DID typically develops in individuals who, during very early childhood, have experienced extreme and chronic abuse, usually including elements of sexual, physical, and emotional abuse. Profound isolation from others at the time of the traumatic events also contributes to the development of this disorder (Steele et al., 2016; van der Kolk, 2014). Neurobiological evidence also supports a close relationship between PTSD and DID (Reinders & Veltman, 2021). Complete dissociation becomes the individual’s defensive coping mechanism under conditions of such extreme stress, instead of the alternative, which might be a complete psychotic break. Complete dissociation represents the system’s attempt to keep a part of itself healthy and functioning by developing other parts to hold the various emotions, memories, and responses to the trauma. These parts are referred to as “alters,” and an abuse survivor may have developed anywhere from a few to a very large number of alters to hold various emotions or memories. For example, one part may hold and be aware of feeling anger, another part may hold the sadness, and yet another part may hold a specific memory separate from the rest of the system. It is common for some of the parts to be child parts and, if accessed, they can state their age, gender, and role in the system. In contrast to the category of fragmentation, these parts are not aware of each other until the individual is under safe and specialized treatment conditions. Treatment of DID is a highly specialized subset within trauma treatment. The Dissociative Disorders Interview Schedule (Ross et al., 1989) or the Dissociative Experiences Scale (Bernstein & Putnam, 1986) can measure a full range of dissociative symptomatology. Treating individuals with this diagnosis requires specialized training. Model for Integration: The BASK Model To heal fragmentation and dissociation, the individual needs to be able to process a whole and complete memory with all of its component parts. To do so, the memory must be fully integrated within the body–mind system. The BASK model of memory dimensions (Braun, 1988) is used as the foundation of many treatments for dissociation and is a helpful tool to explain what is necessary for a fully integrated memory or activity. BASK is an acronym. B : Behavior A : Affect S : Sensation K : Knowledge In other words, the client must have conscious access to the behaviors or actions of anyone involved in the incident, including themselves, as well as access to their own affect or emotions, to sensations or body feelings, and to knowledge of what happened for the memory to be considered complete. If all of these features are present, available to conscious recollection, and related appropriately to the source event, then a memory can be considered fully integrated. A fully integrated memory can include both nonstressful and stressful events. A positive integrated memory might be the recollection of eating a delicious chocolate birthday cake last week at a birthday party: “I remember the whole family sitting around the dining room table as Dan brought in the cake [behaviors] and feeling surprised, pleased, and a little self-conscious when they sang ‘Happy Birthday’ [affect]. Tasting the chocolate frosting, feeling the smoothness of it on my Conclusion Understanding dissociation is a key element of trauma treatment. It can be conceptualized as an unconscious defensive response of the body–mind system under a combination of conditions of overwhelming stress, extreme pain, and terror, with no avenue for escape. Under these conditions, there is a physiological
Clinical Clues in the Detection of Dissociative Identity Disorder. None of the following signs are sufficient in and of themselves for a diagnosis of DID; however, an increasing number of these symptoms should raise the clinician’s level of concern and prompt a more thorough evaluation and referral to a specialized provider. The signs are (Schiller, 2008): ● Multiple previous psychiatric or psychological diagnoses ● A diverse symptom picture that does not correspond to more usual syndromes ● A history of severe childhood trauma; note that a significant lack of recall may be as important as what is recalled ● Periods of lost time (“I don’t know where I was on Sunday; I have no memory of that day”) or lack of memory about a span of years during childhood (“I can’t remember anything between ages 4 and 12”); note that no or little memory for events before age 4 is developmentally normative ● Behaviors the client cannot explain (“I know that I don’t like jellybeans and can’t imagine how 10 packages ended up in my cupboard”) ● Flashbacks, nightmares, sleepwalking, or auditory hallucinations ● The use of multiple nicknames and other peculiar references to self ● Unusual somatic symptoms not explained from a medical perspective that may vary or spontaneously come and go ● Observations during therapy sessions that include sudden changes in the person’s facial expression unexplained by content or significantly different styles of clothing from one meeting to the next, such that the clinician feels they are dealing with a different person ● Extreme mood swings ● Changes in handwriting tongue, and smelling the aroma of brewed coffee has my mouth watering right now as I remember [sensation]. I remember that it happened last Friday in honor of my 40th birthday” [knowledge]. “I remember running down to the basement with my children as the winds picked up and the radio announced that the hurricane was almost here [behavior]. I felt frightened, anxious, and worried [affect]. I remember having a knot in the pit of my stomach, noticing a sour taste in my mouth, and feeling the sensation of hugging my three children close to my chest [sensations]. I remember that two trees were uprooted from our yard and they crashed against the house, breaking a window during the storm. I know that it has been about a week since the hurricane and they have jus t gotten around to removing the trees that fell” [knowledge]. An integrated memory of a stressful event might be: With dissociation, these four components become separated from each other. The client might experience a sour taste in her mouth but not know why or feel jumpy and anxious on a windy day but not make the connection with the winds from the hurricane. Using the BASK system can also be a way for the clinician to assess the extent of dissociation. Resolution of dissociated trauma material involves the integration of dissociated behaviors (actions: Who did what and when?), affect (feelings: What were the emotions at the time of the events?), sensations (associated body states), and knowledge (cognitions, self-perceptions, and meaning-making). These factors will be discussed more fully in the chapters on treatment.
response and the body releases stress hormones. This release of stress hormones activates either the hyperfocus or the amnesiac response, depending on what the individual senses is necessary for survival. Dissociation is a separation of awareness and a compartmentalization of the experience.
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Book Code: PYFL4024
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