Lynn2012" /> In addition, presentations can vary across cultures, such as [[India]]n patients who only switch alters after a period of sleep – which is commonly how dissociative identity disorder is presented by the media within that country.<ref name="Lynn2012" />

Proponents of non-trauma-related dissociative identity disorder state that the disorder is strongly linked to (possibly suggestive) psychotherapy, often involving [[Repressed memory|recovered memories]] (memories that the person previously had amnesia for) or [[False memory|false memories]], and that such therapy could cause additional identities. Such memories could be used to make an allegation of [[child sexual abuse]]. There is little agreement between those who see therapy as a cause and trauma as a cause.<ref name="Rein2008">{{cite journal|author=Reinders AA |title=Cross-examining dissociative identity disorder: Neuroimaging and etiology on trial |journal=Neurocase |volume=14 |issue=1 |pages=44–53 |year=2008 |pmid=18569730 |doi=10.1080/13554790801992768 |s2cid=38251430}}</ref> Supporters of therapy as a cause of dissociative identity disorder suggest that a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position<ref name="Boysen" /> 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 artificially low recognition of the diagnosis.<ref name="Cardena" /> However, false memory syndrome ''per se'' is not regarded by mental health experts as a valid diagnosis,<ref>{{cite book|last=Rix |first=Rebecca |title=Sexual abuse litigation: a practical resource for attorneys, clinicians, and advocates |publisher=Routledge |year=2000 |page=33 |isbn=978-0-7890-1174-9}}</ref> and has been described as "a non-psychological term originated by a private foundation whose stated purpose is to support accused parents,"<ref name="Carstensen1993">{{cite journal|last1=Carstensen |first1=L. |last2=Gabrieli |first2=J. |last3=Shepard |first3=R. |last4=Levenson |first4=R. |last5=Mason |first5=M. |last6=Goodman |first6=G. |last7=Bootzin |first7=R. |last8=Ceci |first8=S. |last9=Bronfrenbrenner |first9=U. |last10=Edelstein |first10=B. |last11=Schober |first11=M. |last12=Bruck |first12=M. |last13=Keane |first13=T. |last14=Zimering |first14=R. |last15=Oltmanns |first15=T. |last16=Gotlib |first16=I. |last17=Ekman |first17=P. |date=March 1993 |title=Repressed objectivity |journal=APS Observer |volume=6 |pages=23 |url=https://blogs.brown.edu/recoveredmemory/files/2010/06/APS_Observer_letter.pdf}}</ref> and critics argue that the concept has no empirical support, and further describe the [[False Memory Syndrome Foundation]] as an advocacy group that has distorted and misrepresented memory research.<ref name="Dallam">{{cite journal |last1=Dallam |first1=Stephanie J. |title=Crisis or Creation? A Systematic Examination of False Memory Syndrome |journal=Journal of Child Sexual Abuse |date=11 March 2001 |volume=9 |issue=3–4 |pages=9–36 |doi=10.1300/J070v09n03_02 |pmid=17521989 |s2cid=26047059}}</ref><ref name="olio">{{cite book|editor=Cosgrove L |editor2=Caplan PJ |last=Olio |first=KA |title=Bias in psychiatric diagnosis |publisher=Jason Aronson |location=Northvale, N.J |year=2004 |pages=[https://books.google.com/books?id=6XPLguPHzHoC&pg=PA163 163–168] |isbn=978-0-7657-0001-8 |chapter=The Truth About 'False Memory Syndrome'}}</ref>

A review of recent research into DID found not one empirical study into the sociocognitive model in the 2011-2021 period, identifying the model as "a source of unresolved criticism of the trauma model", not an empirical hypothesis in its own right. Some major skeptics of trauma-related DID have in recent years abandoned single-cause models of the disorder, arguing for an end to the controversy as no such model can provide a "complete or fully satisfactory account" of DID.<ref name=boysen2024/> As part of their "trans-theoretical" model Lynn et al. suggested that trauma may be more important than sociocognitive factors in clinical cases.<ref name=lynn2022>{{cite journal|last1=Lynn|first1=Steven Jay|last2 = Polizzi|first2 = Craig| last3 = Merckelbach| first3 = Harald| last4=Chiu |first4= Chui-De|last5=Maxwell|first5=Reed|last6 = van Heugten| first6=Delena| last7= Lilenfeld|first7 = Scott O.| year = 2022| title=Dissociation and Dissociative Disorders Reconsidered: Beyond Sociocognitive and Trauma Models Toward a Transtheoretical Framework| journal = Annual Review of Clinical Psychology| volume = 9| number = 18 |pages = 259-289|doi=10.1146/annurev-clinpsy-081219-102424}}</ref> 

===Children===

The rarity of DID diagnoses in children is cited as a reason to doubt the validity of the disorder,<ref name="pmid15560314"/><ref name=Boysen/> and proponents of both etiologies believe that the discovery of dissociative identity disorder in a child who had never undergone treatment would critically undermine the non-trauma related model. Conversely, if children are found to develop dissociative identity disorder only after undergoing treatment it would challenge the trauma-related model.<ref name=Boysen/> {{As of|2011}}, approximately 250 cases of dissociative identity disorder in children have been identified, though the data does not offer unequivocal support for either theory. While children have been diagnosed with dissociative identity disorder before therapy, several were presented to clinicians by parents who were themselves diagnosed with dissociative identity disorder; others were influenced by the appearance of dissociative identity disorder in popular culture or due to a diagnosis of psychosis due to hearing voices – a symptom also found in dissociative identity disorder. No studies have looked for children with dissociative identity disorder in the general population, and the single study that attempted to look for children with dissociative identity disorder not already in therapy did so by examining siblings of those already in therapy for dissociative identity disorder. 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.<ref name=Boysen/>

The initial theoretical description of dissociative identity disorder was that dissociative symptoms were a means of [[coping (psychology)|coping]] with extreme stress (particularly childhood sexual and physical abuse), but this belief has been challenged by the data of multiple research studies.<ref name=Lynn2012>{{cite journal |last1=Lynn |first1=S. J. |last2=Lilienfeld |first2=S. O. |last3=Merckelbach |first3=H. |last4=Giesbrecht |first4=T. |last5=Van Der Kloet |first5=D. |title=Dissociation and Dissociative Disorders: Challenging Conventional Wisdom |journal=Current Directions in Psychological Science |volume=21 |pages=48–53 |year=2012 |doi=10.1177/0963721411429457 |issue=1|s2cid=4495728 }}</ref> Proponents of the trauma-related model claim the high [[correlation and dependence|correlation]] of child sexual and physical abuse reported by adults with dissociative identity disorder corroborates the link between trauma and dissociative identity disorder.<ref name=Hersen2012/><ref name=Lynn2012/> However, the link between dissociative identity disorder and maltreatment 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 bias|selection]] and referral bias.<ref name=Hersen2012/><ref name=Lynn2012/> Most studies of trauma and dissociation are [[cross-sectional study|cross-sectional]] rather than [[longitudinal study|longitudinal]], which means researchers can not attribute [[correlation does not imply causation|causation]], and studies avoiding [[recall bias]] have failed to corroborate such a causal link.<ref name=Hersen2012/><ref name=Lynn2012/> In addition, studies rarely [[Scientific control|control for]] the many [[#Comorbid disorders|disorders comorbid with dissociative identity disorder]], or [[Dysfunctional family|family maladjustment]] (which is itself highly correlated with dissociative identity disorder).<ref name=Hersen2012/><ref name=Lynn2012/> The popular association of dissociative identity disorder with childhood abuse is relatively recent, occurring only after the publication of ''[[Sybil (Schreiber book)|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]]'', reported no memory of childhood trauma.<ref name=McNally2005>{{cite book |title=Remembering Trauma |pages=[https://books.google.com/books?id=88Axi0huzYwC&pg=PA11 11–26] |year=2005 |author=McNally, Richard J.|publisher=[[Harvard University Press]]|author-link=Richard McNally |isbn=978-0-674-01802-0}}</ref>