The Verbal Behavior of Dissociative Identity Disorder

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Introduction

            Dissociative Identity Disorder (DID), previously called Multiple Personality Disorder (MPD), has long been engulfed in controversy. One side believes psychopathology is irrelevant and the behaviors are created and maintained by social contingencies (Huntjens, Postma, Peters, Woertman, & Van der Hart, 2003; Kihlstrom, 2005; Kohlenberg, 1973; Merckelbach, Devilly, & Rassin, 2002; Paris, 2012; Phelps, 2000; Spanos, 1994). The other side believes there is psychopathology and that the development is due to a single or recurring traumatic event in the individual’s life (Brand & Loewenstein, 2014; C.G., 1999; Dell, 2006; Ellason, Ross, & Fuchs, 1996; Gleaves, 1996; Howell, 2011; Moline, 2013; Pearlman & Courtois, 2005; Reinders et al., 2006; Ringrose, 2012; Ross & Ness, 2010). However, this division of theory, does not seem to maintain in the treatment literature. Most of these treatments attempt to integrate the various personalities of the individual into one cohesive whole (Kluft, 1999). The purpose of this paper is to offer an interpretation of DID from a behaviorist perspective to attempt to reconcile many of the clashing points between theoretical models of DID. 

Diagnosis

            To begin our analysis, we will start with the Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition (DSM – 5) criteria for diagnosing Dissociative Disorders (DD). The DSM – 5 criteria for DD are as follows:

A.   Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

B.    Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

C.    The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D.   The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

E.    The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

As seen above, an explicit definition of DID is not given. Instead, a set of critical features are listed for diagnosis (American Psychological Association, 2013). The features I will draw attention to are those listed as A, B, and C. Criteria A requires “two or more distinct personality states.” While this is slightly problematic as there is not a clear, descriptive definition of “personality states,” the word “distinct” gives us something to work off of. Criteria A can be taken to mean there are two or more independent, and unrelated sets of behaviors that an individual can exhibit. Criteria B requires “recurrent gaps in the recall…that are inconsistent with ordinary forgetting.” Again, this is slightly problematic due to no explicit amount of forgetting, which, once crossed, checks off this criterion. However, such vague criteria, allows a clinician’s judgment to fill in the gaps, which, in the case of DID is important as every patient will have a different baseline of functioning and remembering. Criteria C relates directly to this last point. In order for an individual to be diagnosed with Dissociative Identity Disorder, their symptoms need to cause, “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” This, like criteria B, is up to the judgment of the clinician. However, to have a better theoretical understanding of what DID consists of, a few terms need to be defined.

Specifically, we need to define “dissociation,” “personality,” and behavioral “classes.” Since the DSM – 5 does not give us an explicit definition of dissociation or personality, we are left with the definitions from the Merriam-Webster Dictionary. Here, “dissociation” is defined as: “the separation of whole segments of the personality (as in multiple personality disorder) or of discrete mental processes (as in the schizophrenias) from the mainstream of consciousness or of behavior” (“Dissociation”, n.d.). “Personality” is: “the complex of characteristics that distinguishes an individual or a nation or group; especially: the totality of an individual's behavioral and emotional characteristics” (“Personality”, n.d.). By combining these terms together we get that dissociation is the separation of whole segments of characteristics and behaviors from an individual’s mainstream of behavior. In behavioral terms, this can be conceptualized in terms of stimulus and response classes, which are sets of stimuli or behaviors that are grouped together in an individual by a common consequence. For example, the stimulus class of foods and the response class of greeting others. All the stimuli you respond to by eating and receiving the consequence of “fullness” or nourishment are grouped into the stimulus class of "food." Whereas all the responses you do to initiate the joint attention of a conversation with someone else will be grouped into a response class. Thus the definition of dissociation can be stated: The separation of one or more specific stimulus and/or response class such that very little, if any, overlap exists between one class and another. We will go more in-depth with this definition in the coming sections.

Onset

While there is significant agreement among psychologists that DID is typically the outcome of recurring and severe childhood trauma (i.e. physical/sexual abuse, repeated medical trauma, extreme neglect, etc.) (Brand & Loewenstein, 2014; C.G., 1999; Dell, 2006; Ellason et al., 1996; Gleaves, 1996; Howell, 2011; Moline, 2013; Pearlman & Courtois, 2005; Reinders et al., 2006; Ringrose, 2012; Ross & Ness, 2010), there are some that believe the phenomena observed and reported in DID is created and maintained by the social community (Huntjens et al., 2003; Kihlstrom, 2005; Kohlenberg, 1973; Merckelbach et al., 2002; Paris, 2012; Phelps, 2000; Spanos, 1994). However, this distinction is unnecessary. If DID is truly created and maintained by the community (whether through rule-governed behavior, social contingencies, or environmental arrangement), this could have easily been initiated with trauma in the individual’s past.

The DSM-5 presents four ways the onset of DID typically occurs: “1) removal from the traumatizing situation (e.g., through leaving home); 2) the individual’s children reaching the same age at which the individual was originally abused or traumatized; 3) later traumatic experiences, even seemingly inconsequential ones, like a minor motor vehicle accident; or 4) the death of, or the onset of a fatal illness in, their abuser(s)” (American Psychological Association, 2013; (Howell, 2011; Moline, 2013; Ringrose, 2012). What is notable about these situations are that they are either the removal of the traumatic situation or a recurrence of some stimulus condition of that traumatic event (intra- or extra-organismic). Taking the above-mentioned definition of dissociation, it would make sense that a certain set of behaviors (including verbal behaviors) would be advantageous during an unavoidable traumatic event. These behaviors, depending on the severity of the event and recurrence, would either immediately or progressively be formed into a class with the consequence being some kind of negative reinforcement (avoiding, even just verbally, the punishment of the abuse). In other words, if the event or events were physically unavoidable, avoidance nevertheless takes over; however, in this case, the avoidance is verbal rather than physical. The stimulus and response classes throughout the individual’s history (trauma) have become advantageous to both talk about these situations in terms of happening to other people and to potentially exhibit an entirely different personality. In this situation, the individual will contact negative reinforcement when a stimulus or evoked response related to the trauma is present in their environment (again, including intra- or extra-organismic variables) as the dissociation allows them to avoid any punishment that was once the consequence for this class. In this sense, even the memory of an event can be a conditioned punisher (refer to the “treatment” section for more information). This kind of avoidance behavior is often characterized as a “defense mechanism” in psychoanalysis (C.G., 1999; Gleaves, 1996; Howell, 2011; Kluft, 1999; Merckelbach et al., 2002; Moline, 2013; Pearlman & Courtois, 2005; Stubley, 2014). An example of this is illustrated by Howell:

“A traumatically abused and terrified child may well deal with overwhelming affect and pain by distancing herself from this experience to such a degree that she disidentifies with the experience and becomes an observer (rather than an experiencer) of the event. In this depersonalized state, she then pseudodelusionally (Kluft, 1984) views this as happening to another child. This “other child” then “holds” the affects and memories that are unbearable to the little girl watching from above. This separation protects the child from being continually overwhelmed and safeguards the ability to function.” (Howell, 2011, p. 86)

 Treatment

In treating Dissociative Identity Disorder, the majority of clinicians use a process called integration. Depending on the source, this process can have varying steps. However, all of these steps are centralized around the idea of combining the different personalities (alters) into one (C.G., 1999; Howell, 2011; Janet, 1925; Kluft, 1999; Ringrose, 2012). This concept initially started with Pierre Janet’s phase-oriented model of treatment. This model outlines three stages: “(a) stabilization and symptom reduction, (b) treatment of traumatic memories, and (c) personality integration and rehabilitation” (Howell, 2011, p. 168). Since then, there have been many iterations of these three phases; however, Kluft and Fine offer explicit tactics that are readily acknowledged and used by other clinicians (Howell, 2011; Moline, 2013; Ringrose, 2012). These tactics include, but are not limited to 1) encouraging the dominant alter to address the other alters aloud and ask any listening alters to respond; 2) starting a journal where any of the alters can write down their thoughts; 3) the clinician talking directly to one of the alters instead of allowing them to come out randomly; 4) having the dominant alter map out the names of the other alters and how they relate; and 5) providing support for their everyday functioning to “strengthen the patient as a whole” (C.G., 1999; Kluft, 1999, p. 291). Almost all of these methods can be characterized by having the alters talk with each other. This inevitably results in the sharing of thoughts and memories to the other alters, which, to fully understand the significance of, we first need to discuss memory and stimulus control.

Memory is often thought of as a storage mechanism within the brain such that one can later retrieve past moments in full detail similar to a file in a filing cabinet. However, anyone who has ever tried to remember something knows this isn’t exactly how it works. We often find ourselves only able to remember snippets of an event or conversation (Kolers & Roediger, 1984; Palmer, 1991; Paris, 2012). We may even find ourselves engaging in strategies to “jog our memory” like pulling up a photo from the event or looking at our calendar to remember what we were doing based on the events written down. Let’s take the example of someone asking, “What did you have for breakfast last Wednesday?” Some may be able to answer this fairly quickly because they were just talking about it with someone else or they have a routine of what they eat every day; however, many others would need to take more time to answer. During this time, people engage in various strategies (i.e. starting from something we do remember then following the chain, etc.) to come to a more or less accurate response. In other words, “We have not unearthed a trace or record of what happened in the past. Rather, we engage in behavior anew” (Palmer, 1991).

We can expand this to other situations and find that it both holds true and is highly dependent on the stimuli in your environment (stimulus control). Almost everyone has experienced a situation where we walk into another room and completely forget why we were there. At this moment, we will then start to engage in strategies to remember. We may look around the room trying to find the thing we might have been coming to get. We may back-trace our steps to the point where we started. Either way, with whatever strategy is used, they all center around attempting to re-establish the stimulus control that evoked that behavior (even if this behavior was a thought you had)(Kolers & Roediger, 1984; Palmer, 1991). From this, we find that memories can both be a part of a stimulus class and act as conditioned stimulus control. What is particularly notable about stimulus control, though, is that when a stimulus or response class is created, stimuli and responses that are overt are not the only aspects of the environment that are captured. Whatever stimuli are present covertly are also captured. Thus, if the person was feeling scared, angry, anxious, etc. these feelings will also be included in the classes created (Ortu, 2012; Palmer, 2009). So, even when there is no chance of an individual with DID contacting the previous abuse again, any stimuli that are part of the dissociated class will evoke the avoidance behaviors consistent with dissociating.

We can now see how sharing thoughts and memories between alters can be equated to sharing the conditioned stimulus control between alters of the various stimulus and response classes that have been dissociated. This becomes extremely useful in a treatment setting as a clinician can expose the individual to small amounts of their trauma at a time. However, this gradual exposure in and of itself will not facilitate change in the alters. If anything, causing the alters to talk with each other without taking into account the maintaining consequence could actually exacerbate the issues due to the fact that the stimuli in the dissociated classes were conditioned with the consequence of abuse.

Taking into account this conditioning, it is easy to see that by interacting with these stimuli through “alters,” the individual is still contacting negative reinforcement by avoiding the conditioned stimuli and responses. These classes may even be inadvertently reinforced and maintained by the social community if a stimulus in one of the classes is present in the environment and the individual successfully avoids it through one or more of their alters. In order to address this avoidance, a clinician must create a space for these alters to express their thoughts and feelings in a safe and controlled way where the individual can still dissociate. By allowing the individual to continue to dissociate, the clinician is able to facilitate negative reinforcement for the individual’s contact with some of the stimuli and responses in the separated classes.

By clarifying and understanding the dynamics of DID, clinicians are better able to provide support for these individuals. Unfortunately, this is likely to be an uphill battle for years to come as “it is not socially adaptive to show one’s fragmented personality” (Howell, 2011, pg 2). The lack of a consistent model or understanding of DID by the general population, and even worse, the clinical and research populations, has hindered the treatment for these individuals. Hopefully, by striking a balance between interpretations, we, as a community can expand support for those with Dissociative Disorders.

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