Etiology of Dissociative Identity Disorder

Neuropsychiatrist Pierre Marie Félix Janet (1859-1947) and Sigmund Freud, both addressed the issue of what was, at that time called “multiplicities,” but their ideas went in “dissociated” directions. Freud’s teachings became popular, while Janet’s were scorned. The 1960’s and 70’s might have even been worse, as psychiatrists reported their observations in the media, rather than in peer reviewed journals, resulting in a chaotic time for psychology. They described mixed and confusing portrayals of what are known today as other specified dissociative disorder(OSDD and prior to 2013 as DDNOS in the DSM), borderline personality disorder (BPD), antisocial personality disorder (psychopath, sociopath), narcissist personality disorder (NPD) and as they stumble, fell and avoided Janet’s work,, they did still manage to include a bit of dissociative identity disorder into the mix of what was then called multiple personality disorder.

Enter the 1980’s, when Onno van der Hart and Ellert Nijenhuis, two neuropsychologists, unearthed the writing and recorded lectures of Janet, who had discerned there were two different disorders with overt state switching: dissociative identity disorder and OSDD, and he reported the differences in uncanny detail. Janet also understood introjected behavior, and how it is imitated by dissociated states in both complex Dissociative Disorders (dissociative identity disorder and OSDD). While an individual with a Dissociative Disorder can have a Personality Disorder, they only have a Personality Disorder if every personality state shares the disorder, otherwise it’s an introjected behavior belonging to only select personality states. Dissociative Disorders can be fixed, while Personality Disorders cannot, so the distinction is important. This brings us to today, where most have accepted what Janet tried to teach the world – long ago. Neurologists, biologists, psychologists, geneticists and psychiatrists are beginning to understand how the etiology of dissociative identity disorder is unique to itself. No other mental disorder is like it, and none maintain the same insane complexity.

Dissociative identity disorder is not “like” OSDD
Dissociative identity disorder is unique in its etiology, presentation, experience and its entire system of neurology, chemistry and internal physical makeup. The only shared qualities it has with OSDD is the fact that there is dissociative amnesia, state switching, elaborated less than distinct states, and both disorders evolved through childhood trauma rather than having a base in genetics. ” While genetics are important for some mental disorders, the genes needed to “cause” Dissociative Disorders are common to every human on the planet. (Lanius et al.,  2014) (Vermetten et al., 2007) (van der Hart et al., 2006)

Etiology of dissociative identity disorder

This disorder begins in infancy when “enough” psychological trauma is suffered so the brain is unable to calm for months at a time, which is compounded by a lack of consistent nurturing and soothing. Then either the harmful environment persists beyond infancy, or somewhere between infancy and five years of age, a like-environment recurs. (Lanius et al.,  2014)

Many factors combine to cause dissociative identity disorder
At least nine factors must come together, starting in infancy and more or less continue throughout very early childhood, in order for this disorder to take hold.

1. Defenseless 
An infant is the victim, and that child is defenseless to the actions and inactions of their caregivers. That utter defenselessness propagates changes the brain, as the mind and brain interact to defend against their greatest perceived threat – the caregivers. After the first year o69f life, the child is less dependant, although certainly not ready to head out on their own. A toddler still needs a caregiver, and so does any child under the age of five. While they are not completely defenseless, as an infant is, they are incapable of existing without a caretaker of some sort. It’s highly appropriate to say that a child is defenseless from birth to the age of five, and that is the age that is targeted in those with dissociative identity disorder. (Lanius et al.,  2014)

2. Terrorized throughout infancy
For dissociative identity disorder to result, there must be consecutive months of terror enacted upon an infant.

3. Terrorized between infancy and five 
Following infancy, the terror again must consume a child’s existence between infancy and the age of four or five.

4. Unsoothed 
Neurologists have taken giants leaps as they use fMRI scans to verify not only the existence of dissociative identity disorder, but to identify how the disorder evolves. To gain a basic understanding of the etiology of the disorder, one must grasp the simplest idea of Stephen Porges’ polyvagal theory. The theory explains that when the brain cannot make sense of its “environment,” a series of functions will transpire. These functions are referred to as fight, flight, freeze, feign and fear. A consistently terrorized and unsoothed infant will cycle through them all, but ultimately will stay in the fear reaction. (Lanius et al.,  2014) Following infancy if the child is still in the terrorizing environment, which will be the case in those who develop dissociative identity disorder, then their brain will still be unable to calm. This is what is meant when researchers say a child must be soothed, but Ulrich F. Lanius, Sandra L. Paulsen and Frank M. Corrigan add more to this. They reported, in their 2014 book, that when the brain is kept in a state of terror for prolonged periods of time in very early childhood, then any attempt to later calm is not possible. They go on to hypothesize that even if a caregiver were to attempt to calm an infant or very young child that has been terrorized for months, it might not be enough to calm their brain because the cranial nerves are no longer able to respond to outside input. (Lanius et al.,  2014)

5. True attachment is not possible 
An true attachment will not exist between an adult who the child is with on a daily basis. In dissociative identity disorder the link between the primary caregiver cannot be formed, and it’s this deprivation that drives a child to pull from other resources. On the other hand, In OSDD, there will be an attachment of some sort to a primary caregiver, so the child is not mentally on their own. In dissociative identity disorder the child is emotionally isolated, and has no one on a consistent basis, in which they can rely on and bond with. They are alone mentally, and their inner world is their only consistent source of soothing. Such a child will startle easily, and they will be abashedly forward in the fear they show toward their primary caregiver, and it is fear, rather than anger or despondency. Lack of any attachment, confusion and a terrorized mind are seen in all young children who develop dissociative identity disorder. The literature tends to summarize all this by simply saying, the child lacks a secure attachment with their primary caregiver, but as you can see, it’s more involved than that. In fact, what the child develops, even though it’s called a “disorganized attachment,” is not an attachment at all. It’s fear – terrible, crippling fear. (Lanius et al., 2014) Lanius et al., do address the idea that some people have that they were not “abused,” and still have dissociative identity disorder, but this is not possible. These individuals probably have OSDD. (Lanius et al., 2014)

6. Trauma events are active in the mind 
A child with the above experiences is unable to process trauma into memory. Exactly why is still on the chopping block, but Lanius et al, hypothesize that the brain is unable to communicate with the mind effectively, resulting in the dysfunction. Ellert Nijenhuis proposes that the mind and the brain both communicate well, but the mind is not ready to accept the signals for processing the brain is sending out. (Lanius et al., 2014)

7. Structural dissociation
Because trauma stays in the mind structural dissociation results, which is an altering of the personality. Instead of a personality made up of many states that freely communicate with each other and switch with ease, the personality is changed into one that keeps the trauma separate from the states that will attend to daily life tasks. For more see structural dissociation. (van der Hart et al., 2006)

Unprocessed trauma held in the subconscious mind
8. Following structural dissociation, trauma events are still not processed and remain in the mind, often until the individual dies or they successfully complete the needed steps of integration and trauma processing.

9. Dissociative states are created
There are two types of dissociated states in dissociative identity disorder: less than distinct, which “hold” “remembered trauma,” and distinct states that are highly phobic of the “remembered trauma.” This is the only disorder that has the ability to create more than one distinct state, and it is that which causes the brunt of the problems in this mental disorder. For more see personality states. (van der Hart et al., 2006) (Lanius et al.,  2014) (Vermetten et al., 2007)

Integration and communication between personality states 
10. The process of integration will naturally strive to heal the damage caused by the trauma, but advanced work cannot be done until a point is reached where at least one distinct state, while in the conscious mind, can communicate with and accept at least one less than distinct state that is communicating from the subconscious mind.

Integration and trauma processing

11. Integration will only proceed quickly when the individual begins to focus their mind on it. This is the idea of therapy. Communication is the first step, but it’s closely followed by hard work that is necessary to finally process the trauma events into memory in the brain.

The Polyvagal Theory
Dr. Stephen Porges, director of the Brain-Body Center at the University of Illinois at Chicago, designed the theory called Polyvagal Theory. It explains what happens in the brain of an individual in an adverse environment. The vagal nerve, a set of cranial nerves and its many branches are the primary focus of his work. For our purpose, as we discuss dissociative identity disorder, we need only concern ourselves with the tenth-cranial nerve, because it’s through this avenue that the brain connects to the body when adverse environmental conditions effect an individual. Let’s narrow our thinking to a child under the age of five, or better yet, an infant. An infant is alone, and no one responds to the babies distress, leaving the child fearful. In order to calm that polyvagal response someone needs to sooth the child. Without soothing, the child will remain in a state of fear. In the case of infants who succumb to dissociative identity disorder, they are left in a state of terror throughout most of their infancy. The terror of their childhood does not have to be overtly continuous, but mentally it cannot stop without intervention. It’s thought that after long periods (months on end) where a child has been subjected to a terrorizing environment without soothing from an adult, the child will loose the ability to calm their brain until they work, usually for years, on the integration process.

(Lanius et al.,  2014)