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Beyond Alters: Prioritizing an Archive of Feelings over an Archive of Trauma in DID Treatment

Nestled at the intricate intersection of psychological complexity and clinical controversy, dissociative identity disorder (DID) invites an exploration into the multifaceted nature of mental health discourse. According to the American Psychological Association (APA, 2022), multifaceted symptoms of DID notably involve a conspicuous discontinuity in the sense of self and agency, fracturing the identity into two or more distinct personality states, sometimes resembling experiences akin to possession within certain cultural contexts. Various alterations across domains such as affect, behavior, consciousness, memory, perception, cognition, and potentially, sensory-motor functioning occur, which can be externally observable or internally experienced by the individual (APA, 2022). Memory-related disturbances, including gaps in recalling daily events, substantial personal information, and traumatic experiences, stand out, distinguished from ordinary forgetting by being negatively impactful across different functional areas of an individual’s life.


DID not only involves divergent memory function but also manifests other distinct symptoms, such as the emergence of recurrent, unwelcome, and involuntary possession-form identities that cause notable distress or impairment. Although possession states can emerge universally, the majority are typically integral components of accepted cultural or religious practices and thus, do not coincide with DID diagnostic criteria (Spiegel et al., 2011, as cited in APA, 2022).


The intersection of DID symptoms and cultural practices underscores the importance of a diagnostic approach that is both sensitive to and discerning of normative behaviors within an individual’s cultural and social context. This consideration is particularly salient when considering pediatric populations where DID symptoms might masquerade as, or be dismissed as, typical childhood behaviors. In children, distinguishing DID symptoms from typical behaviors such as engaging with imaginary playmates or fantasy play becomes crucial due to the nuanced manifestation of symptoms in younger populations (APA, 2022).


Delving deeper into symptoms associated with DID, individuals might experience themselves as depersonalized observers of their actions and speech, feeling unable to intervene. The subjectivity of these symptoms may encompass hearing voices of different types (e.g., a child’s voice, or voices providing commentary on thoughts or behaviors) and, in some cases, hallucinations across auditory, visual, tactile, olfactory, and gustatory modalities (Longden et al., 2016, as cited in APA, 2022).


From a diagnostic perspective, the APA (2022) asserts that a diagnosis of DID requires the presence of at least two distinct personality states or experiences reminiscent of possession. The visibility of these states may be influenced by factors like psychological motivations, stress levels, internal conflicts, cultural context, emotional resilience, and others. This visibility varies between individuals, with some, especially those with non-possession-form DID, displaying subtle or no external signs of their discontinuity of identity. In non-possession-form DID, even varying attributes like distinct names or handwriting styles of dissociative personality states are not mandatory for a diagnosis and occur only in a minority (Loewenstein, 2018 as cited in APA, 2022).


Dissociative amnesia under Criterion B of DID diagnostic criteria involves several aspects: 1) gaps in autobiographical memory, encompassing critical life events; 2) forgetfulness of recent occurrences or well-honed skills; and 3) encountering possessions that the individual does not recall owning. Dissociative fugues, representing another significant symptom, involve amnesia for travel, not strictly limited to stressful or traumatic episodes but also enveloping everyday incidents, hence individuals might encounter pronounced gaps in ongoing memory and episodes of “time loss” (Dell, 2013; Staniloiu & Markowitsch, 2014, as cited in APA, 2022).


To encapsulate, a diagnostic attribution of DID requires a distinct disruption of identity, characterized by two or more separate personality states or experiences akin to possession. Additionally, recurrent gaps in the recall of everyday events, essential personal information, and traumatic episodes, incongruent with ordinary forgetting, must be evident. These symptoms should induce clinically significant distress or impairment in various life aspects and cannot be a normative part of a cultural or religious practice or attributable to substance physiological effects or another medical condition. This structured diagnostic framework affirms a detailed and sensitive approach, ensuring specificity and inclusivity in recognizing individuals affected by this multifaceted disorder (APA, 2022).


After exploring symptoms and diagnostic criteria for establishing a DID diagnosis, attention shifts towards curating a multifaceted treatment strategy. The treatment of DID commonly amalgamates various therapeutic techniques, aiming to manage the intricacies of the disorder by navigating through the various personality states and working towards an integrated, cohesive identity (APA, 2022). This involves both addressing the disruptive episodes of dissociation and equipping the individual with adaptive coping mechanisms to manage distress and impairment in daily life.

Navigating treatment approaches for DID reveals an arena permeated by both experimental interventions and traditional therapeutic strategies. The scarcity of empirical studies on treatments for DID with pharmacological interventions is apparent with no existing findings of psychophermecuticals showing efficacy in addressing the disorder (Lynn et al., 2016). Moreover, while numerous case studies have presented various therapeutic strategies for DID and reported positive outcomes, a stringent evaluation of these interventions is complicated by a lack of randomized controlled trials and other methodological challenges, which opens the door to multiple alternative explanations for symptom reductions, such as placebo effects and regression to the mean (Lynn et al., 2016).


Addressing dissociative symptoms and their complex intertwining with factors such as post-traumatic stress disorder (PTSD) and other stressors, treatments like multimodal cognitive processing therapy have shown promise in some contexts, albeit within a framework that requires additional, rigorous investigation (Resick, Suvak, Johnides, Mitchell, & Iverson, 2012, as cited in Lynn et al., 2016). A cautious approach towards interventions, particularly those rooted in the Posttraumatic Model (PTM) which sometimes involves suggestive practices related to memory recovery and interaction with alters, is critical given the potential for such approaches to elicit further symptom complexity and severity (Lynn, Condon, & Colletti, 2013, as cited in Lynn et al., 2016).

Equally, a cautious approach is critical when approaching the Sociocognitive Model (SCM) interventions. Advocates of this perspective propose that DID largely emerges from social construction and reinforcement. According to this model, media influences, sociocultural expectations, and suggestive therapeutic methods may play a significant role in the manifestation of DID (Lynn et al., 2016). While the SCM avoids the potential for enabling through therapy, it may inadvertently function with reduced empathy due to possible instances of counter-transference from the therapist. Counter-transference, a scenario where therapists project their unresolved conflicts onto the client, can conceivably occur, particularly when a therapist perceives a patient’s ideas or experiences as socially constructed.


When considering the studies and discussions, it is essential to clearly note the divergence in perspectives among researchers and clinicians regarding the efficacy and ethical considerations embedded in various treatment modalities given that the primary concern of mental health professionals is patient mental health. Fortunately, arbitration for this very concern has led to a fascinating development within the discourse on DID and dissociation. There exists a budding convergence in the perspectives of proponents of the PTM and the SCM. Dalenberg et al. (2012) and Lynn et al. (2014) have illustrated that, while emanating from seemingly divergent theoretical frameworks, there are domains where the PTM and SCM find common ground (Dalenberg et al., 2012; Lynn et al., 2014, all as cited in Lynn et al., 2016).


There is a burgeoning consensus acknowledging that factors including biological vulnerabilities, family environment, social support, developmental aspects, and psychiatric history, play a crucial role in shaping dissociative experiences and symptoms. A notable reconciliation in perspectives is observed where some PTM adherents recognize that individuals with DID might inadvertently come to believe they embody multiple personas and that DID partially constitutes a disorder of self-understanding, a viewpoint that resonates with SCM principles (Dalenberg et al., 2012, as cited in Lynn et al., 2016). Moreover, they admit that variables like fantasy proneness can potentially lead to inaccurate trauma reports and that discerning the impacts of a pathological family environment from trauma effects on dissociation can be complex (Dalenberg et al., 2012, as cited in Lynn et al., 2016).


On the flip side, SCM theorists have conceded that trauma might wield a non-specific causal influence on dissociation by amplifying stress and negative emotional states, especially pertinent to depersonalization/derealization in scenarios involving potent aversive events, such as natural disasters (Lynn et al., 2014, as cited in Lynn et al., 2016). Furthermore, SCM advocates acknowledge that transient dissociative reactions might extend over a longer duration in those predisposed to negative emotionality, notably when this is accompanied by concurrent psychopathology (Lynn et al., 2014, as cited in Lynn et al., 2016). They also contemplate the possibility that attributes like fantasy proneness and suggestibility could potentiate an overestimation of a genuine, albeit potentially weak or moderate, relationship between dissociation and trauma (Lynn, Lilienfeld, Merckelbach, Giesbrecht, & van der Kloet, 2012, as cited in Lynn et al., 2016). An alternative hypothesis proposes that early trauma might heighten the propensity towards elevated levels of fantasy proneness or absorption, which in turn might escalate susceptibility to the iatrogenic and cultural impacts propounded by the SCM, thereby augmenting the probability of a DID diagnosis in the wake of these influences.


Significantly, both the SCM and PTM concur on the principle that individuals diagnosed with DID generally do not consciously simulate or fabricate the condition but genuinely come to believe in their multiple selves (Lynn et al., 2014, as cited in Lynn et al., 2016). Thus, the subjective experience of “multiplicity” is acknowledged as authentic, thereby knitting a common thread between the two models.


Validation of this disorder has been a very complicated matter and whether the validation exists therapeutically or in books and film like through that of Sybil or through social media channels like TikTok, given the complex interplay of memory, identity, and experience, which are weaved into elevated levels of fantasy proneness or absorption—which hails both the idea of a spectrum of delusion and vulnerability being a core factor of what dissociative disorders and more specifically, what DID is—it is important to be revolutionary in pursuing treatment modalities that once and for all show efficacy in treatment.


It simply is neither enough to emotionally enable people with the symptoms nor is it acceptable to discount them because of social influence. Furthermore, while a theoretical arbitration between SCM and PTM provides an olive branch through understanding that DID is potentially a disorder of self-understanding and that trauma has a causal and bolstering impact on potentiating symptoms associated with this dissociative disorder, dots need to be connected so that the disorder of self-understanding, a disorder of delusion, a disorder of vulnerability, can get treated. If not, there will continue to be uncertain at best and ineffective, unempathetic, or enabling engagements at worst, for those who have DID.


It is important to turn briefly to how in Trauma and Recovery in a chapter called “A New Diagnosis,” a survivor of trauma, Hope, talks about her experience with her early and now defunct diagnosis of “paranoid schizophrenic,” before addressing the future of DID treatment. For Hope, it was trauma that led her to abandon the label, the diagnosis. For Hope, “It’s really just a lifetime of grief…” The author of the book, Judith Herman (1997), identifies that Hope manifests the predominant symptoms of the now defunct diagnosis of multiple personality disorder and Hope notes:


“I forsook my paranoid schizophrenia, and packed it up with my troubles, and sent it to Philadelphia.”


There are three important matters to address here: 1) what a lifetime of grief means; 2) that while the diagnosis of “paranoid schizophrenic” was no longer interpolated into who she is, it was nonetheless packed with her “troubles”; and 3) the broadness of “troubles.” The first two matters of address will be addressed in the following paragraph.


Hope's reflection, “It’s really just a lifetime of grief…” within the framework of Trauma and Recovery, provides a poignant and layered insight into her journey with trauma and psychiatric labels. Despite her eventual forsaking of the paranoid schizophrenia diagnosis, Hope encapsulates it, along with her “troubles,” and metaphorically sends it away. Yet, there’s an inherent acknowledgment of its coexistence with her lived experiences, emphasizing that while she distances herself from the label, it’s not outright rejected or negated (she didn’t metaphorically burn it for example.) This subtle retention implies a recognition of the complex, multifaceted relationship individuals have with psychiatric diagnoses, wherein they may neither fully embrace nor completely relinquish them. It unveils a nuanced perspective wherein the diagnostic label, even when set aside, persists as a part of a person’s narrative, reflecting the complexity of intertwining trauma, grief, and psychiatric conceptualizations in one's identity and recovery journey.


Trauma narratives are a deep and frequent autoethnographic category of modernity and they are deeply insightful and powerful and while the following will not negate or discount narratives, there are certain problems that arise when these narratives are granted a metaphysical status through trauma being deemed a preeminent framework in psychology. To be clear, the PTM is now being identified as a model that makes trauma more than just a descriptor of an event or experience; trauma under the PCM becomes a foundational explanation for a host of psychological phenomena, an almost ontological category of being.


On the other hand, SCM’s approach tends towards reductionism in its understanding of the self and trauma. The SCM situates the emergence and perpetuation of DID in sociocultural influence and suggestive therapeutic practices like how in a dialogue with the American Psychological Association (2019), Elizabeth Loftus highlighted the relevance of her "misinformation effect" paradigm, which posits that an individual’s recall of an event can be altered after exposure to incorrect data. Loftus underscored instances from past years in which therapists might insinuate that a patient's symptoms mirror those found in persons who have endured childhood maltreatment, which could inadvertently guide the development of unfounded memories steered by therapeutic implications (APA, 2019). However, this risks potentially oversimplifying the complex, interwoven relationship between a person’s existential reality and their traumatic experiences. To be clear, the SCM is now being identified as a model that elides the deeper metaphysical layers that the PTM endeavors to address, particularly regarding how trauma permeates the self’s internal organization and expression.


Through the lens of the PTM, trauma is not simply an event but a cataclysm that fractures the self, disrupting the existential continuity and coherence of identity. This model contemplates the implications of such a fracture, questioning how the self navigates, accommodates, and internalizes such profound disruption. Contrarily, SCM circumvents these depths, anchoring itself in observable and verifiable social and cognitive processes, and thereby potentially neglecting the existential quagmire that trauma and DID present.


Now, this return to addressing the strengths and weaknesses of these models after addressing their metaphorical olive branch earlier serves a purpose. That purpose is to illuminate something that both models seem unwilling to acknowledge, and this returns now to the third matter of address regarding Hope’s recollection, but more so how all three points work together.


A history of trauma and a former psychological conceptualization not completely relinquished are both “troubles.” Trauma is both a deeply scarring trouble and—not to minimize misdiagnosis—a severe trouble. Being misdiagnosed is nevertheless one of her troubles. Hope likely has also experienced troubles in a multitude of other terrains too. All people experience trouble. Certainly, people who have experienced trauma can also experience trouble with cashing a check. They can experience trouble when a balloon pops before they can bring it to a baby shower. They can experience trouble after smudging ink on a piece of paper. They can experience trouble in an argument with someone that they love who loves them back in return. The point of the matter is that Hope’s “lifetime of grief” is not categorically the same as her lifetime of troubles. This is something both models seem to miss like not seeing the forest for the trees.

Navigating through the landscape of models that characterize trauma as a cataclysmic event, or those that scrutinize the reliability of memory and recall, reflects an overarching pattern of endeavors to distill the complexity of experiences into neatly organized frameworks. Both the models that position trauma as an earthquake shattering through the entirety of one’s being and those which question the soundness of recall in the generation of trauma narratives, while distinctive in approach, seemingly offer a reductionist “blue pill”—a comfortable illusion that simplifies the perplexity and manifold experiences into palatable, comprehensible bits. Similarly, models that extend an olive branch towards an understanding of the vulnerabilities inherent within DID diagnoses grapple with the intricate weave of memory, trauma, and self-construction, yet still often inadvertently encapsulate them into reductive categorizations. Such simplifications, albeit providing structured pathways to conceptualizing and engaging with trauma and DID, may inadvertently skim across the surfaces of deeper, multilayered realities and struggles that individuals experience. Despite the achievements of these models in enhancing understanding and dialogues surrounding DID and trauma, there persists a conspicuous gap in developing therapeutically efficacious modalities for DID that can holistically engage with the nuanced, multidimensional aspects of the experiences of those navigating through its realities. This raises a critical conversation about the necessity to transcend beyond comfortably reductive models and delve into an exploration that embraces, acknowledges, and engages with the profound depths, diversities, and complexities inherent within narratives of trauma and experiences of DID.


Without these new modalities, people like Hope exist in a space of pure identification. Essentially a vacuum of vulnerability, delusion, external influence (some are denouncements of the true nature of their reality and others are their trauma, memories, and alters getting turned into the biggest experience in their reality). Ann Cvetkovitch wrote An Archive of Feelings and within her archive is an “Archive of Trauma.” Now, she does make clear (Cvetkovitch, 2003) that the purpose of her work is to ultimately elucidate the Archive of Feelings, but she writes:


The nuances of everyday emotional life contain the residues that are left by traumatic histories, and they too belong in the Archive of Trauma.


Whether or not this is a contradiction is a matter for a different exploration, but it creates a pretty bleak situation for someone with DID. The individual causally connected to DID is likely the most severe and extreme case of such diagnosed individual but with so much rhetoric in circulation about trauma in a multitude of disciplines and in deep penetration in psychology combined with the reductionist “blue pill” of models of address with the added disruptions to these people’s minds and a lack of efficacious treatment, is there anything about DID that isn’t encapsulated in Eifel 65’s song “Blue (Da Ba Dee)”?


Eiffel 65's song “Blue (Da Ba Dee)” subtly underscores a metaphor regarding DID in the context of it being a disorder of self-understanding. The monochromatic blue world narrated from an external viewpoint serves as a metaphor for the external and clinical perceptions of an individual's identity and experiences. Meanwhile, the repetitive and seemingly nonsensical “Da ba dee da ba di” in the chorus (Eiffel 65, 1999), expressed by the individual themselves, reflects the internal chaotic and fragmented self-perception often inherent in DID. The contrast between external observations and internal experiences symbolizes the overarching dilemma in comprehending and addressing DID and trauma, where societal and clinical narratives, while attempting to define and encapsulate experiences, may inadvertently oversimplify, or misrepresent the intricate and disorderly realities of self-understanding and self-experience encountered by those navigating through the enigmatic internal terrains of DID. Thus, the song becomes an unexpectedly lucid metaphor, illustrating the dissonance between observable behaviors and internal emotional chaos, urging for an approach in psychological discourses that bridges the gap between external categorization and the multifaceted internal narrative.

Indeed, the conceptualization and diagnostic criteria for DID have perpetually transformed within the psychiatric domain, navigating from its initial label of "multiple personality" in the DSM-II to a nomenclature shift in the DSM-IV that underscored alterations in identity over the manifestation of numerous personalities (APA, 1968, 1994, as cited in Lynn et al., 2016). The APA’s subsequent DSM-5 iteration nuanced this further, accentuating shift in self-perception and autonomy, the occurrence of dissociative amnesias, and acknowledging cultural variances wherein personality shifts might be interpreted as spiritual possessions (APA, 2013, as cited in Lynn et al., 2016). Yet, the evolutionary trajectory of DID's diagnostic criteria presents hurdles for practitioners due to its inherent ambiguity, particularly in delineating a "personality state" or distinguishing commonplace forgetfulness from clinically relevant amnesia. Additionally, the encompassing of both individual and collateral observations in the diagnostic procedure for DID might expand its diagnostic breadth, creating potential snares by amplifying dependency on evaluators' perceptions, especially when individuals may mask their symptoms (Lynn et al., 2016). This contrasting dilemma of evolving understanding and diagnostic challenges, particularly in the realm of dissociation, underscores a pivotal point: the prevailing lack of efficacious therapeutic modalities for DID insinuates that perhaps the contemporary conceptualization of DID might be omitting a critical element, necessitating a reevaluation and potential recalibration in its theoretical and clinical approach.


Navigating from the multifaceted discussion surrounding current modalities’ failure to effectively treat DID, it becomes pertinent to introduce the concept of alexithymia, especially considering its potential interlinkages with dissociative disorders. Alexithymia pertains to a psychological construct characterized by an individual’s difficulty in identifying and articulating emotional states in themselves and others, often resulting in a suboptimal social functioning and an inclination towards utilitarian thinking and externalized thinking. This entails a struggle not only in understanding one’s emotional interiority but also in effectively conveying emotions or employing them to inform and guide thoughts, behaviors, and interpersonal interactions.

In the context of DID, the dialogue involving alexithymia becomes particularly relevant when considering the potential complexities and disruptions inherent in emotional processing and expression for individuals navigating the disorder. Especially since, Reyno et al. (2020) found a strong association between alexithymia and dissociation, particularly in clinical populations.


Delving into the intricate findings of Reyno et al. (2020), alexithymia is significantly associated with dysfunctional methods of emotion regulation. Specifically, individuals displaying alexithymic traits often engage in avoidant defenses, which involve both conscious strategies like actively sidestepping distressing emotions, and unconscious mechanisms, such as dissociating during distressing moments and encountering difficulties in recalling upsetting or traumatic events. Such patterns can also manifest as primitive defense styles like projection and denial (Parker, Taylor & Bagby, 1998; Taylor, Bagby, & Parker, 1997; Meganck, Vanheule, & Desmet, 2013, as cited in Reyno et al., 2020).


Moreover, the implications of alexithymia extend into wider mental health challenges. These individuals face heightened risk factors for various psychiatric disorders, including psychotic, mood, and anxiety disorders (Frewen, Dozois, Neufeld, & Lanius, 2008; Li, Zhang, Guo & Zang, 2015; Westwood, Kerr-Gaffney, Stahl, & Tchanturia, 2017, as cited in Reyno et al., 2020). Interestingly, difficulty in identifying feelings emerged as a primary predictor for these negative outcomes, underlying the profound significance of emotion awareness in regulating psychological stress (Grabe et al., 2008; Ogrodniczuk, Piper, & Joyce, 2011; Terock et al., 2017; Terock et al., 2015, as cited in Reyno et al., 2020).


On the other hand, dissociation is understood as an altered state of consciousness marked by a detachment from sensations, emotions, and cognitive processes. Its manifestations can range from mild daydreaming to severe pathological forms like DID. Significantly, higher instances of pathological dissociation are observed among populations that have endured childhood trauma, especially when such traumas lead to attachment anxiety (Rafiq, Campodonico, & Varese, 2018; Dalenberg et al., 2012; Kong, Kang, Oh & Kim, 2018; Lyssenko et al., 2017, as cited in Reyno et al., 2020). Dissociation can further present both positively, with heightened emotional, sensory, and perceptual experiences, and negatively, with reduced or even absent emotional responses. This latter form, negative dissociation, often acts as an unconscious defense against intolerable negative emotions.


` The exact mechanisms interlinking alexithymia and negative dissociation remain a topic of debate. However, both seem to be tied to experiences of developmental trauma, potentially suggesting trauma as a mediating factor (Craparo et al., 2014, as cited in Reyno et al., 2020). Bucci’s multiple code theory of emotion processing suggests that when the two primary components of emotion schema (sensory/visceral sensations with motor urges and symbolic representations) fail to integrate, alexithymia can result (Bucci, 1997, as cited in Reyno et al., 2020). Dissociation, on the other hand, represents a psychological disconnect between self-experiences, impeding the integration of cognition and emotion. Essentially, while alexithymia may reflect a capacity deficit, dissociation represents a psychological defense mechanism (Schimmenti & Caretti, 2014, as cited in Reyno et al., 2020). Both conditions, however, ultimately impair the ability to modulate emotional processes through cognitive means, critically impacting the experience, interpretation, and regulation of emotions.


Now, there lies a vast terrain of possibilities for research and therapeutic interventions for DID associated with the unique and overlapping dynamics of trauma, alexithymia, and dissociation. Addressing the core deficits in emotional processing in alexithymia and the defense mechanisms at play in dissociation, especially in the shadow of trauma, might be the key to unlocking more effective and holistic treatments for individuals plagued by these conditions. An example of the interrelationship of these dynamics might occur in environments that are dismissive or abusive, children may come to perceive that expressing their emotional experiences is either unsuitable, unproductive, or might put them in harm's way, leading to increased instances of alexithymia (Aust et al., 2013; Paivio & McCulloch, 2004, as cited in Reyno et al., 2020).

Trauma as a mediating factor to both DID and alexithymia raises several questions for future DID research. Does the deficit nature of a developed alexithymia have a causal relationship with DID? To further clarify this question, it is important to note that the coexistence of alexithymia and DID seemingly represents a paradox where emotional richness as depicted by symptoms of the latter are juxtaposed against a backdrop of emotional opacity or inscrutability associated with the former. How then does the inability to perceive and articulate emotions correlate with a disorder characterized by disparate and robust emotional states?

There is no clear answer to these questions yet but given that DID is often rooted in traumatic experiences and considering that alexithymia is also prevalent in populations who have experienced trauma, the intersection between these two psychological phenomena warrants deeper investigation. Particularly, a crucial examination of whether the emotional compartmentalization intrinsic to DID might be misconstrued or inadequately understood, especially when alexithymia complicates the emotional clarity across diverse identity states.


It’s plausible to hypothesize that alexithymia might be a manifestation or byproduct of the dissociative processes inherent in DID. The emotional blunting or difficulty in emotional articulation (alexithymia) could potentially be a protective mechanism (and so deficit also functions as protection), serving to further segregate and compartmentalize emotional experiences among distinct identities. Alternatively, it may suggest that the emotional experiences of different identities in DID are not as vivid or differentiated as traditionally understood and that conscious displays of multiple personalities are deficient attempts at emotional communication. These possibilities indeed hint that our current understanding of DID, particularly concerning emotional processing and expression, may be lacking or perhaps misoriented.


Further, while trauma as a mediator between dissociation and alexithymia is clearly an important matter of discussion, the matter clearly doesn’t lower trauma’s preeminent status in accordance with DID. While certainly trauma need not be delinked from DID—and in fact it would go against research findings to do so—on a purely metaphorical level, it is important to remember that there isn’t simply an Archive of Trauma but an Archive of Feelings. If not, people like Hope take the “blue pill” and continue to live only in the blue world.


For therapists, such understandings may challenge one of the traditional ways of providing therapy for DID patients, centering the alters.

This figurative idea is amplified by Bob et al. (2013) who explored the extent to which mild “pseudoneurological” symptoms in a healthy young population might be related to stress-induced psychopathological symptoms or instead be attributed to unexplained somatic factors and discovered that the pseudoneurological symptoms associated with somatoform dissociation have a significant relationship with stress-related psychopathology, even in the face of minor stressors. However, some findings may be affected by the presence of "medically unexplained symptoms" in the general population, which could have causes other than somatic dissociation, potentially skewing the results. Still, the study supports the idea that pseudoneurological symptoms largely stem from psychological roots, with dissociative mechanisms playing a role in their somatic manifestation, even though some symptoms could be influenced by somatic factors. The primary factor affecting these symptoms appears to be stress, including “relatively mild stressors,” not just trauma (Bob et al., 2013).


While somatic form dissociation does not present the same way as dissociation does in the presentation of DID, this does underscore the nuanced and multifaceted nature of dissociative phenomena, suggesting that trauma and stress, in all their gradations, may influence a spectrum of dissociative outcomes. Further, when it is also factored in that the same study revealed a relationship between the pseudoneurological symptoms and alexithymia, the connection between an impaired capability to discern and process internal emotional experiences, a hallmark of alexithymia, and the disruption of conscious awareness seen in somatic dissociation (Bob et al., 2013) underscores that the argument about the intricate ties between trauma, stress, alexithymia, and dissociation is becoming even clearer.


With this argument strengthened and efficacious treatment of DID lacking, it is important to not simply address problems and justifications for those arguments but to provide a grounding path forward for therapy. The interaction of alexithymia with multiple types of dissociation indicates that the Perth Alexithymia Questionnaire-Short Form (PAQ-S) might be a way forward for both clinical and research insight. This six question questionnaire measures for alexithymia in time-pressured settings and demonstrates validity in identification of this trait (Preece et al., 2023).


Given the intricate interplay between alexithymia and dissociation, PAQ-S emerges as a potentially powerful tool both for practitioners and researchers. For individuals with DID, timely identification of alexithymia using the PAQ-S can be a transformative first step. Recognizing the presence of alexithymia in DID patients can lead to an approach that simultaneously addresses the dissociative states inherent in DID and the emotional opacity stemming from alexithymia.


For therapists, such understandings may challenge one of the traditional ways of providing therapy for DID patients, centering the alters.


A major therapeutic understanding of DID predominantly emphasizes the distinct personalities or identities manifested by patients. However, when alexithymia is factored into the matter, it might indicate that these distinct personalities are superficial manifestations of deeper emotional and cognitive disruptions. As such, the primary therapeutic focus should shift from these alter identities to the foundational mechanisms that give rise to them. This entails a profound exploration of emotional dysregulation, stress, trauma, and notably, the patient's difficulty in both identifying and articulating emotions, as characterized by alexithymia.


Incorporating the role of alexithymia into the therapeutic approach to DID can pivot the treatment towards enhancing the patient's emotional literacy. Intensive introspective techniques might be applied, enabling patients to better understand, label, and convey their emotions. Therapies like Mindfulness-based Cognitive Therapy (MBCT) or Dialectical Behavior Therapy (DBT) could be instrumental, given their emphasis on emotional regulation and interpersonal effectiveness. Moreover, if the emotional numbness of alexithymia is a protective mechanism for those with DID, therapeutic measures must be meticulously crafted to avoid any retraumatization. This requires guiding individuals delicately, understanding the origin of these mechanisms, and facilitating the discovery of safer emotional outlets.


Further integrating the hypothesis that the distinct personalities in DID are merely deficient articulations of profound emotional states, narrative therapy might assist patients in constructing a cohesive, emotion-centric narrative of their experiences. By focusing on the emotions and underlying experiences, rather than the discrete identities communicating them, a more lucid understanding of their emotional framework can be achieved. Ultimately, the therapeutic goal would be less about integrating identities and more about achieving a holistic synthesis of emotional experiences. By offering individuals the tools and understanding to identify, process, and express their emotions without defaulting to distinct identities, therapy can provide a more encompassing approach.


In essence, this reframed understanding of DID, underpinned by the nexus with alexithymia, champions a comprehensive approach that delves into the patient's emotional world. Recognizing the intricate relationship between DID and alexithymia has the potential to revolutionize therapeutic interventions, centering on a holistic emotional reconciliation.


Ultimately, DID stands at the intersection of mental health intricacy, characterized by a mosaic of clinical considerations. As per the APA’s (2022) guidelines, its diagnostic features encompass a range from a fractured self-perception to memory disruptions, distinguishing it from other psychological disorders. These complexities extend to its symptomatic scope, which encompasses alterations in consciousness and experiences of depersonalization. Nevertheless, rigorous diagnostic processes ensure its accurate and specific identification by not merely recognizing diverse personality states but by discerning their origins, differentiating normative cultural experiences from pathological ones, and understanding the disorder's nuanced manifestations across various demographics, such as children.


As therapeutic interventions for DID are explored, a vast expanse opens, echoing the disorder's intricacies. Treatment oscillates between traditional and experimental means, with no universal remedy in either pharmacological or psychotherapeutic realms. Amid this landscape, the PTM and the SCM stand out, offering different vantage points on DID's roots and therapeutic approach. However, despite these distinctions, scholars from both camps seem to be finding common ground, recognizing the roles of trauma, societal influence, fantasy proneness, and self-comprehension.

Both clinical and popular culture's portrayal of DID further complicates the discourse. Though some representations validate and support those grappling with DID, others risk perpetuating myths or oversimplifying a profound disorder. The tension between accurate representation and sensationalism underscores the need to approach DID with a balance of scientific rigor and deep empathy.


In addressing the treatment landscape, the collective mission should move beyond binary debates, focusing instead on holistic interventions for the well-being of those with DID. This involves acknowledging the disorder's legitimacy while crafting treatments rooted in both compassion, creativity, and future clinical efficacy.

Furthermore, the introduction of alexithymia—a condition characterized by difficulty in identifying and describing emotions—in the discussion around DID underscores the significance of emotion in understanding the human mind. By understanding alexithymia's emotional inscrutability with DID's profound dissociative states (or a further hypothetical, alexithymia’s defensive qualities and DID’s exaggeratory qualities), it may be possible to perceive DID not just as a manifestation of multiple personalities but as a reflection of fragmented emotional experiences seeking articulation. Recognizing the complex ties between trauma, stress, alexithymia, and dissociation is vital. The future of DID therapy might shift from merely integrating identities to centering on emotional understanding, promoting emotional literacy, and comprehension.


To summarize, DID, with its potentially deep interplay with alexithymia, presents an intricate emotional landscape within individuals. This relationship emphasizes the continual evolution of research and adaptability in therapeutic practices. In navigating this intricate web, the prospect of a more comprehensive, empathetic, and effective therapy for DID patients emerges—one that delves deep, beyond the reach of the multiplicity, and into the vastness of emotional experiences.


References


American Psychological Association. (2019, October). How memory can be manipulated, with Elizabeth Loftus, PhD [Audio podcast episode]. Speaking of Psychology. https://www.apa.org/news/podcasts/speaking-of-psychology/memory-manipulated. Last updated: August 2023.


American Psychological Association. (2022). Diagnostic and statistical manual of

mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Bob, P., Selesova, P., Raboch, J., & Kukla, L. (2013). ‘Pseudoneurological’ symptoms, dissociation and stress-related psychopathology in healthy young adults. BMC Psychiatry, 13(149). https://doi.org/10.1186/1471-244X-13-149


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