Fact or Factitious? A Psychobiological Study of Authentic and Simulated Dissociative Identity States

BACKGROUND: Dissociative identity disorder (DID) is a disputed psychiatric disorder. Research findings and clinical observations suggest that DID involves an authentic mental disorder related to factors such as traumatization and disrupted attachment. A competing view indicates that DID is due to fantasy proneness, suggestibility, suggestion, and role-playing. Here we examine whether dissociative identity state-dependent psychobiological features in DID can be induced in high or low fantasy prone individuals by instructed and motivated role-playing, and suggestion. METHODOLOGY/PRINCIPAL FINDINGS: DID patients, high fantasy prone and low fantasy prone controls were studied in two different types of identity states (neutral and trauma-related) in an autobiographical memory script-driven (neutral or trauma-related) imagery paradigm. The controls were instructed to enact the two DID identity states. Twenty-nine subjects participated in the study: 11 patients with DID, 10 high fantasy prone DID simulating controls, and 8 low fantasy prone DID simulating controls. Autonomic and subjective reactions were obtained. Differences in psychophysiological and neural activation patterns were found between the DID patients and both high and low fantasy prone controls. That is, the identity states in DID were not convincingly enacted by DID simulating controls. Thus, important differences regarding regional cerebral bloodflow and psychophysiological responses for different types of identity states in patients with DID were upheld after controlling for DID simulation. CONCLUSIONS/SIGNIFICANCE: The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e.g., iatrogenic) origin

Fact or Factitious? A Psychobiological Study of Authentic and Simulated Dissociative Identity States

Background: Dissociative identity disorder (DID) is a disputed psychiatric disorder. Research findings and clinical observations suggest that DID involves an authentic mental disorder related to factors such as traumatization and disrupted attachment. A competing view indicates that DID is due to fantasy proneness, suggestibility, suggestion, and role-playing. Here we examine whether dissociative identity state-dependent psychobiological features in DID can be induced in high or low fantasy prone individuals by instructed and motivated role-playing, and suggestion.Methodology/Principal Findings: DID patients, high fantasy prone and low fantasy prone controls were studied in two different types of identity states (neutral and trauma-related) in an autobiographical memory script-driven (neutral or trauma-related) imagery paradigm. The controls were instructed to enact the two DID identity states. Twenty-nine subjects participated in the study: 11 patients with DID, 10 high fantasy prone DID simulating controls, and 8 low fantasy prone DID simulating controls. Autonomic and subjective reactions were obtained. Differences in psychophysiological and neural activation patterns were found between the DID patients and both high and low fantasy prone controls. That is, the identity states in DID were not convincingly enacted by DID simulating controls. Thus, important differences regarding regional cerebral bloodflow and psychophysiological responses for different types of identity states in patients with DID were upheld after controlling for DID simulation.Conclusions/Significance: The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e. g., iatrogenic) origin.</p

Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder: A PET study and neurobiological model

Imaging studies in posttraumatic stress disorder (PTSD) have shown differing neural network patterns between hypo-aroused/dissociative and hyper-aroused subtypes. Since dissociative identity disorder (DID) involves different emotional states, this study tests whether DID fits aspects of the differing brain-activation patterns in PTSD. While brain activation was monitored using positron emission tomography, DID individuals (n=11) and matched DID-simulating healthy controls (n=16) underwent an autobiographic script-driven imagery paradigm in a hypo-aroused and a hyper-aroused identity state. Results were consistent with those previously found in the two PTSD subtypes for the rostral/dorsal anterior cingulate, the prefrontal cortex, and the amygdala and insula, respectively. Furthermore, the dissociative identity state uniquely activated the posterior association areas and the parahippocampal gyri, whereas the hyper-aroused identity state uniquely activated the caudate nucleus. Therefore, we proposed an extended PTSD-based neurobiological model for emotion modulation in DID: the hypo-aroused identity state activates the prefrontal cortex, cingulate, posterior association areas and parahippocampal gyri, thereby overmodulating emotion regulation; the hyper-aroused identity state activates the amygdala and insula as well as the dorsal striatum, thereby undermodulating emotion regulation. This confirms the notion that DID is related to PTSD as hypo-aroused and hyper-arousal states in DID and PTSD are similar. (C) 2014 Elsevier Ireland Ltd. All rights reserved

Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder:A PET study and neurobiological model

Imaging studies in posttraumatic stress disorder (PTSD) have shown differing neural network patterns between hypo-aroused/dissociative and hyper-aroused subtypes. Since dissociative identity disorder (DID) involves different emotional states, this study tests whether DID fits aspects of the differing brain-activation patterns in PTSD. While brain activation was monitored using positron emission tomography, DID individuals (n=11) and matched DID-simulating healthy controls (n=16) underwent an autobiographic script-driven imagery paradigm in a hypo-aroused and a hyper-aroused identity state. Results were consistent with those previously found in the two PTSD subtypes for the rostral/dorsal anterior cingulate, the prefrontal cortex, and the amygdala and insula, respectively. Furthermore, the dissociative identity state uniquely activated the posterior association areas and the parahippocampal gyri, whereas the hyper-aroused identity state uniquely activated the caudate nucleus. Therefore, we proposed an extended PTSD-based neurobiological model for emotion modulation in DID: the hypo-aroused identity state activates the prefrontal cortex, cingulate, posterior association areas and parahippocampal gyri, thereby overmodulating emotion regulation; the hyper-aroused identity state activates the amygdala and insula as well as the dorsal striatum, thereby undermodulating emotion regulation. This confirms the notion that DID is related to PTSD as hypo-aroused and hyper-arousal states in DID and PTSD are similar. (C) 2014 Elsevier Ireland Ltd. All rights reserved

“Glass brain” renderings show differences in the processing of the trauma-related text (indicated with a small ‘t’) and the neutral text (indicated with a small ‘n’) within the trauma-related identity state (TIS).

<p>Differences in regional cerebral blood flow patterns for the dissociative identity disorder (DID) group (left) and the comparison of this group to the high (middle) and low (right) fantasy prone DID simulating controls (CH and CL respectively) are depicted. See <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone-0039279-t003" target="_blank">Table 3</a> for the specific areas.</p

Memory script effects between dissociative identity states.

<p>Overview of brain areas with statistically significant cerebral blood flow changes when comparing DID patients to high or low DID simulating controls (CH and CL respectively) for the trauma-related memory script effects between dissociative identity state.</p><p>DID  =  dissociative identity disorder patient group.</p><p>CH  =  high fantasy prone DID simulating control group.</p><p>CL  =  low fantasy prone DID simulating control group.</p>I<p> =  <i>A priori</i> brain areas based on Reinders et al. (2006) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Reinders2" target="_blank">[40]</a>.</p>II<p> =  Brain areas found only in the DID within group analysis.</p>III<p> =  Brain areas found in the DID within group analysis, in the DID versus CH between group analysis <i>and</i> in the DID versus CL between group analysis.</p>IIIa<p> =  Brain areas found in the DID within group analysis <i>and</i> in the DID versus CH between group analysis.</p>IIIb<p> =  Brain areas found in the DID within group analysis <i>and</i> in the DID versus CL between group analysis.</p>IV<p> =  Brain areas not found in the DID within group analysis <i>but</i> appear in the between group analysis DID versus CH <i>or</i> DID versus CL.</p>1<p> =  first peak voxel in the cluster of the specified size.</p>2<p> =  second peak voxel in the cluster of the specified size.</p>3<p> =  third peak voxel in the cluster of the specified size.</p>**<p> =  whole brain multiple comparison correction (<i>p</i><0.05) using false discovery rate statistics <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Genovese1" target="_blank">[85]</a>.</p>*<p> =  region of interest multiple comparison correction (<i>p</i><0.05) using false discovery rate statistics <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Genovese1" target="_blank">[85]</a>.</p>u<p> =  Callosomarginal sulcus (SCM) ( =  Cingulate sulcus).</p>v<p> =  Supramarginal gyrus (Rostral I. Parietal Lobule).</p><p>(x, y, z)  =  MNI coordinates in mm.</p><p>L/R  =  Left/Right.</p><p>kE  =  clustersize in voxels (one voxel is 2×2×2 mm).</p><p>NISn  =  neutral identity state exposed to the neutral memory script.</p><p>NISt  =  neutral identity state exposed to the trauma-related memory script.</p><p>TISn  =  trauma-related identity state exposed to the neutral memory script.</p><p>TISt  =  trauma-related identity state exposed to the trauma-related memory script.</p><p>BA  =  Brodmann area.</p><p>I.  =  inferior; M.  =  middle; S.  =  superior.</p

Memory script effects within dissociative identity state.

<p>Overview of brain areas with statistically significant cerebral blood flow changes when comparing DID patients to high or low DID simulating controls (CH and CL respectively) for the trauma-related memory script effects within dissociative identity state.</p><p>DID  =  dissociative identity disorder patient group.</p><p>CH  =  high fantasy prone DID simulating control group.</p><p>CL  =  low fantasy prone DID simulating control group.</p>I<p> =  <i>A priori</i> brain areas based on Reinders et al. (2006) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Reinders2" target="_blank">[40]</a>.</p>II<p> =  Brain areas found only in the DID within group analysis.</p>III<p> =  Brain areas found in the DID within group analysis, in the DID versus CH between group analysis <i>and</i> in the DID versus CL between group analysis.</p>IIIa<p> =  Brain areas found in the DID within group analysis <i>and</i> in the DID versus CH between group analysis.</p>IIIb<p> =  Brain areas found in the DID within group analysis <i>and</i> in the DID versus CL between group analysis.</p>IV<p> =  Brain areas not found in the DID within group analysis <i>but</i> appear in the between group analysis DID versus CH <i>or</i> DID versus CL.</p>1<p> =  first peak voxel in the cluster of the specified size.</p>2<p> =  second peak voxel in the cluster of the specified size.</p>3<p> =  third peak voxel in the cluster of the specified size.</p>**<p> =  whole brain multiple comparison correction (<i>p</i><0.05) using false discovery rate statistics <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Genovese1" target="_blank">[85]</a>.</p>*<p> =  region of interest multiple comparison correction (<i>p</i><0.05) using false discovery rate statistics <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Genovese1" target="_blank">[85]</a>.</p>u<p> =  Callosomarginal sulcus (SCM) ( =  Cingulate sulcus).</p>v<p> =  Supramarginal gyrus (Rostral I. Parietal Lobule).</p><p>(x, y, z)  =  MNI coordinates in mm.</p><p>L/R  =  Left/Right.</p><p>kE  =  clustersize in voxels (one voxel is 2×2×2 mm).</p><p>NISn  =  neutral identity state exposed to the neutral memory script.</p><p>NISt  =  neutral identity state exposed to the trauma-related memory script.</p><p>TISn  =  trauma-related identity state exposed to the neutral memory script.</p><p>TISt  =  trauma-related identity state exposed to the trauma-related memory script.</p><p>BA  =  Brodmann area.</p><p>I.  =  inferior; M.  =  middle; S.  =  superior.</p

Main effects.

<p>Overview of brain areas with statistically significant cerebral blood flow changes when comparing DID patients to high or low DID simulating controls (CH and CL respectively) for the dissociative identity state main effects.</p><p>DID  =  dissociative identity disorder patient group.</p><p>CH  =  high fantasy prone DID simulating control group.</p><p>CL  =  low fantasy prone DID simulating control group.</p>I<p> =  <i>A priori</i> brain areas based on Reinders et al. (2006) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Reinders2" target="_blank">[40]</a>.</p>II<p> =  Brain areas found only in the DID within group analysis.</p>III<p> =  Brain areas found in the DID within group analysis, in the DID versus CH between group analysis <i>and</i> in the DID versus CL between group analysis.</p>IIIa<p> =  Brain areas found in the DID within group analysis <i>and</i> in the DID versus CH between group analysis.</p>IIIb<p> =  Brain areas found in the DID within group analysis <i>and</i> in the DID versus CL between group analysis.</p>IV<p> =  Brain areas not found in the DID within group analysis <i>but</i> appears in the between group analysis DID versus CH <i>or</i> DID versus CL.</p>1<p> =  first peak voxel in the cluster of the specified size.</p>2<p> =  second peak voxel in the cluster of the specified size.</p>3<p> =  third peak voxel in the cluster of the specified size.</p>**<p> =  whole brain multiple comparison correction (<i>p</i><0.05) using false discovery rate statistics <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Genovese1" target="_blank">[85]</a>.</p>*<p> =  region of interest multiple comparison correction (<i>p</i><0.05) using false discovery rate statistics <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0039279#pone.0039279-Genovese1" target="_blank">[85]</a>.</p>u<p> =  Callosomarginal sulcus (SCM) ( =  Cingulate sulcus).</p>v<p> =  Supramarginal gyrus (Rostral I. Parietal Lobule).</p><p>(x, y, z)  =  MNI coordinates in mm.</p><p>L/R  =  Left/Right.</p><p>kE  =  clustersize in voxels (one voxel is 2×2×2 mm).</p><p>NIS  =  neutral identity state.</p><p>TIS  =  trauma-related identity state.</p><p>BA  =  Brodmann area.</p><p>I.  =  inferior; M.  =  middle; S.  =  superior.</p