Dissociation: Is it Trauma Based or Fantasy Based?

Is dissociation trauma based or fantasy based?

In the Trauma Model (TM) of dissociation, dissociation is conceptualized as being a reaction to antecedent traumatic stress and/or severe psychological adversity (Nijenhuis, Vanderlinden, & Spinhoven, 1998; Putnam, 1997; Spiegel, 1984). Some authors have proposed an alternative hypothesis, known as the Fantasy Model (FM) of dissociation*, which posits that dissociation is not caused by trauma; rather, these authors argue that individuals prone to dissociation are suggestible and fantasy prone, and therefore confabulate false memories of trauma (e.g., Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008; Merckelbach, Horselenberg, & Schmidt, 2002). A recent review examined the extant research to determine which model had the greatest empirical support and found strong support for the TM but not for the FM (Dalenberg et al., 2012). The authors found that the relationship between dissociation and trauma did not disappear when objective measures of trauma were used. Furthermore, dissociation was found to be highest immediately after trauma and to dissipate in most individuals over time as well as in response to trauma treatment. Research supported the TM theories about memory fragmentation and amnesia. Contrary to the FM hypothesis that dissociative individuals are suggestible, the relationship between dissociation and suggestibility was found to be weak and inconsistent, with dissociation explaining only 1 – 3% of suggestibility. Furthermore, dissociation continued to be significantly related to trauma even when fantasy proneness was controlled. Given the strong evidence across many researchers utilizing a variety of methodologies, Dalenberg et al. concluded that there was strong empirical support for the TM – specifically, there was compelling evidence that trauma causes dissociation and almost no support for the FM of dissociation.

*This model is also sometimes referred to as the sociocognitive and/or iatrogenic models of dissociation.

An empirical examination of six myths about dissociative identity disorder:

Brand, B. L., Sar, V., Stavropoulos, P., Kruger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating fact from fiction: An empirical examination of common myths about dissociative identity disorder. Harvard Review of Psychiatry, 24(4), 257-270. doi: 10.1097/HRP.0000000000000100

Despite the ever-growing literature on dissociative identity disorder (DID, formerly known as multiple personality disorder), a number of misconceptualizations and myths about the disorder remain to be addressed. The absence of research to substantiate these beliefs, as well as a body of research that refutes them, confirms their mythical status. The cost of ignorance about DID is high not only for individual patients, but for the whole support system in which they live. Fortunately, empirically derived knowledge about DID has replaced outdated myths. We have highlighted six popular myths about DID and respective empirical evidence counteracting the claims below (see Brand et al., Harvard Review of Psychiatry for the studies supporting the evidence listed below [7]).

MYTH

EVIDENCE-BASED FACT
1. DID is a “fad”
  • DID is not a “fad” that has died. The authors browsed PsycInfo and Medline using the terms “multiple personality disorder” or “dissociative identity disorder” in the title for the period 2000 – 2014. The search yielded 1,339 hits for this fifteen-year period. The high number of publications about DID indicates an enduring scholarly and clinical interest in DID.
  • DID patients can be reliably and validly diagnosed with structured and semi-structured interviews including the Structured Clinical Interview for Dissociative Disorders-Revised (SCID-D-R) and the Dissociative Disorders Interview Schedule (DDIS).
2. DID is primarily diagnosed in North America by DID experts who over-diagnose the disorder
  • DID patients are consistently identified in outpatient, inpatient, and community samples around the world.
  • DID is diagnosed by clinicians around the world with varying degrees of expertise in DID.
  • Studies show that most individuals who meet criteria for DID have been treated in the mental health system for 6 to 12 years before they are finally correctly diagnosed.
3. DID is rare
  • The prevalence rates of DID have been studied in community samples, psychiatric inpatients, psychiatric outpatients, the general population, and a specialized inpatient unit for substance dependence suggest otherwise. DID is found in approximately 1.1 – 1.5% of representative community samples.
  • Studies assessing groups with particularly high exposure to trauma or cultural oppression show the highest rates of DID.
4. DID is an iatrogenic disorder rather than a trauma-based disorder
  • Researchers concluded from their review and a series of meta-analyses that little evidence supports the position that DID is created by suggestion, fantasy, or iatrogenesis; these ideas are put forward by proponents of the “Fantasy Model” [FM] (sometimes also called the “Sociocultural Model” or “Iatrogenic Model”) of DID of dissociation [47].
  • The correlations between trauma and dissociation were as strong in studies that used objectively verified abuse as in those relying on self-reported abuse. This strongly contradicts the FM hypothesis that DID individuals fantasize their abuse [47].
  • Dissociation predicted only 1 – 3% of the variance in suggestibility, thereby disproving the FM’s notion that dissociative individuals are highly suggestible. [47]
  • Additionally, no study has been conducted in any clinical population that strongly supports the FM of dissociation.
5. DID is the same entity as Borderline Personality Disorder (BPD)
  • While DID and BPD can frequently be diagnosed in the same individual, nevertheless they appear to be discrete disorders. Recent clinical observational studies as well as systematic studies using structured interview data have distinguished DID from BPD.
  • When the comorbidity between BPD and DID is evaluated specifically, the patients with comorbid BPD and DID appear to be more severely impaired compared to individuals with either disorder alone.
6. DID treatment is harmful to patients
  • This claim is inconsistent with empirical literature which documents improvements in the symptoms and functioning of DID patients when trauma treatment consistent with expert consensus guidelines is administered [46] [61] [160].
  • Early case series and inpatient treatment studies demonstrate that treatment for DID is helpful, rather than harmful, across a wide range of clinical outcomes.

*For a comprehensive list of references used in Brand et al., please see here.

[1] Nijenhuis, E. R. S., Vanderlinden, J., & Spinhoven, P. (1998). Animal defensive reactions as a model for trauma-induced dissociative reactions. Journal of Traumatic Stress, 11, 243-260. 

[2] Putnam, F.  W. (1997). Dissociation in children and adolescents: A developmental model. New York: Guilford.

[3] Spiegel, D. (1984). Multiple personality as a post-traumatic stress disorder. Psychiatric Clinics of North America, 7(1), 101-110.

[4] Giesbrecht, T., Lynn, S. J., Lilienfeld, S. O,, & Merckelbach, H. (2008). Cognitive processes in dissociation: An analysis of core theoretical assumptions. Psychological Bulletin, 134, 617-647. 

[5] Merckelbach, H., Horselenberg, R., & Schmidt, H. (2002). Modeling the connection between self-reported trauma and dissociation in a student sample. Personality and Individual Differences, 32, 695-705. 

[6] Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Cardeña, E., … & Spiegel, D. (2012). Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychological Bulletin, 138(3), 550.

[7] Brand, B. L., Sar, V., Stavropoulos, P., Kruger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating fact from fiction: An empirical examination of common myths about dissociative identity disorder. Harvard Review of Psychiatry, 24(4), 257-270.