Made clear by events such as the terrorist attacks in New York, NY, on September 11, 2001, the December 26, 2004, tsunami in Indonesia, and the July 7 attacks in London, England, trauma is, unfortunately, part of our everyday lives and culture. Even so, trauma survivors and trauma symptomatology remain vastly misunderstood. Terms such as dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD), traumatic amnesia, false memory, and recovered memory often elicit strong emotional reactions from mental health professionals.
Unfortunately, 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. It is our goal in this article to provide the practicing clinician in psychiatry and psychology with an overview of the literature on traumatic memory, the DID diagnosis, and false and recovered memory so as to both dispel misconceptions about these concepts and provide a foundation of resources to reference when you encounter a trauma patient in your practice. What follows is a list of critical questions that organize this information.
What Are Dissociative Experiences?
The current version of the Diagnostic and Statistical Manual of Mental Disorders1 defines dissociation as “a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment” and dissociative amnesia as “reversible memory impairment in which memories of personal experience cannot be retrieved in verbal form.” Additional dissociative experiences frequently described in the literature include depersonalization (an altered perception of the self) and derealization (and altered perception of one's surroundings). The dissociative disorders are dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and dissociative disorder – not otherwise specified.
Although not formally acknowledged as psychiatric phenomena until the 1980s, dissociative symptoms were recognized by practicing clinicians and researchers as early as the late 1800s. Freud and Janet considered what we now call dissociation to be a coping strategy to keep memories of traumatic experience outside conscious awareness. PTSD and dissociative symptoms also were demonstrated to be associated with various forms of wartime trauma. Although dissociative experiences may occur with several different types of psychopathology (eg, panic attacks, depression), research suggests a connection between traumatic experiences (eg, child abuse, combat, physical or sexual assaults, natural disasters) and dissociative symptoms.2
Despite differing ideas about the underlying biological and psychological mechanisms of dissociation, researchers generally agree that traumatic events are so overwhelming, both physically and psychologically, that the components of traumatic memory (eg, narrative, behavior, affect, sensations, arousal) can be blocked from conscious awareness and disconnected from one another.3–5 Trauma affects normal information processing in a way that interferes with both the accessibility and the integration of memories. Amnesia and the self states in DID are necessary for maintaining attachment to caregivers in cases where trauma occurs in the context of trusted relationships (eg, intrafamilial child sexual abuse).6,7 Core psychological needs for comfort, nurturance, and soothing can be satisfied in fantasy or kept as separate memories, while memory for scenes of abuse may be dissociated out of awareness so that the child can tolerate depending on their abuser/protector(s) for basic care and survival. These model patterns of relatedness are both simultaneous and contradictory but cannot be noticed if the child is to maintain physiologic stability.
Is Traumatic Memory Different from Normal Memory?
Stress and trauma appear to affect memory, both at the neurological level and in terms of subjective experience. A physiological consequence of traumatic stress can be a disabling of the neural mechanism responsible for encoding the appropriate spatiotemporal (time and place) context of memory.4 With nontraumatic “everyday” experiences, autobiographical memories are formed such that context, events, feelings, and the relations among them are blended together. Moderate levels of stress can produce blended and exceptionally vivid autobiographical memories due to enhanced encoding of spatiotemporal information (caused by the facilitative effect of stress hormones on hippocampus function) and of emotional attributes (caused by hormonal effects on amygdala function).
However, at extreme levels of stress associated with traumatic events, the hippocampus-based system basically shuts down while the amygdala-based system is enhanced.4 This alteration can lead to emotional and somatic information being stored separately from the spatiotemporal contexts within which the relevant events occurred. Retrieval of this disconnected information can become (and hence may feel) disorganized, fragmented, and perhaps incomprehensible. As Jacobs and Nadel4 described, under such circumstances, “memory fragments — physical, emotional, cognitive, and behavioral memories derived from the full complement of traumatic (and possibly other) experiences — are independently available.”
The implication of this physiologically based disconnection is that, particularly with severe trauma, patients report at least initially “remembering” the event in somatosensory (eg, visual, olfactory, auditory, kinesthetic) form.5 These experiences are sometimes referred to as body memories. Only over time do individuals construct a complete narrative that may or may not explain what happened. This process is in marked contrast with memories for everyday events or even significant but non-traumatic life events that are typically not experienced in olfactory, visual, auditory, or kinesthetic form.
In summary, there seem to be critical differences between how people experience memories of traumatic events compared with memories of significant personal, nontraumatic events. Traumatic memory appears to be stored initially as sensory fragments without a coherent semantic component. When initially reactivated, recovered memories are rarely in the form of a narrative but rather appear as fragmentary implicit memories. These implicit memories manifest symptomatically or behaviorally as flashbacks, somatic experiences, dreams/nightmares, intense affective experiences, or transference re-enactments.4,8
Can a Person not Remember a Traumatic Experience?
Many clinicians are under the impression that PTSD is solely a disorder of intrusive symptoms. However, in our opinion, the phenomenology of PTSD comprises more than just a constant flooding of memories, but includes the possibility of dissociative amnesia. One needs to look no further than DSM1 to be reminded that re-experiencing symptoms is only one aspect of PTSD. Avoidance (including amnesia for some, or all, of the traumatic event) is a second major aspect of the disorder, which is more aptly understood as a constant struggle between re-experiencing and avoidance. As noted by Leskin, Kaloupek, and Keane,9 “The hallmark of PTSD adjustment is the reciprocal oscillation between re-experiencing and avoidance.”
Despite controversies surrounding the existence of traumatic (dissociative) amnesia, reviews of the literature support several points consistently:
- Amnesia for trauma occurs in survivors of natural disaster, combat, prison/torture, the Holocaust, violent crime, rape, child physical abuse, and child sexual abuse.4,8,10,11
- A significant subpopulation (averaging around 30%) of people who report histories of child abuse also report a period of amnesia for it.8,10,12
- Amnesia for trauma is associated with certain characteristics of abuse: early onset, duration, severity (ie, level of sexual violence, injury, repetition, multiple perpetrators) and relationships involving trust and dependency.8,10
It is also important to note that the apparent amnesia associated with trauma generally only applies to declarative memory (eg, autobiographical knowledge) and not to nondeclarative memory (eg, feelings, sensations, and habits). This distinction is critical. The effect of trauma on the two types of memory may be paradoxically opposite. As Jacobs and Nadel4 noted, “[Traumatic stress] can cause amnesia for the autobiographical context of the stressful event and hypermnesia for the emotional memories produced by them.” A person can feel the intense emotion and pain associated with a trauma but have no idea where the feelings are coming from. Such an experience obviously is bewildering to the client and may also be hard for a therapist to understand or to diagnose accurately.
It is important to distinguish the phenomenon of traumatic amnesia from the mechanism(s) responsible for it. There are numerous possible mechanisms proposed for amnesia including: “normal forgetting” due to lack of retrieval cues and interference, avoidance (conscious minimization and denial), lack of discussion (practice) due to shame, lack of state dependent retrieval cues, repression, and dissociation.8,12,13,14 As described above, amnesia also may be understood as simply a direct physiological effect of stress, although this mechanism clearly does not explain all instances of amnesia. There may also be numerous mechanisms working together or, more likely, different instances or types of amnesia have differing mechanisms.
What About “Recovered” Memories?
A recovered memory may be defined as a memory for an event that is inaccessible for some period of time (amnesia) and is later retrieved. In the current context, the more controversial memories are of traumatic events; however, it is certainly possible to have a recovered memory of nontraumatic experiences (eg, suddenly remembering where one's keys are after an hour of inability). Recovered memories of trauma are documented in patients who have corroborated memories of abuse (in retrospective and prospective studies).10,15,16,17 Recovered memories also can be produced reliably in laboratory situations.12
Memories may be “triggered” after a period of amnesia by situations that are similar to the original traumatic event, general emotional activation, relationships, hearing about others' recent traumatic events, sexual encounters, or seeing someone associated with the trauma or with the time period of the trauma.8,11,13 Interestingly, some research has found that recovered memories are least likely to occur in the context of psychotherapy.8 When they do, there are frequently additional memories recovered while working on previously known memories. As Leskin et al.9 noted, “One of the expected consequences of exposure treatment sessions is reactivation of additional details for reported memories, as well as triggering previously un-recalled memories.” The significance of this statement should not be minimized. Their point is that memory recovery is a normal part of established, empirically supported therapies for PTSD.
Are Traumatic/Recovered Memories Accurate?
Clinicians may face this question when clients ask us if what they are “remembering” is real or veridical. Furthermore, there may be external reasons why accuracy is questioned. The unfortunate answer is that, as with any memory, traumatic or recovered memories may or may not be accurate. There is no evidence that recovered memories, particularly for the central themes of traumatic events, are any more or less accurate than continuous memories of abuse.8,17,18 However, as we described above, extreme trauma can disrupt the storage of the spatial-temporal aspects of a memory. In addition, the process by which somatic fragments are reconstructed into a coherent narrative is imperfect and subject to influence.
Jacobs and Nadel4 described the circumstances under which recovered traumatic memories are likely to be more or less accurate, according to their model of the psychophysiology of reconstructed memory. They argued that memories would be most accurate if a person had experienced one massive traumatic event. With similar, repeated traumas, there would be less but still some degree of confidence in specific memories. Consider a person who has had experienced numerous different traumatic events (eg, sexual assaults by different perpetrators, numerous traumatic war experiences, several automobile accidents). Because the spatiotemporal context of the varying events could be linked inaccurately to the somato-emotional memory fragments, the authors argued they would have little confidence in the memory for specific events.
However, to conclude a lack of confidence in the specifics of a memory is different from concluding a person has not been traumatized. In fact, it is the severity, variety, and extent of the trauma that theoretically causes the problems with accurate retrieval and reconstruction. It is also important to note that this model applies to memory for events that involved extreme levels of stress. Memories of less stressful events may be blocked and recovered through differing mechanisms, the accuracy of which has not been established (but also not challenged empirically).
Is DID a Valid Psychiatric Diagnosis?
This question is one of two that one commonly hears regarding DID (the other, concerning its etiology, is discussed below). There is no gold standard for establishing diagnostic validity for any psychiatric diagnosis. An examination of three different guidelines for establishing diagnostic validity19 used criteria by Robins and Guze,20 Spitzer and Williams,21 and Blashfield, Sprock, and Fuller.22 The authors concluded that all three sets of criteria supported the validity of DID (and hence its inclusion in DSM). Although much more research clearly is needed, it is also clear that the data on the validity of DID are as strong if not stronger than for most accepted forms of psychopathology. For example, the diagnostic reliability (when assessed with structured interviews) for DID is actually higher than for most psychiatric disorders. These authors also noted that DID is one the few disorders currently supported by taxometric research, an empirical/statistical approach to psychiatric classification developed by Paul Meehl.30
Formal assessment instruments can aid in the diagnosis of the dissociative disorders. The Structured Clinical Interview for DSM-IV Dissociative Disorders IV (SCID-D-IV)23 is the “gold standard” for diagnosis. It consists of five symptom areas — amnesia, depersonalization, derealization, identity confusion, and identity alteration — and yields rich information about the patients' symptom manifestations and internal dynamics.
Another structured interview, the Dissociative Disorders Interview Schedule,24 assesses dissociation along with a range of comorbid psychiatric symptoms and can be used as a diagnostic tool or screening instrument.25 The Dissociative Experiences Scale26 is the most psychometrically sound and widely used self-report screening measure of dissociative experiences.
Isn't DID Extremely Rare?
Many clinicians do not question the reality of DID but view it as so rare that there is no need to assess for it or consider it as a differential diagnosis. Although DID once was believed to be extremely rare, prevalence estimates have increased recently, indicating that DID is not an uncommon psychiatric condition. Although some mental health professionals attribute this rise in diagnosis to overzealous clinicians suggesting the diagnosis to highly hypnotizable patients, a more likely scenario is that the increased recognition of DID is a result of improved awareness of the effects of child abuse and dissociative disorder symptomotology, as well as the advent of diagnostic criteria and formal assessment for DID.27,28
Results from a large-scale nonclinical epidemiological study indicate that, in nonclinical populations, as many as 10% of people may suffer from a diagnosable dissociative disorder, with 1% suffering from clinical DID (according to DSM-III-R criteria).29 Several prevalence studies conducted with psychiatric samples (in several different countries) have indicate that up to 12% of psychiatric inpatients may have unsuspected/undiagnosed MPD/DID.29 In a follow-up taxometric study of pathological dissociation (not completely analogous to DID, but similar), the estimated base rate in the general population was 3.3%.30
Although more large-scale population-based studies are necessary to solidify prevalence estimates for DID, overall, these studies indicate that DID is a widespread psychiatric diagnosis and that it may be underestimated because mental health professionals do not ask patients questions regarding dissociative disorder symptomotology. For example, patients do not volunteer experiences of depersonalization as an unusual event if it has been present since childhood. For them, being detached from their body is normal. The prevalence of DID seems to be in the same range as disorders such as schizophrenia or anorexia nervosa.
What About Iatrogenic DID and “False Memory Syndrome”?
Both of these topics are common in the popular media and are becoming increasingly common in the scientific literature. However, it is important to consider that, in contrast with the wealth of data on the validity of DID, there are virtually no empirical data supporting the validity of the iatrogenic DID concept or false memory syndrome (FMS). Regarding iatrogenic (ie, created by therapy) DID, Brown et al.31 concluded that “these sparse data fail to meet a minimal standard of scientific evidence justifying the claim that a major psychiatric diagnosis like dissociative identity disorder per se can be produced through suggestive influences in therapy.” Others have reached similar conclusions, noting that the iatrogenic model is based on numerous incorrect assumptions about the psychopathology, assessment, and treatment of DID.27
More recent attempts to resurrect the iatrogensis model are based on opinion rather than data. Of course, these conclusions do not mean that a therapist could not make a client with DID worse. However, doing so would not be iatrogenesis (ie, the creation of a problem) and only illustrates the need to provide adequate training in treating this complex disorder.
FMS also is difficult to define because proponents of the concept have never really offered a clear description of what it is supposed to look like.32 The term syndrome is supposed to refer to “a grouping of signs and symptoms, based on their frequent co-occurrence, that may suggest a common underlying pathogenesis, course, familial pattern, or treatment selection.”1 None of these “signs and symptoms” have ever been described in the literature on FMS.
In 1996, Pope32 raised several critical questions about the empirical basis for the many claims about FMS that had appeared in the literature; these questions still have not been answered. In one published empirical study, Hovdestad and Kristiansen33 concluded that “the weak evidence for the construct validity of the phenomenon referred to as FMS, together with the finding that few women with recovered memories satisfied the criteria and that women with continuous memories were equally likely to do so, lends little support to the FMS theory.” More recently, Dallam34 concluded that “in the absence of any substantive scientific support, ‘False Memory Syndrome’ is best characterized as a pseudoscientific syndrome that was developed to defend against claims of child abuse.”
Of course, these conclusions do not mean that memory is always accurate, and there is a wealth of empirical evidence suggesting that there are a variety of conditions (including those described above) that can lead to distortions of memory. What most of this research suggests is that, when memory errors occur, they frequently are consistent with a person's actual experience. Another interpretation is that they are schema-consistent or plausible. In line with our discussion, accuracy for a specific memory probably is most questionable in a person with a history characterized by multiple traumatic events. However, concluding that an individual memory is inaccurate is much different from saying that a person's entire trauma history is false.
Why Does the Treatment of Traumatic Memory Require Special Attention and Skill?
This question can be addressed at two different levels. At the first level, we refer to the general treatment literature for posttraumatic conditions. A complete discussion of this topic is beyond the scope of this article; see Leskin et al.9 for overview of treatments for traumatic memory, Keane35 for a review of psychological treatments for PTSD, and Maldonado, Butler, and Spiegel36 for a similar review for dissociative disorders. However, one point that should be made clear is that empirically supported treatments for trauma generally involve direct exposure to the trauma memories themselves. Exposure in this context refers to remembering, thinking about, talking about, or even writing about what happened. However, comprehensive treatment guides by Chu37 and Gold38 stress that addressing the traumatic memories is far from all that one does with such patients. Furthermore, one can easily worsen a patient's condition by addressing traumatic memories too early in treatment and before adequate coping skills exist. Thus, phases of psycho-education and stabilization generally are necessary before trauma resolution should be attempted.39
The second interpretation of this question has more to do with how one should “treat” (or respond to) individual reports of trauma memories when they are encountered as part of assessment or therapy. Recommendations about how to work with patients during this time include supporting the validity of the patient's experience and being open to the possibility of an abuse history, allowing the patient to construct his or her own narrative without suggestion, and avoiding making conclusions about trauma history without evidence.10
Furthermore, it is critical to be aware that dissociative amnesia is dynamic; patients can go in and out of dissociation and denial as memories of personal experience become activated. Overall, in therapy with trauma survivors who have had periods of dissociative amnesia, fragments of memory are recovered progressively and reorganized repeatedly.
As noted, clinicians should not confirm the accuracy of reported memories. However, neither should they directly challenge them or communicate to a client that a memory will not believed in the absence of corroboration. According to a statement issued by the American Psychiatric Association Board of Trustees,40 expression of such disbelief is likely to cause the patient further pain and decrease his or her willingness to continue treatment.
Where Can I Learn More About These Topics?
In addition to the many references cited in this article and the others in this issue, two primary sources of information are the International Society for the Study of Dissociation ( http://www.issd.org) and the International Society for Traumatic Stress Studies ( http://www.istss.org). Both have journals devoted to this area, the Journal of Trauma & Dissociation and Journal of Traumatic Stress, respectively. Also, the Sidran Foundation ( http://www.sidran.org) is a valuable resource for training and education information, as well as books and articles on these topics.
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- Dalenberg CJ. Accuracy, timing, and circumstances of disclosure in the treatment of recovered and continuous memories of abuse. J Psychiatr Law. 1996;24(2):229–275. doi:10.1177/009318539602400206 [CrossRef]
- Gleaves DH, May MC, Cardeña E. An examination of the diagnostic validity of dissociative identity disorder. Clin Psychol Rev. 2001;21(4):577–608. doi:10.1016/S0272-7358(99)00073-2 [CrossRef]11413868
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- Blashfield RK, Sprock J, Fuller AK. Suggested guidelines for including or excluding categories in the DSM-IV. Compr Psychiatry. 1990;31(1):15–19. doi:10.1016/0010-440X(90)90049-X [CrossRef]2297982
- Steinberg M. Structured Clinical Interview for DSM-IV Dissociative Disorders – Revised (SCID-D-R). 2nd ed. Washington, DC: American Psychiatric Publishing; 1994.
- Ross CA, Heber S, Norton GR, Anderson G, Barchet P. The Dissociative Disorders Interview Schedule: a structured interview. Dissociation. 1989;2:169–189.
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