Pathophysiology of Dissociative Identity Disorders
Dissociation is the disruption of the normal integrative processes of consciousness, perception, memory, and identity that define selfhood. It is increasingly understood as a complex and chronic posttraumatic psychopathology closely related to severe, particularly early, child abuse. Children who have been maltreated or abused are at risk for experiencing a host of mental health problems, including dissociative identity disorder. This condition is characterized by a) the presence of 2 or more distinct personality states or what some cultures may describe as an experience of possession, and b) recurrent episodes of amnesia.
The deleterious effects of childhood abusive experiences on growth and development have been well documented and are associated with various later mental health problems. Diagnosis of dissociative identity disorder (DID) is not usually made until adulthood, long after the extreme maltreatment thought to engender the condition has occurred. Therefore, although the most common cause of the disorder is agreed to be early, ongoing, extreme physical and/or sexual abuse, accounts of such abuse are usually provided retrospectively by the patient and lack objective verification. Researchers have shown that, in many instances, borderline personality disorder and posttraumatic stress disorder (PTSD) in adulthood may be traced to childhood abuse.
The existence of significant dissociative psychopathology related to physical and sexual abuse experienced in childhood was known to clinicians in the last century. However, only recently have modern mental health practitioners begun to appreciate implications of this forgotten linkage. Clinical and research reports indicate that a history of physical and sexual abuse in childhood is more common among adults who develop major mental illness than previously suspected. Dissociation has also been linked specifically to childhood physical neglect in patients diagnosed with schizophrenia. Various degrees of dissociative disorders are recognized, ranging from passive disengagement and withdrawal from the active environment to severe dissociative disorder characterized by disturbances in both identity and memory and best understood as a posttraumatic, adaptive dissociative response to the fear and pain of overwhelming trauma, most commonly abuse. Fully expressed DID is not often diagnosed as such in the pediatric population.
Dissociation is a psychophysiologic process that alters a person’s thoughts, feelings, or actions so that, for a time, certain information is not associated or integrated with other information as it normally is. This process, which manifests along a continuum of severity, produces a range of clinical and behavioral phenomena involving alterations in memory and identity. In extreme cases, the process gives rise to a set of psychiatric syndromes known as dissociative disorders. Not all abused children develop a dissociation disorder; however, studies have shown that abused children demonstrate more dissociation than nonabused children do.
Regarding DID, Kluft’s reports from 1984 and 1987 view the condition as a chronic dissociative PTSD originating in childhood. He has proposed a 4-factor theory to explain the genesis of DID, as follows:
- Individuals have an innate potential to dissociate that is reflected in hypnotizability ratings;
- Traumatic experiences in early childhood may disturb personality development, leading to greater potential for psychodynamic dividedness;
- Individuals may be denied the chance to spontaneously recover because of continued emotional and/or social deprivation; and
- Final presentation is shaped by psychodynamic and extrinsic factors, including psychosocial influences.
Credit: Author: Muhammad Waseem, MD., MS., for Medscape (Abridged)