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Dissociation is a common and often overlooked symptom in traumatised children. Although there is a lack of a scientific consensus as to the nature of dissociation and very limited research about dissociative identity disorder (DID) in children, the authors have seen children given this diagnosis recently referred to their clinic and are concerned about this practice and the parenting approaches that have ensued. The diagnosis of DID in children may be rare or of doubtful validity, but repeated traumatic experiences of an interpersonal nature can have a profound effect on a child's identity, memory and self-organisation. Furthermore, abuse and neglect can increase the risk of dissociative symptoms. This brief article considers dissociation in post-traumatic stress disorder, then outlines developmental factors hypothesised to be associated with dissociation in childhood and early adulthood. It warns that clinicians should keep an open mind about how dissociation may manifest transdiagnostically, and concludes with recommendations for further research.
Dissociative identity disorder:
a developmental perspective
Simon Wilkinson & Margaret DeJong
Dissociation is a common and often overlooked
symptom in traumatised children. Although there
is a lack of a scientific consensus as to the nature
of dissociation and very limited research about dis-
sociative identity disorder (DID) in children, the
authors have seen children given this diagnosis
recently referred to their clinic and are concerned
about this practice and the parenting approaches
that have ensued. The diagnosis of DID in children
may be rare or of doubtful validity, but repeated
traumatic experiences of an interpersonal nature
can have a profound effect on a childs identity,
memory and self-organisation. Furthermore,
abuse and neglect can increase the risk of dis-
sociative symptoms. This brief article considers
dissociation in post-traumatic stress disorder,
then outlines developmental factors hypothesised
to be associated with dissociation in childhood
and early adulthood. It warns that clinicians should
keep an open mind about how dissociation may
manifest transdiagnostically, and concludes with
recommendations for further research.
Dissociative disorders; post-traumatic stress dis-
order; trauma.
We write as consultant psychiatrists at a national
specialist clinic in the UK, which since the 1980s
has taken referrals for children who have experi-
enced abuse and neglect. In the course of this work
we have learned that dissociation is a common and
often overlooked symptom in traumatised children.
In the past year, however, we have seen two children
referred to the clinic already diagnosed with dis-
sociative identity disorder (DID) and have been con-
cerned about the diagnoses and advice parents have
been given.
There is very limited research about DID in chil-
dren, and there are developmental questions to be
asked about making such a diagnosis at an age
when identities are still forming. At the same time,
repeated traumatic experiences of an interpersonal
nature can have a profound effect on a childs iden-
tity, memories and self-organisation. It is common
for children who have been removed from home to
have a limited or confused understanding of why
this has happened, and to have negative thoughts
about themselves from which they may take refuge
in fantasy. They may have had formative experi-
ences, such as of sexual abuse, which have not
been acknowledged by the adults in their lives.
Such circumstances must necessarily be a breeding
ground for identity confusion. Although the diagno-
sis of DID may be rare or even of doubtful validity in
children, we are keen that this should not obscure an
improved understanding of how abuse and neglect
increase the risk of dissociative symptoms.
Defining dissociation
A review of dissociation is complicated by the lack of
a clear scientic consensus as to its nature. It may, of
course, be non-pathological. Some of the symptoms
in the Dissociative Experiences Scale (DES)
(Dubester 1995), such as driving and not remember-
ing part of the journey, are a part of everyday life.
The same applies to the fantasy, role-play and
imaginary friends of childhood. Meta-analytic data
have indeed shown gradual decreases in dissociation
with age (van Ijzendoorn 1996). Meanwhile, there is
debate about what psychiatric symptoms may be
treated as dissociative. Consider for example the cri-
teria for post-traumatic stress disorder (PTSD). The
DSM-5 (American Psychiatric Association 2013)
has adopted a dissociative subtype of PTSD,
featuring symptoms of depersonalisation and
derealisation, but many authors argue that
ashbacks are also dissociative (Dorahy 2015). As
vivid, sensory, fragmentary experiences, they
certainly are not integrated in the way of typical
autobiographical memories. Auditory hallucina-
tions have also been treated as dissociative in
nature (Moskowitz 2009), and this may be recognis-
able to clinicians who notice how voices often reect
traumatic themes in a patients life.
The DSM-5 criteria for DID refer to recurrent
gaps in the recall of everyday events, important per-
sonal information and/or traumatic events that are
inconsistent with ordinary forgetting. Amnesia for
traumatic events, whether complete or partial, is,
however, recognised as a common feature of PTSD
in both the ICD-10 and DSM-5 classications
(World Health Organization 1993; American
Psychiatric Association 2013). Historically, such
Simon Wilkinson, BA(Oxon),
MBBS, MRCPsych, is a consultant
child and adolescent psychiatrist at
Great Ormond Street Hospital,
London, UK. He is head of the
Parenting and Child Team at the
hospital, which carries out expert
witness work for the family courts
and assessments and treatment of
children who have experienced abuse
and neglect. He has published in the
area of complex post-traumatic stress
disorder. Margaret DeJong, BA,
MDCM, FRCPsych(Can), FRCPsych
(UK), is an honorary consultant child
and adolescent psychiatrist at Great
Ormond Street Hospital, London. She
was head of the Parenting and Child
Team at the hospital for 12 years and
was involved for many years in
multidisciplinary expert witness work
in complex child protection cases.
She developed specialist expertise in
the field of maltreatment and pub-
lished in this area.
Correspondence: Dr Simon
First received 20 Mar 2020
Final revision 2 Apr 2020
Accepted 14 May 2020
Copyright and usage
© The Authors 2020
BJPsych Advances (2020), page 1 of 3 doi: 10.1192/bja.2020.35
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amnesia has been seen as a defence mechanism, but
more recent work on PTSD has looked at memory
dysfunction, one observation being that affected
people simultaneously experience excessive involun-
tary remembering (such as ashbacks) and impaired
intentional recollection (Brewin 2007). This picture
will, of course, be further complicated when trau-
matic events occur at a preverbal stage or an age
when autobiographical memories are not yet as reli-
ably encoded and stored.
Evidence showing a high level of comorbidity
between borderline personality disorder and DID
(Dorahy 2014) should therefore be thought about
in the light of which symptoms in the former (feel-
ings of emptiness, disturbances in self-image) may
consist of dissociative elements. The DSM-5 recog-
nises this in its reference to severe dissociative symp-
toms as a possible feature. In what can become a
polarised debate about the presence or absence of
a disorder, we are keen therefore to keep an open
mind about how dissociation may manifest trans-
diagnostically and with a spectrum of severity.
The association between early-life trauma
and dissociation
The research which informed the adoption of a
dissociative subtype of PTSD in DSM-5 showed
that dissociation predicted higher PTSD severity
and levels of comorbid psychiatric disorders (van
Huijstee 2018). Those with the dissociative
subtype were more likely to have a history of
early-life trauma; why might this be the case? This
question has attracted a number of hypotheses.
First, given that dissociation is more common in
childhood, could traumatised children be more
vulnerable to a deviation in developmental
trajectory that leads to more persistent dissociative
experiences? Second, does attachment play a role
in a stress diathesis model (discussed further
below)? Third, is it simply due to the fact that
early-life trauma is highly correlated with
increased chronicity and severity (Dorahy 2015).
We are also prompted to reect that children are
usually helpless in the face of maltreatment,
meaning that dissociation may offer some relief
from experiences that are otherwise inescapable.
The evidence has tended to suggest that, although
trauma exposure increases risk, there are other
factors at play, and some people will experience dis-
sociation without such exposure (Briere 2006).
Several longitudinal studies have shown family
environmental factors contributing to the develop-
ment of dissociative symptoms independently of,
and more signicantly than, trauma exposure;
these include parental dissociative symptoms and
maternal unavailability (Ogawa 1997) and lack of
involvement and contradictory, role-reversed or dis-
oriented parental responses (Dutra 2005).
The potential role of attachment style
A replicated nding in these studies and others
(Carlson 1998) is that disorganised attachment
styles in infancy predicted dissociative symptoms
in adolescence and young adulthood. Children with
a disorganised attachment will show contradictory
behaviours (both proximity-seeking and avoidant)
towards caregivers presumed to be experienced
as either frightening or frightened (Main 1990) and
producing a paralysing motivational conict for
the child. Disorganised attachment behaviour is
often marked by moments of freezing, dazing or
trance-like states that bear a phenotypic resem-
blance to dissociation. This inability to develop
strategies for comfort and protection, with a failure
to integrate conicting and discrete emotional
states may, it is hypothesised, increase vulnerability
to dissociation as a response to future stressors
(Liotti 2004).
Diagnosis of DID in children: the evidence
and potential effect on parenting advice
When it comes to DID in children, however, the evi-
dence base is very small. Boysen (2011) summarises
this and nds a total of 255 children described in the
literature, with four research groups in the USA
accounting for 65% of the cases, and 93% of the
cases emerging from descriptions of children in
treatment. With an evidence base of this nature,
there can be no condent claims about the validity
of the diagnosis, let alone its prevalence or what
effective treatment might look like.
In spite of this, we have had several children
referred to our clinic with diagnoses of DID. This
has led to advice to parents to acknowledge and
respond to their childrensaltersand attribute feel-
ings and behaviours to them. We are very concerned
about this practice: children with traumatic back-
grounds are especially in need of emotionally sensitive
parenting to become more secure in their attachment
relationships. They also need help gradually to
develop a more integrated sense of self as individuals
who are valued for stable traits and preferences and
who feel responsible for their actions, all of which is
likely to be impeded by attention paid to alters.
A call for further research
While wishing to advocate a high degree of caution
about the diagnosis of DID in childhood we are
keen to understand more about how parenting,
other aspects of the family environment and trau-
matic experiences may, in additive ways, increase
vulnerability to dissociation. There is a need for
Wilkinson & DeJong
2BJPsych Advances (2020), page 1 of 3 doi: 10.1192/bja.2020.35
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more research, which should include increased use
of measures of dissociation in population and clin-
ical samples and further longitudinal studies collect-
ing data on risk inuences such as attachment status
over time. It is conceivable that DID is more
common from adolescence, a time when psycho-
logical reworking of early trauma takes place, and
identity formation is a key developmental task.
Given the strength of recent evidence demonstrating
an association between emotional abuse and neglect
and a range of mental illnesses, increased risk of dis-
sociation should also be researched (Humphreys
2020). Evidence in some analyses that parental dis-
sociation is a risk factor for dissociative symptoms in
children (Ogawa 1997) should prompt more genetic-
ally informed research. Furthermore, are there inter-
ventions that may reduce the future incidence of
dissociation in those who are vulnerable? In the
meantime, clinicians should be vigilant to the possi-
bility of dissociation in traumatised children as well
as to the wider impact their experiences have on
identity, memory and self-organisation, and thera-
peutic work should be directed accordingly.
Author contributions
Both authors made contributions to the conception
of this article and analysis of the research literature.
S.W. wrote the rst draft and both authors subse-
quently revised it, gave approval for its nal form
and take responsibility for the content.
Declaration of interest
ICMJE forms are in the supplementary material,
available online at
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... The science is convincing to those on each side of the DID fence. The strength of opinion is clear from the Paris paper (2019) and its eLetter responses (Brand 2020;Brewin 2020;Paris 2020) and linked commentaries (Radcliffe 2019; Tyrer 2019) and from the opinion pieces that these have attracted (Temple 2020;Wilkinson 2020). ...
An article in BJPsych Advances on the topic of dissociative identity disorder gave rise to a number of linked commentaries and a vigorous eLetter debate. This commentary, by the Editor, points out the journal's role as a CPD journal and clarifies its position on the publication of reviews and opinion pieces on controversial topics.
Full-text available
Abstract The DSM-5 formally recognizes a dissociative subtype of PTSD ('PTSD with dissociative symptoms'). This nomenclative move will boost empirical and theoretical efforts to further understand the links between dissociation, trauma and PTSD. This paper examines the empirical literature showing that patients with PTSD can be divided into two different groups based on their neurobiology, psychological symptom profile, history of exposure to early relational trauma and depersonalization/derealization symptoms. It then explores the conceptual and empirical challenges of conceiving one of these types as reflecting a 'dissociative' type of PTSD. First, this classification is based on the presence of a limited subset of dissociative symptoms (i.e., depersonalization, derealization). This sets aside an array of positive and negative psychoform and somatoform dissociative symptoms that may be related to PTSD. Second, empirical evidence suggests heightened dissociation in PTSD compared to many other disorders, indicating that dissociation is relevant to PTSD more broadly, rather than simply to the so-called dissociative subtype. This paper sets out important issues to be examined in the future study of dissociation in PTSD, which need to be informed by solid conceptual understandings of dissociation. [184 words].
Full-text available
Objective: Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation. Methods: The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment. Results: DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID. Conclusions: The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.
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During the past decade, research findings, theoretical reflections, and clinical experiences have woven together the themes of attachment disorganization, dissociative processes, and vulnerability to trauma-related emotional disorders. The resulting unitary perspective is captured in this article by an overview of inquiries on unresolved traumatic memories based on the Adult Attachment Interview (AAI) and of studies on the sequelae of early disorganized attachments. To illustrate the intriguing clinical implications of this unitary perspective, the author considers such topics as vulnerability to complex trauma-related disorders, delayed dissociative responses to past traumatic memories, and the definition of psychological trauma. Some psychotherapeutic implications of the interplay between trauma-related disorders and attachment disorganization are briefly addressed in the concluding section. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Dissociative behaviors and their relation to both the self and self-organization were examined using the developmental psychopathology perspective in a prospective longitudinal study of high-risk children. Participants were 168 young adults (n = 79 females, n = 89 males, age = 18-19 years) considered high-risk for poor developmental outcomes at birth due to poverty. The present study investigated whether trauma, sense of self, quality of early mother-child relationship, temperament, and intelligence were related to dissociative symptomatology measured at four times across 19 years. Findings were (a) age of onset, chronicity and severity of trauma were highly correlated and predicted level of dissociation; (b) both the avoidant and disorganized patterns of attachment were strong predictors of dissociation; (c) dissociation in childhood may be a more normative response to disruption and stress, while dissociation in adolescence and young adulthood may be more indicative of psychopathology; (d) preliminary support was found for a model proposed by G. Liotti that links disorganized attachment, later trauma, and dissociation in adulthood; and (e) strong support was found for N. Waller, F. W. Putnam, and E. B. Carlson's contention that psychopathological dissociation should not be viewed as the top end of a continuum of dissociative symptomatology, but as a separate taxon that represents an extreme deviation from normal development.
Background: Researchers have documented that child maltreatment is associated with adverse long-term consequences for mental health, including increased risk for depression. Attempts to conduct meta-analyses of the association between different forms of child maltreatment and depressive symptomatology in adulthood, however, have been limited by the wide range of definitions of child maltreatment in the literature. Objective: We sought to meta-analyze a single, widely-used dimensional measure of child maltreatment, the Childhood Trauma Questionnaire, with respect to depression diagnosis and symptom scores. Participants and setting: 192 unique samples consisting of 68,830 individuals. Methods: We explored the association between total scores and scores from specific forms of child maltreatment (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and depression using a random-effects meta-analysis. Results: We found that higher child maltreatment scores were associated with a diagnosis of depression (g = 1.07; 95 % CI, 0.95-1.19) and with higher depression symptom scores (Z = .35; 95 % CI, .32-.38). Moreover, although each type of child maltreatment was positively associated with depression diagnosis and scores, there was variability in the size of the effects, with emotional abuse and emotional neglect demonstrating the strongest associations. Conclusions: These analyses provide important evidence of the link between child maltreatment and depression, and highlight the particularly larger association with emotional maltreatment in childhood.
Recently, a dissociative subtype of post-traumatic stress disorder (PTSD) has been included in the DSM-5. This review focuses on the clinical and neurobiological features that distinguish the dissociative subtype of PTSD from non-dissociative PTSD. Clinically, the dissociative subtype of PTSD is associated with high PTSD severity, predominance of derealization and depersonalization symptoms, a more significant history of early life trauma, and higher levels of comorbid psychiatric disorders. Furthermore, PTSD patients with dissociative symptoms exhibit different psychophysiological and neural responses to the recall of traumatic memories. While individuals with non-dissociative PTSD exhibit an increased heart rate, decreased activation of prefrontal regions, and increased activation of the amygdala in response to traumatic reminders, individuals with the dissociative subtype of PTSD show an opposite pattern. It has been proposed that dissociation is a regulatory strategy to restrain extreme arousal in PTSD through hyperinhibition of limbic regions. In this research update, promises and pitfalls in current research studies on the dissociative subtype of PTSD are listed. Inclusion of the dissociative subtype of PTSD in the DSM-5 stimulates research on the prevalence, symptomatology, and neurobiology of the dissociative subtype of PTSD and poses a challenge to improve treatment outcome in PTSD patients with dissociative symptoms.
The Dissociative Experiences Scale (DES) has now been used in over 100 studies on dissociation. This article reports on a series of meta-analyses to test some of the theoretical assumptions underlying the DES and to examine the instrument's reliability and validity. Studies with the DES were identified through Psychlit, Medline, Social Sciences Citation Index, and Current Contents. Across studies in similar domains (e.g., studies on multiple personality disorders) combined effect sizes were computed using the Rosenthal-Mullen approach. The DES showed excellent convergent validity with other dissociative experiences questionnaires and interview schedules (combined effect size: d = 1.82; N = 5,916). The DES also showed impressive predictive validity, in particular concerning dissociative disorders (Multiple Personality Disorder: combined effect size d = 1.05; N = 1,705) and traumatic experiences (post-traumatic stress disorder: combined effect size d = 0.75; N = 1,099; and abuse: combined effect size d = 0.52; N = 2,108). However, the discriminant validity was less well established. The DES is sensitive to response and experimenter biases. It is recommended to average DES-scores over more points in time and over more judges. The DES seems to measure the current view on past dissociative experiences. The model of dissociation as a form of autohypnosis failed to receive support from the data. A developmental model to interpret dissociation is proposed.
Dissociative identity disorder (DID) remains a controversial diagnosis due to conflicting views on its etiology. Some attribute DID to childhood trauma and others attribute it to iatrogenesis. The purpose of this article is to review the published cases of childhood DID in order to evaluate its scientific status, and to answer research questions related to the etiological models. I searched MEDLINE and PsycINFO records for studies published since 1980 on DID/multiple personality disorder in children. For each study I coded information regarding the origin of samples and diagnostic methods. The review produced a total of 255 cases of childhood DID reported as individual case studies (44) or aggregated into empirical studies (211). Nearly all cases (93%) emerged from samples of children in treatment, and multiple personalities was the presenting problem in 23% of the case studies. Four US research groups accounted for 65% of all 255 cases. Diagnostic methods typically included clinical evaluation based on Diagnostic and Statistical Manual of Mental Disorder criteria, but hypnosis, structured interviews, and multiple raters were rarely used in diagnoses. Despite continuing research on the related concepts of trauma and dissociation, childhood DID itself appears to be an extremely rare phenomenon that few researchers have studied in depth. Nearly all of the research that does exist on childhood DID is from the 1980s and 1990s and does not resolve the ongoing controversies surrounding the disorder.
The test-retest reliability of the Dissociative Experiences Scale (DES; Bernstein EM, Putnam FW [1986] Development, reliability, and validity of a dissociation scale. The Journal of Nervous and Mental Disease 174:727-735) in a clinical sample was found to be .93 for the total DES score and .95, .89, and .82 for the three subscale scores of amnesia, depersonalization-derealization, and absorption (dissociative identity disorder [DID], DSM-IV), respectively. Test-retest reliabilities within diagnostic groups of multiple personality disorder, dissociative disorder not otherwise specified, and a general other category of psychiatric diagnoses were obtained for total and subscale scores on the DES. These ranged from .78 to .96. Tests of mean scores across the two test sessions showed the total and subscale scores to be temporally stable. The DES was also found to be highly internally consistent: Cronbach's alphas of .96 and .97 were observed for the total DES scores taken at times 1 and 2, respectively. Construct validity of the DES was demonstrated by differentiation among the subscale scores in a repeated-measures analysis of variance (F[2,154] = 32.03, p < or = .001). Normality and general distribution issues were also addressed and provided a rationale for using the DES with parametric statistics. Reasons why the DES (as it was originally designed) is not appropriate as a dependent measure in outcome research are discussed, along with needed future research. Implications of the findings for the clinical usefulness of the DES as a diagnostic instrument are noted.