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Dissociative Identity Disorder Theories and Treatments
Running head: Neurobiological Driven Treatment of DID
Neurobiological Research Driven Treatment for Dissociative Identity Disorder
Neurobiological Driven Treatment of DID 2
Dissociative Identity Disorder (DID) is an often misunderstood phenomenon by clinicians and
lay people alike. Current research leads experts to believe that this disorder may often go
unnoticed or be misdiagnosed due to the overlapping symptomology and abundance of
comorbidities that exist within DID. Its prevalence may in fact, be greater than currently
reported. Although many theories exist, most theories converge on the idea that DID is a result of
severe and often repeated trauma occurring in early childhood. These trauma based theories
conceptualize that what manifests as a debilitating disorder in adulthood was meant as a
protective coping mechanism and shield for the traumatized child. Much of the brain research
concerning DID reveals findings consistent with the disorder of post- traumatic stress syndrome.
(PTSD.) Though DID begins in early childhood, it is most often diagnosed in adolescence or
adulthood. Though there have been success stories, treatment of DID has been largely
unsuccessful on a global scale. Recent neurobiological research on the causes, functions, and
mechanisms of DID provides a new hope and foundation upon which clinicians can base their
treatment plans. More research is needed for full apprehension and productive treatment of this
Neurobiological Driven Treatment of DID 3
Neurobiological Research Driven Treatment for Dissociative Identity Disorder
Dissociative Identity Disorder (DID) is under-researched and often misunderstood.
(Chlebowski & Gregory, 2012). The disorder can be intimidating to both doctors and counselors.
Many researchers agree with Gleaves and Williams (2005) when they lament that,
…many professionals have no formal education and training in the psychopathology,
assessment and treatment of posttraumatic stress disorder (PTSD) and dissociative
disorders. In particular, many of the ideas that clinicians have about DID may come from
hearsay or the popular media, not theoretical and empirical research regarding trauma and
dissociation. (p. 648)
There is a great need for clinicians to be made aware, educated and trained in the theories and
treatment of dissociative disorders and specifically, DID. A review of the literature helps to
crystalize the origins, purposes and processes of this disorder. Treatment of DID has been largely
unsuccessful in the past, but current research providing insight into the processes of dissociation
is providing clinicians with the direction needed to create successful treatment plans. The bulk of
this review will resolve around treatment of DID as it presents in adolesence or adulthood
because as Boysen (2011) concludes from his review of research on childhood DID,
“…childhood DID itself appears to be an extremely rare phenomenon…” (p. 329).
Neurobiological Driven Treatment of DID 4
“Dissociation means to bring apart, split off or disconnect elements that have something in
common, as the opposite of association.” (Diseth, 2005, p. 79) The Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) (DSM -
5) acknowledges that dissociation can affect memory, consciousness, identity and perception of
environment. Sensation, movement and other bodily functions can also be disturbed. Many or
all of these occurances are common in the patient with DID. What sets DID apart from the other
dissociative disorders is the prescence of a disruption of identity. In order to meet the DSM -5
criteria for DID, two or more separate personality states must exist and exhibit amnesia in
relation to each other. Often several of these parts will take control of the behavior of the
individual. Although reports vary and further research is needed, Johnson and collegues, as sited
in Chlebowski & Gregory, (2012), found DID to be prevalent among about 1.5% of the general
population. Foote and colleagues found the prevelance to be between 5-6% among both
inpatient and outpatient psychiatric patients (as cited in Chlebowski & Gregory, 2012). Females
are much more likely to meet criteria for DID with Maldonado, Butler & Spiegel (as cited in
Durand & Barlow, 2013) reporting as high as a 9:1 ratio. Ross (1997) as well as Sackeim &
Devanand (1991), found that clinicians report the average number of separate identities to be
around 15 (as cited in Durand & Barlow, 2013).
Most treatment models for DID agree that intergration of dissociated parts is the
culminating and confirming factor of healing. Unfortunately, research by Ross (1997) suggests
that roughly 22% of those suffering from DID will achieve full integration after two full years of
continuous therapy (as cited in Durand & Barlow, 2013). This poor prognosis makes it clear that
further research is needed to bring about effective treatment in the future. With intergration as
Neurobiological Driven Treatment of DID 5
the main goal for healing, much of the current research resolves around discovering the causes,
functions and mechanisms of the process of trauma related dissintegration. If we can learn how
and why the brain was able to dissociate, maybe we will gain a better understanding of the
processes needed to undo the effects of severe and complex dissociation.
It was in the late 1990s that dissociative traits were measured in general population
studies and correlations were found between dissociative symptoms and those with childhood
abuse in their past. Currently, the focus is on understanding the developmental causes and
outworkings of the trauma-related dissociative process and its connection to possible treatment
models. (Diesth & Christie, 2005) The revelation of neurobiological implications of
dissociation through recent research has proved helpful to this cause.
“The difficulty that individuals may have with synthesizing and personifying terrifying
experiences seems related to biological reactions to severe threat.” (Nijenhuis, van der Hart, &
Steele, 2010) The mind and body connection is powerful in relation to trauma and dissociation
and may be a key to unlocking the mystery that once seemed to surround DID. Both structural
and chemical reactions have been linked to trauma related dissociation. “In both animal and
human studies, early stress has been shown to be associated with changes in the structure of the
hippocampus, which plays a crucial role in learning, memory, and stress regulation.” (Vermetten,
Schmahl, Linder, Loewenstein, & Bremner, 2006, p. 630) A study by Vermetten et al.(2006)
found a 19.2% decrease in the mean volume of the left and right hippocampus of DID patients.
But Nijenhuis et al. (2010) report that “women who fully recovered from DID had more
hippocampal volume compared to women with DID.” (p.4) In this case, the damage to the
Neurobiological Driven Treatment of DID 6
hippocampus created by trauma-related dissociation was somehow reversed, and volume
regained in the healing process! The connections being made in these findings should provide
hope and direction to researchers, clinicians, and sufferers of DID that solid, researched based
treatments are on the horizon.
Research Driven Treatments
The phase oriented treatment of DID for instance, in a preliminary finding is linked with
substantial growth of both the left and right hippocampal volume. (Nijenhuis, van der Hart, &
Steele, 2010) This treatment consists largely of three phases. The goal of the treatment, as stated
by Nijenhuis et al. (2010) “concerns resolution of the structural dissociation of the personality by
exposing the dissociative parts of the personality, and their mental contents to each other in
carefully planned steps that promote integration and preclude re-dissociation” (p. 18). The first
phase, according to Nijenhuis et al. (2010) involves increasing the coping capabilities of the
patient. During this phase, phobia of dissociated parts of the personality are addressed and
overcome. In order for DID to be maintained, dissociated parts will remain phobic of each other
while the part of the personality most often apparent to the world will persist in phobia of
traumatic memories. In order to return to unity, the therapist must help the patient go from fear
to acceptance of her parts and memories. Attachment phobias are dealt with and hopefully lead
to a secure alliance with the therapist and cooperative relationships between dissociated parts.
Nijehuis et al. (2010) are careful to point out that, in order to prevent redissociation from
occuring, the patient must be secure in her acceptance of parts and strengthened in coping skills
before moving to phase two. This phase involves overcoming the phobia of traumatic memories
through gradual access and exposure. Substantiated methods for the treatment of PTSD, such as
Eye Movement Desensitization and Reprocessing, Cognitive Behavioral Therapy, guided
Neurobiological Driven Treatment of DID 7
imagery, and hypnosis, are commonly used in this phase. The main goals of the third phase,
according to Nijenhuis et al. (2010) are overcoming fears of intimacy, synthesizing dissociated
parts of the personality and learning to replace dissociative and avoidant measures with healthier
coping mechanisms to face the tragic griefs caused by early endured trauma. Diesth & Christie
(2005), agree with this model when they conclude that, “the currently agreed aim of
treatment…is to reveal the trauma, then work through it by introducing new frames and
strategies for coping and control…” (p. 284). They also recommend that, “The most successful
treatment approach is often the most eclectic…” (p. 285) and encourage therapists to be well
researched and flexible. (p. 285) They warn that therapuetic interventions be based on what is
currently known about the neurobilogical processes of dissociation and trauma.
Some of the treatments recommended by Diesth & Christie (2005) include the use
of dissociation as a tool to help patients gradually approach their trauma memories, increase
affect tolerance, and gain control over intrusive images. Schema-focused cognitive therapy
points out early maladaptive schemas and works to restructure them into healthier, more truthful
perspectives. Diesth & Christie provide neurobiological support for the use of hypnotherapy
when they remind us that, “since traumatic experiences are coded in a special emotional state and
not accessible only by cognitive approaches, therapists…integrate hypnotherapeutic approaches”
DID has long been a source of controversy and some mystery among
professionals and the community at large. Fortuneately, new research into the brain chemistry
and structures affected by DID is providing insight into the causes, functions and mechanisms of
Neurobiological Driven Treatment of DID 8
this disorder. These insights have provided researchers and clinicians with a foundation to base
formation of individualized treatment plans to assist patients to achieve integration of personality
and to put adaptive coping mechanisms in place of maladaptive dissociative coping strategies.
Vermetten et al. (2006) encourage us that, “These findings may have clinical implications for the
treatment of DID patients….understanding DID as…involving neural circuitry alterations in
brain areas associated with…PTSD may help clinicians better understand…treament sessions.”
(p.635) More research is needed in the area of neurobiological affects of DID. As researchers
uncover more information it is hopeful that the percentage of DID patients achieving full
intergration of personality will increase significantly.
Neurobiological Driven Treatment of DID 9
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Boysen, G. A. (2011). The Scientific Status of Childhood Dissociative Identity Disorder: A
Review of Published Research. Psycotherapy and Psycosomatics, 80, 329-334.
Chlebowski, S. M., & Gregory, R. M. (2012). Three Cases of Dissociative Identity Disorder and
Co-Occuring Boderline Personality Disorder Treated with Dynamic Deconstructive
Psycotherapy. American Journal of Psychotherapy, 66 (2), 165-180.
Diesth, T. H., & Christie, H. J. (2005). Trauma related dissociative (conversion) disorders in
children and adolescents - an overview of assessment tools and treatment principles.
Nordic Journal of Psychiatry, 59, 278-292.
Diseth, T. H. (2005). Dissociation in children and adolescents as reaction to trauma-an overview
of conceptual issues and neurobiological factors. Nordic Journal of Psychiatry, 59, 79-
Durand, M. V., & Barlow, D. H. (2013). Essentials of Abnormal Psychology. Belmont :
Wadsworth, Cengage Learning.
Gleaves, D. H., & Williams, T. (2005). Critica Questions: Trauma, Memory, and Dissociation.
Psychiatric Annals, 35 (8), 648-654.
Nijenhuis, E., van der Hart, O., & Steele, K. (2010). Trauma-Related Structural Dissociation of
the Personality. Activitas Nervosa Superior, 52 (1), 1-23.
Vermetten, E., Schmahl, C., Linder, S., Loewenstein, R. J., & Bremner, D. J. (2006).
Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder. American
Journal of Psychiatry, 163 (4), 630-636.