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A critical analysis of myths about dissociative identity disorder

Article  in  Annales Médico-psychologiques revue psychiatrique · August 2021

DOI: 10.1016/j.amp.2021.10.007

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 A Critical Analysis of Myths About Dissociative Identity Disorder
Une Analyse Critique des Mythes Relatifs au Trouble Dissociatif de l’Identité

Olivier Dodier1, Henry Otgaar2,3,4, Steven Jay Lynn5

1
UPR APSY-v, Université de Nîmes, France
2
Maastricht University, The Netherlands
3
City, University of London, UK
4
Catholic University of Leuven, Belgium
5
Binghamton University (SUNY), U.S.A.

In Press, Annales Médico-psychologiques

Correspondence concerning this article should be addressed to Olivier Dodier, UNIV.

NIMES, APSY-V, F-30021 Nîmes Cedex 1, France.

[email protected]

The authors declare no conflict of interest.

Les auteurs ne déclarent aucun conflit d’intérêt.

1
Abstract

In a review of the literature in this journal, Piedfort-Marin et al. (2021) identified what they

purported to be myths about dissociative identity disorder (DID) and dissociative amnesia.

When responding to these beliefs, they supported the Trauma Model of dissociation and

argued for a causal etiological link between trauma and dissociative conditions. In contrast,

they challenged the Sociocognitive Model (SCM), which they claimed rejects the existence of

DID and associated disorders (e.g., dissociative amnesia) and considers symptoms to be the

byproduct of fantasy, suggestion, and the iatrogenic effect of psychotherapies. In this article,

we critically evaluate the authors' arguments and propose a more balanced, accurate, and

comprehensive view of the sociocognitive model. We demonstrate that this model neither

rejects the existence of DID, nor a link between trauma and dissociation potentially mediated

by a variety of cognitive-affective-behavioral variables. We argue, contrary to Piedfort-Marin

et al., that the tendency to confabulate and other cognitive and socio-cultural variables may

also contribute to the development of DID. We contend that a multifactorial integrative

etiological perspective can move the field beyond a limited focus on controversies that divide

the TM and SCM models of dissociation.

Keywords: Amnesia, Dissociative identity disorder, Dissociation, Trauma, Dissociative

Amnesia

Résumé

Dans une revue de littérature parue dans ce journal, Piedfort-Marin et al. (2021), ont relevé et

répondu à plusieurs croyances relatives au trouble dissociatif de l’identité (TDI). Pour

certaines d’entre elles, ils ont opposé le modèle traumatique de la dissociation, suggérant un

lien étiologique causal entre trauma et TDI et le modèle sociocognitif qui, selon eux, rejette

l’existence du TDI et de troubles associés (e.g., amnésie dissociative) et considère que

2
l’expression symptomatique est le résultat d’invention, de suggestion et d’effet iatrogène des

psychothérapies. Dans ce commentaire, nous répondons aux arguments des auteurs en

proposant une vision plus nuancée, plus exacte et plus complète du modèle sociocognitif.

Nous démontrons ainsi que ce modèle ne rejette ni l’existence du TDI, ni celle d’un lien

causal entre trauma et dissociation, et proposons qu’un tel lien, s’il existe, serait plutôt

indirect et médié par une variété de dérégulations cognitives, affectives et comportementales.

Nous soutenons, contrairement à Piedfort-Marin et al., que la tendance à l’affabulation et

d’autres facteurs cognitifs et socioculturels peuvent aussi contribuer au développement du

TDI. Nous plaidons ainsi pour une approche étiologique multifactorielle intégrative et

invitons à sortir de l’opposition classique entre les modèles traumatique et sociocognitif de la

dissociation.

Mots clés : Amnésie, Trouble dissociative de l’identité, Dissociation, Trauma, Amnésie

dissociative

3
 1. Introduction

Dissociative Identity Disorder (DID) is as controversial in the scientific literature as it is

fascinating and compelling to the public in popular culture. The intriguing question of the co-

existence of several distinct identities resident in one individual has been dramatized in many

successful movies, such as Fight Club or, more recently, Split. DID is characterized in the

DSM–5 (American Psychiatric Association, 2013, p. 291) “by the presence of two or more

distinct personality states or an experience of possession and recurrent episodes of amnesia”

(see Piedfort-Marin et al., 2021, for a more exhaustive presentation of this disorder). As

Piedfort-Marin et al. (2021) pointed out, DID is also the subject of many misconceptions

about the occurrence of its symptoms and its etiology. In their literature review, Piedfort-

Marin and colleagues (2021) addressed five myths they believe are often encountered when

discussing DID: (i) DID is schizophrenia; (ii) DID does not exist; (iii) DID develops in

response to the influence of the media and/or therapists in suggestible people who are fantasy

prone; (iv) The etiology of DID is iatrogenic and not posttraumatic; and (v) Amnesia for the

terrifying traumatic stories that DID people report in therapy is not likely, and such stories

have been invented.

To discuss and share the scientific view regarding these myths, Piedfort-Marin et al.

(2021) compared two models, namely the trauma model (TM) of dissociation and the

sociocognitive model (SCM) to explain the development of DID. The TM asserts a direct

causal link between trauma and the development of DID (e.g., Brand et al., 2018; Dalenberg

et al., 2013), whereas the SCM is an open model that considers the potential influence and

interaction among social and cognitive variables (e.g., fantasy proneness; cognitive failure;

suggestibility; peer, therapist or media influence; e.g., Giesbrecht et al., 2008; Lynn et al.,

2014) as antecedents of dissociative experiences and symptoms. Piedfort-Marin et al. (2021)

mainly rejected the tenets of the SCM and were more in favor of the TM. Specifically, they

4
concluded the following: DID is distinct from schizophrenia; it develops independent of

influence of therapists, media, or more generally sociocognitive variables; the origin of DID is

traumatic in nature; and people with DID do not exhibit proneness to fantasy or confabulation.

Rather, the horrifying events of childhood sexual abuse reported by people with DID in

therapy are real and known to law enforcement. In this critical commentary, we challenge a

number of interpretations of the literature that Piedfort-Marin et al. (2021) advanced and

argue for a more balanced, accurate, and comprehensive interrogation of potential antecedents

of DID beyond trauma. While we agree that DID is not schizophrenia and recovered

memories of terrifying childhood events may be accurate, we view other claims as more

questionable. We will argue that some contentions are fallacious in that they inaccurately

attribute claims to proponents of the SCM that they have not advanced (e.g., “dissociative

amnesia cannot exist”). Furthermore, we will show that the authors failed to consider recent

contributions to the literature that would have provided a more accurate view of the

complexity that DID represents. Finally, we will posit that accounts advanced by the SCM are

more nuanced than what the authors portray.

To structure our commentary, we focus on aspects of Piedfort-Martin et al.’s review

(2021) that we judge to be the most problematic. We will not elaborate on possible

differences between DID and schizophrenia, as there is scant disagreement that DID should

be confused with schizophrenia. However, we will focus on the following issues: 1) Does

DID exist, 2) Does DID have a traumatic origin, 3) Does dissociative amnesia exist, and 4)

Are the horrific stories of people with DID unfounded?

2. Does Dissociative Identity Disorder Exist?

Piedfort-Marin et al. (2021) criticized three issues that they attributed to the SCM: DID

is caused by media influence, it has an iatrogenic origin (i.e., an influence of therapy and

5
therapists), and people with DID are fantasy prone. We do not find their arguments

convincing, either because they are not supported by compelling evidence, or because they

disregard certain aspects of the literature supportive of the SCM. We will therefore follow the

organization of the authors' three subsections and provide a critical evaluation of their

contentions.

2.1. Media and DID

According to Piedfort-Marin et al. (2021), proponents of the SCM identified the release

of a novel (and its movie adaptation), Sybil, as the source of the outbreak of DID diagnoses

and that DID would only be a fad. We agree with Piedfort-Marin et al. (2021) that, contrary to

Paris (2012) it does not appear to be the case that DID only manifested in the 1980–1990

period before disappearing. A quick search on Medline using the keywords “Dissociative

Identity Disorder” and “Multiple Personality Disorder” shows that, as illustrated in Figure 1, a

rise in publications on these topics occurred in the 1980s, and the publication hits remain

quite high and relatively stable. However, the fact that papers are published on the topic of

DID should not be conflated with valid and reliable evidence for the TM. Considering the

popularity (even among scientists) of a disorder as evidence of its existence would be

exemplify an argumentum ad populum.

6
Figure 1

Number of Publications per Year Identified in a PudMed Search Using the Keywords

“Dissociative Identity Disorder” and “Multiple Personality Disorder”

250

200

150

100

50

0
1940 1950 1960 1970 1980 1990 2000 2010 2020

Critically, the authors omitted the fact that the case described in Sybil is based on

fabricated and/or misleading information, as exposed by the investigative journalist Deborah

Nathan (2011). According to Shirley Mason, the woman renamed Sybil in the book, stated

that her therapist suggested symptoms of DID, and that she enacted the role of a person with

“multiple personalities” largely to please her therapist (Paris, 2012). Another significant

omission by the authors was that there was no credible or corroborated evidence of childhood

abuse in the case, a problem that plagues much of the research on DID. In fact, Mason’s

childhood appeared to be quite ordinary (Paris, 2012).

In support of the claim that the media does not affect the genesis of DID, Piedfort-

Marin et al. (2021) referred to Dell's study (2006) showing that of all the symptoms of DID,

83–95% of people diagnosed with DID exhibited 15 symptoms (out of 23) that were

“unknown to the media, to the general public, but also to the majority of health care

professionals” (p. 379) because they would be subjective and unobservable. Such a finding,

according to Dell (2006) and Piedfort-Marin et al. (2021) would contradict the SCM.

7
However, the authors did not disclose several critical limitations of this study. First, the

assertion that the 15 symptoms in question are unknown to the public, the media and health

practitioners is not supported by any evidence in Dell's article (2006), or any evidence we are

aware of. The fact that the symptoms are experiential, subjective, and not evident to

onlookers, for example, does not signify that they are not known to exist, particularly given

that publicized accounts of DID are widely disseminated in the media.

Second, the DSM–5 (American Psychiatric Association, 2013) lists in the differential

diagnosis section no less than 10 other disorders or types of disorders that could be confused

with DID (e.g., post-traumatic stress disorder, bipolar disorder, depressive disorder, psychotic

disorder). Thus, many of the 15 symptoms frequently evident in DID patients, which are

claimed to be unknown, are present in one or more disorders and not specific to DID. Among

the eight remaining symptoms frequently found in DID there exist (i) those known to the

public, the media, and health professionals, and (ii) symptoms that make it possible to rule out

other disorders from the differential diagnosis; for example, the presence of two (or more)

distinct personality states. In short, this study alone has no apparent bearing on the SCM.

The authors observed that, despite the release of several movies featuring DID, “there

does not seem to have been an increase in treatment demands for DID” (Piedfort-Marin et al.,

2021, p. 379). Furthermore, the authors concluded that they find it “difficult to draw the

conclusion that DID is always the result of media influence” (p. 379). The SCM does not

assert the extreme case that “DID is “always the result of media influence.” To the contrary,

according to the SCM, media exposure is only one of multiple pathways by which DID might

develop (Lilienfeld et al., 1999; Lynn et al., 2014). Moreover, the SCM does not assert a

monotonic relation between media exposure and the genesis of DID (although such a relation

is possible) or demand for treatment of DID.

8
 2.2. Is DID Iatrogenic?

According to Piedfort-Marin et al. (2021), what makes the proponents of the SCM

reason that DID could be the result of therapist influence is that “the clinical presentation of

DID becomes more explicit after the beginning of treatment” and that presentation would be a

reflection of the therapist who would “take advantage, most of the time unconsciously, of the

patient's cognitive failures, high level of imagination and suggestibility” (p. 379). Proponents

of the SCM have expressed concerns regarding the use of suggestive techniques in

psychotherapy in diagnosing and treating DID (Lilienfeld, 2007; Spanos, 1996). These

methods include journaling, hypnosis, referring to different personality states with different

names, mapping purported personality systems, attempts to recover memories associated with

different personalities, and so forth (Lilienfeld, 2007). These techniques arguably would reify

presentations of identity confusion and the expression of puzzling and disturbing symptoms in

terms of a narrative of “multiple selves” consistent with DID. Narratives that emerge in

therapy may thus be a function of suggestive methods, but also can arise from widely

available cultural beliefs about DID and idiosyncratic ways individuals represent their

subjective experience of self-fragmentation. Even adherents of the TM concede that some

cases of DID can be iatrogenic (Dalenberg et al., 2012), although the rate of occurrence of

such cases is unknown.

Simulation studies reveal that healthy people are readily able to mimic symptoms of

DID in laboratory contexts with minimal cues to do so (see Boysen & van Bergen, 2014;

Spanos et al., 1985; Stafford & Lynn, 2002), implying that sociocultural narratives regarding

DID are widely accessible to the general public. However, the ability to simulate DID should

not be conflated with the idea that DID itself is typically simulated or faked, which is not the

case, other than in probably rare forensic contexts. The SCM does make such a claim.

Piedfort-Marin and colleagues (2021) rejected the idea that individuals with DID exhibit

9
high levels of suggestibility stating that dissociation would explain only 1% of the variance in

suggestibility. Piedfort-Martin et al.’s concern regarding suggestibility is based on Dalenberg

et al.'s meta-analysis (Dalenberg et al., 2012) whose study inclusion criteria have been

criticized (Lynn et al., 2014; Patihis & Lynn, 2017). Dalenberg et al. (2012) used studies that

measured dissociation mostly with the Dissociative Experience Scale (DES, Bernstein &

Putnam, 1986). However, Dalenberg’s analysis excluded studies conducted with a modified

version of the DES, the DES–C (Wright & Loftus, 1999), which was developed to counteract

the floor effect and skewness of the distribution encountered in nonclinical populations.

Patihis and Lynn (2017) found no empirical justification for excluding DES–C studies. In

fact, the DES and the DES–C performed comparably across indices of psychopathology,

highlighting the problem of comorbidity of psychological symptoms in discerning the

specificity of trauma to dissociation. Additionally, both scales secured evidence for only weak

correlations between trauma and dissociation, with correlations ranging between r = .122 and

r = .269 across the two studies, whereas the correlation with the DES and both fantasy

proneness and cognitive failures ranged between r = .50 and r = .60 across these measures

(Study 1). In fact, the correlations between sexual abuse and harassment and dissociation were

not statistically significant (Study 2), consistent with other studies cited by Dalenberg et al.

(2012), which found little or no association of trauma with dissociative experiences. One

could argue that the Patihis and Lynn (2017) findings were secured in a non-clinical sample

and therefore not relevant to severe dissociation. However, there was no evidence for the

findings to be associated with different levels of trauma and, more generally, scant studies

have directly compared the correlations across patient and healthy individuals or traumatized

and non-traumatized individuals in the context of the same study. Still, we acknowledge the

possibility that future research will reveal that trauma plays a more causative role in some

populations of individuals and across different types of trauma.

10
 2.3. Does DID Reflect Fantasy Proneness?

Piedfort-Marin and colleagues (2021) suggested that, contrary to what the SCM implies,

“there is no strong evidence that DID is the product of a fantasy proneness (...)” (p. 380). The

authors rejected the argument of positive correlations observed between DES scores and

different measures of fantasy proneness, because “as the DES includes many items referring

to absorption (the ability to do an action while in a non-pathological daydreaming state), it is

not surprising that correlations are found between the DES and different measures of

daydreaming tendency and imagination” (p. 380). In addition to the fact that fantasy

proneness is not only characterized by a proneness to daydreaming and imagination, but also

by difficulties in distinguishing between reality and fantasy, the proportion of variance

explained by fantasy proneness in dissociation remains large (i.e., 32%, Pekala et al., 1999),

even when the DES absorption items are excluded, which is more than the approximately

10% of variance that represents the average correlation (i.e., effect size, r = .32) between

dissociation and trauma reported by Dalenberg et al. (2012; see Lynn et al., 2014). Although

the authors accurately reported the findings of van der Boom et al. (2010) that fantasy

proneness did not play a mediating role in the association between trauma and dissociation,

van der Boom et al. (2010) themselves emphasized that their results did not support a direct

causal relation between trauma and dissociation either, given findings of only a modest

correlation.

Piedfort-Marin et al. (2021) criticized the fact that most studies investigating the

associations between fantasy proneness and dissociation were not conducted with clinical

samples but with general public samples (e.g., students) and claimed that these studies do not

allow for satisfactory conclusions. To bolster this claim, the authors cited Nijenhuis and

Reinders’s study (2012) that reported low mean scores in DID patients on a fantasy proneness

11
scale (CEQ, Merckelbach et al., 2001). The DID sample scores were lower than several

control groups (e.g., actors, fantasy gamers, and patients diagnosed with borderline

personality disorder). Nevertheless, this study has notable limitations that warrant caution in

interpreting the results. First, crucial information is missing (e.g., the sample size of the

control groups, the characteristics of these samples, the control participants’ possible

traumatic history, their score on dissociation scales). Second, clinical patients may be

motivated to suppress endorsement of items that tap fantasy proneness in order to not

invalidate their DID diagnosis, as merely the product of fantasy. Accordingly, there is reason

to suspect strong biases, particularly among patients with DID in psychotherapy, to

underreport scores on measures of fantasy-proneness and for correlations between measures

of fantasy proneness and dissociation to be attenuated. However, this plausible contention

remains to be confirmed empirically. Third, although scores on the CEQ were low in the DID

condition, the researchers reported no statistical comparison of mean scores across

comparison conditions. Fourth, Piedfort-Martin et al. (2021) conflated mean scores with

correlations, which are the appropriate analysis to shed light on the association between

fantasy proneness and dissociation, as mean scores are independent of correlations.

Importantly, in a recent meta-analysis of 132 articles with 24,007 participants,

Merckelbach et al. (in press) found that the link between fantasy proneness and dissociative

experiences and the link between fantasy proneness and an eight-item version of the DES that

tapped more serious dissociative pathology was appreciably higher (respectively, r = .52 and r

= .40). So, contrary to what Piedfort-Marin et al. (2021) contend, considerable evidence exists

for a sizable and meaningful relation between fantasy proneness and dissociation.

Unfortunately, adherents of the TM, like Piedfort-Marin et al. (2021), often overlook or

minimize findings not entirely supportive of their perspective.

12
 2.4. Final remarks

The suggestion that proponents of the SCM consider that DID does not exist (p. 380) is

not founded. Decades ago, Lilienfeld et al. (1999) dismissed this contention as a

“pseudoissue” (p. 509) and conceded what is obvious: some people express symptoms of

DID. Rather than quarrel about the existence of DID, the SCM addresses the etiology of the

disorder and the role of trauma, sociocognitive variables presumed to be linked with

dissociative experiences, and the mechanisms that contribute to the diagnosis. Current

discussions still focus on these three points of controversy (Lynn et al., 2019a).

Piedfort-Marin and his colleagues (2021) claimed that SCM proponents use the DES as

a measure of dissociation “while asserting that dissociation is a universal phenomenon

without a traumatic origin, whereas the DES is built on the assumption of a traumatic origin

of severe dissociation” (p. 380). It is unclear what the relevance is of the scale being “built on

the assumption of a traumatic origin…” in terms of how it is related to the validity and

psychometric properties of the scale. What is relevant to the SCM is that weak-to-moderate

correlations between reports of trauma and dissociation, which we consider in the next

section, imply that other variables or mechanisms must be elucidated to more fully account

for dissociative experiences and disorders.

3. Does DID Have a Traumatic Origin?

Piedfort-Marin et al. (2021) state that SCM researchers rejected the idea of an

etiological association between trauma and dissociation because DID patients reporting

childhood traumatic experiences would suffer the effects of “the malleability of memory

which would be vulnerable to suggestion” (p. 380). We contend that this is possible and add

the imperative that memory reports—whether of traumatic or nontraumatic events (Bernsten

& Nielsen, 2021)—should be corroborated by objective evidence where possible, given the

13
widely accepted finding that memory is reconstructive (e.g., Barlett, 1932), prone to

inaccuracies, and sensitive to the influence of external sources, including the media (Bernsten

& Nielsen, 2021; Nahleen et al., 2019).

As Piedfort-Marin et al. (2021) pointed out, the proponents of the SCM do not reject a

potential etiological role of trauma in dissociation (p. 378). Nevertheless, we maintain that the

evidence for trauma playing a necessary, sufficient, specific, or direct role in the genesis of

dissociation is not as compelling as the TM model and Piedfort-Marin et al. (2021), in

specific, maintain. In fact, the evidentiary basis for the TM is neither compelling nor

convincing: It rests largely on modest (on average) and inconsistent correlational findings

based on uncorroborated reports of trauma, rather than on replicated positive findings based

on longitudinal studies of confirmed traumatic events (Giesbrecht et al., 2008; Patihis &

Lynn, 2017).

Piedfort-Marin et al. (2021) presented neuroimaging studies to support the idea of a

causal relation between trauma and dissociation. For example, they described a study showing

an association between childhood trauma and reduced hippocampal volume in patients

diagnosed with post-traumatic stress disorder (PTSD) and/or DID (Chalavi et al., 2015). They

stated that “this study concludes that DID is closely related to PTSD and that both disorders

are traumatic in origin” (p. 381).

Nevertheless, we argue that this conclusion is not supported by the quality of the

evidence. Given the impossibility—for obvious ethical reasons—of inducing sufficient levels

of stress in the laboratory to induce trauma, many extant biomarker findings are correlational

and not longitudinal, and therefore do not indicate the direction of the association. Indeed, the

associations between hippocampal volume and trauma may indicate a risk factor for the

experience of distress or trauma due to pre-existing hippocampal abnormality (Childress et

al., 2013). In addition, biomarkers studies generally do not control for the confounding effects

14
of comorbid conditions, include comparison groups matched for general psychopathology,

and distinguish traumatic events from generalized stressors and daily life stress or hassles

(Lynn et al., 2019a). Nor do they typically compare dissociative conditions associated with

reports of a history of trauma versus no history of trauma to isolate the role of trauma, if any.

To our knowledge, there exists no reliable, replicable neurobiological signature specific to

trauma, much less a biomarker that reflects the diversity of traumatic experiences, just as

there is no set of personality characteristics specific to or indicative of trauma or sexual abuse.

Accordingly, we contend that the following conclusion is not warranted: “(…) the most recent

and extensive (neuroimaging) studies confirm that DID is a trauma-induced disorder and that

it is at the extreme end of a continuum of trauma-induced disorders” (Piedfort-Marin et al.,

2021, p. 381).

These considerations aside, we do not reject the potential etiological role of trauma in

dissociative disorders such as DID, but we assume that sociocognitive and other variables

need to be considered in a complete account of dissociative conditions. Lynn et al. (2019), for

example, suggested direct as well as indirect influences on dissociation via sleep disturbances

(see also van der Kloet et al., 2012) and emotion dysregulation. Additionally, as Lynn et al.

(2019) and others discuss, dissociative symptoms can occur in disorders that also are

associated with sleep dysfunctions, cognitive-affective-behavioral dysregulation (e.g.,

borderline personality disorder, schizophrenia spectrum disorders), and alexithymia/poor

meta-cognition, indicating shared vulnerabilities among different manifestations of

psychopathology that are comorbid with dissociative conditions. Whether trauma is causally

connected with these variables remains an open question, but even if it were found to be the

case, it would still not support the proposition that different personality states are separated by

amnesic barriers and associated with independent systems of control, which is a highly

questionable assumption that is not supported by the available evidence, as we will note

15
below in our discussion of interidentity amnesia.

Lynn et al. (2019) recommended moving beyond the traditional TM/SCM debate and

proposed additional factors that may contribute to the development of dissociative disorders.

Supplementing a growing body of research over the past 20 years, which has highlighted the

relation between sleep disturbance and dissociation (e.g., van der Kloet et al., 2012; Watson,

2001; Watson et al., 2015), Lynn et al. (2019) advanced the hyperassociativity hypothesis.

This hypothesis was based on Lynn’s observations of six DID patients who shifted rapidly

and dramatically in their clinical presentation across cognitive-affective-behavioral states in

response to internal and external triggers (Lynn et al., 2019b). Lynn et al. (2019a) defined

hyperassociativity as the fluid association of concepts, memories, or emotions that are weakly

associated semantically and emotionally. To onlookers, such extreme shifts could be

perceived as manifestations of different identities based on traditional notions of DID (Lynn

et al., 2019a).

Lynn et al. (2019a, b], however, did not view such shifts to signify different

“personalities” or identities with independent executive systems, memories, or behavioral

patterns separated by amnesic barriers, as argued by the TM. Rather, Lynn and his colleagues

(2019a, b) posited that cognitive, affective, and behavioral instability and hyperassociativity

evidenced in DID reflects weakly monitored, poorly regulated and processed, dysfunctional

response sets and self-representations that patients and therapists can come to construe as

separate indwelling identities in DID.

Still, this formulation does not exclude an indirect (e.g., via sleep, self-control deficits,

emotional dysregulation) or even a potentially direct role for trauma (i.e., in cases of

depersonalization/derealization in peritraumatic dissociation), among a variety of mechanisms

of dissociative experiences and symptoms. Nor does this perspective dismiss the personal and

social sequelae and costs of trauma and its aftermath. Nevertheless, we contend that scant

16
evidence exists to support Piedfort-Marin et. al. (2021) implication that trauma is a necessary,

sole, or generally sufficient cause of dissociation.

4. Does Dissociative Amnesia Exist?

This section in Piedfort-Marin et al.'s article (2021) is possibly the most problematic.

Here, the authors again respond to arguments or claims that do not accurately reflect those

advanced by proponents of the SCM. First, they argued that for some SCM proponents,

dissociative amnesia “cannot exist” (p. 381). This statement is not consistent with arguments

voiced by critics of dissociative amnesia. For example, Otgaar et al. (2019) stated that “the

idea of repressed memories runs counter to well-established principles of human memory” (p.

1074), not that the phenomenon “cannot exist.” Also, recently, Mangiulli and colleagues (in

press) stated explicitly that “we do not want to imply that dissociative amnesia is a non-

existing diagnostic entity. Rather, our findings highlight that case study data surrounding the

nature and etiology of dissociative amnesia are unconvincing, lacking of convergence and

cohesion across clinicians and academics.” What these authors argue is that the mechanisms

described in the DSM–5 as “dissociative amnesia” do not correspond to current knowledge of

how memory works, either in an ordinary way or in intense stress circumstances. In a recent

French review of the critical literature on dissociative amnesia, Dodier (in press) stated in an

introductory statement: “(...) it is necessary to note that the purpose of this article is not to

assert that dissociative amnesia does not exist. Rather, the purpose is to emphasize both a lack

of evidence for a link between trauma and forgetting but also alternative, more parsimonious

empirical evidence, thus creating an obstacle to the claim that dissociative amnesia exists.” To

say that evidence is lacking for the existence of a phenomenon or process is not the same as

saying that the phenomenon or process does not exist. This epistemological caution is

important in that, contrary to what Piedfort-Marin and his colleagues (2021) claim, skeptical

17
scholars of dissociative amnesia remain quite open to the existence of dissociative amnesia.

However, in the absence of convincing evidence, we contend that continued caution is

warranted.

Second, the authors attributed to the proponents of the SCM the argument that

dissociative amnesia may be ordinary forgetting, and that by forgetting, SCM proponents are

suggesting that people can remember their trauma if they are helped to do so. Piedfort-Marin

et al. (2021) therefore expressed surprise that the “danger of suggestion does not seem to be a

problem here” (p. 381). We see two major concerns with this last claim: (i) the danger of

suggestion is problematic for dissociative amnesia skeptics (see, e.g., Dodier & Patihis, 2021),

and (ii) helping people to remember better can be done completely independently of any

suggestion, as illustrated by the large body of research on non-suggestive forensic

interviewing methods such as the cognitive interview (see Dodier et al, 2021, for real-world

highly stressful experiences; see Memon et al., 2010, for a meta-analysis). It is also entirely

conceivable that individuals will recover ordinarily forgotten (accurate) traumatic memories

on their own and spontaneously in the presence of relevant retrieval cues in everyday life (e.

g., hearing the perpetrator's name, returning to the scene of the abuse). Interestingly, people

who spontaneously recovered memories in this manner were found to be less susceptible to

false memories than people who recovered their memories in therapy (Geraerts et al., 2009),

and their memories were more likely to be corroborated by external evidence than memories

recovered in therapy (Geraerts et al., 2007).

In the following discussion, Piedfort-Marin et al. (2021) relied on two types of studies

to support the validity of dissociative amnesia. First, they presented data from retrospective

studies (i.e., Briere & Conte, 1993; Hermann & Schatzow, 1987) showing that victims of

childhood abuse reported “rates of amnesia (...) in 59% of the cases (out of 450 subjects), and

28% of the women (out of 53) in their sample, respectively” (p. 381). The authors also

18
described the work of Elliott and Briere (1995) finding “20% total amnesia and 42% partial

amnesia” (p. 381). Finally, they reported the findings of Wilsnack et al. (2002) that 25% of a

non-clinical population reported amnesia, of which only 1.8% recovered their memories in

therapy. None of these studies, however, support the validity of dissociative amnesia. The

question asked in these studies is not that of amnesia, but that of the period without memories

of abuse between the event and the study. Researchers have argued that reporting periods

without memories of the events can be explained in terms of alternative processes or

phenomena related to ordinary memory (Dodier & Patihis, 2021, Loftus et al., 1998; McNally

& Geraerts, 2009). To address this issue, Dodier and Patihis (2021) reported very large

inconsistencies in the percentages of self-report of periods without abuse memories (rank =

6%–77%). They then hypothesized that, in addition to methodological weaknesses of studies,

false positives (i.e., mistakenly reporting periods of time without memories) could explain

these large variations in proportions. Using follow-up questions (i.e., asking participants what

they meant exactly when they reported recovering memories of childhood abuse) to limit false

positives, (i) 23% of people reporting memories of childhood abuse had experienced a period

without memory of the events before recovering them at a specific time in their lives, and (ii)

31% of people who initially reported recovering previously forgotten memories had in fact

always had memories, but had reinterpreted them over time. This second result aligns with

hypotheses of alternate developmental phenomena or processes proposed earlier in the

literature (e.g., McNally & Geraerts, 2009). In addition, almost 10% of recovered memories

of childhood abuse that individuals were previously unaware of were recovered in therapy,

and many of the contexts of recovery were consistent with the SCM (e.g., media exposure,

personal documentation on repressed memory of child abuse, discussion with relatives about

childhood abuse and repressed memories).

Additionally, Piedfort-Marin et al. (2021) relied on Williams's prospective study (1994),

19
which reported that 38% of women who had reported abuse 17 years earlier did not

spontaneously recall it during an interview. Nevertheless, this research does not constitute

unambiguous evidence for dissociative amnesia. Loftus et al. (1994), for example, explained

that not spontaneously recalling events by no means provides dispositive evidence that they

have truly been forgotten; that is, people may simply have chosen not to talk about the abuse.

In addition, Piedfort-Marin et al. (2021) stated that this study found that “the closer the

relationship to the perpetrator, the greater the possibility of forgetting the abuse in adulthood”

(p. 382). Although the authors do not provide an explanation for this result, which Williams

(1994) reported, non-pathological social factors might provide an explanation. Indeed, Leach

et al. (2017) observed that when abuse was intrafamilial, younger children were less likely to

disclose it during a police interview. Accordingly, the authors explained, children, especially

if they are young, may not perceive the abuse as such, fear reprisal for disclosure, or feel

loyalty to the abuser. Unfortunately, Piedfort-Marin et al. (2021) conflate cases of not

spontaneously recalling events, or not reporting them for a period of time, with proof of

dissociative amnesia, rather than consider more parsimonious and less controversial

explanations that are available in the literature. In any case, further research is needed to

illuminate the mechanisms underlying the phenomena of recovered memories. Of course,

experiencing traumatic events can lead to memory problems (e.g., involuntary and persistent

memories, encoding failure). However, such problems do not support the existence of

amnesia for entire autobiographical experiences. Moreover, concerning the inter-identity

amnesia often reported in the DID literature (e.g., Eich et al., 1997), researchers have

documented that--despite subjective reports of forgetting information (i.e., amnesia)—when

objective indicators are employed with individuals with DID, information is, in fact,

implicitly transferred from one “identity” to another (Huntjens et al., 2012). Moreover,

performance on inter-identity episodic memory transfer tasks is similar among DID patients,

20
simulators, and healthy control participants (Huntjens et al., 2003).

Finally, Mangiulli and colleagues (in press) reviewed case studies on dissociative

amnesia in the period of 2000-2020. They critically examined 128 case studies and assessed

whether the information reported in these case studies was aligned with DSM–5 criteria for

dissociative amnesia. The authors found, however, that the evidence to support dissociative

amnesia was very weak and plagued with unexplained heterogeneity regarding the origin of

the memory loss. None of the case studies completely satisfied all DSM–5 criteria, and most

case studies failed to consider alternative explanations for the claimed memory loss.

Collectively, at present, evidence to support dissociative amnesia, as a phenomenon distinct

from ordinary forgetting and ruling out memory loss in response to neurological injuries, is

severely lacking. Hence, we encourage clinicians and researchers to consider alternative and

more mundane memory-based explanations more critically for claimed autobiographical

memory loss.

5. Are the Terrifying Stories of People with DID Unfounded?

The authors presented documented cases of paedophile networks in support of their

claim that the terrifying and traumatic events that DID patients report can be real (Piedfort-

Marin et al., 2021)—because, in fact, such events do occur. When people claim to recall

abuse that was formerly forgotten, one always needs to examine the validity of these claims,

which may confirm the accuracy of recovered memories. The proponents of SCM do not deny

the reality of sexual abuse, and they do not deny that recovered memories (even in therapy)

can be accurate. Rather, we assert the imperative to explore a variety of ordinary and non-

controversial explanatory mechanisms before resorting to dissociative amnesia to account for

memory loss (e.g., delayed understanding of the abuse, reluctance to report events, encoding

failure, brain injury).

21
 However, we cannot endorse the use of anecdotal evidence to contradict the false

memory hypothesis. If we must rely on anecdotal cases, it is also possible to propose some

that illustrate cases of false memories. For example, the Benoit Yang Ting case in France,

widely reported in the media, concerns a clinical psychologist who induced false intrauterine

memories in patients of attempted abortions by their mothers. Such memories are highly

unlikely and the criminal investigation, as well as the court decision recognized these

memories as false and induced during suggestive therapy and the therapist was given a one

year suspended prison sentence for abusing vulnerable people. Does this case and the court

finding reduce all memories of childhood abuse to false memories? Surely not. In the same

way, the fact that paedophile networks have been found to be active does not imply that all

memories of childhood abuse, which arise in therapy, are veridical. Only a careful, case-by-

case examination of the events in question and potential factors that may be detrimental to

memory can yield information that can corroborate, no corroborate, or determine the

impossibility of corroborating memories in and out of the therapy context.

6. Conclusion

We argue that that the literature review presented by Piedfort-Marin et al. (2021)

represents an imbalanced and inaccurate accounting of the literature on DID and

misrepresents the SCM. Current proponents of the SCM do not contend that DID or

dissociative amnesia do not exist; that trauma plays no role in the etiology of the disorder

(although that can be the case), and that the memories of terrifying events reported by DID

patients are necessarily false and implanted by unscrupulous or incompetent therapists.

Instead, the SCM proposes that, as is the case in many disorders, sociocognitive and cultural

factors play a role in DID. Nor do SCM proponents claim that all DID symptoms are

invariably media or therapist induced or even necessary or exclusive etiological components.

22
Dwelling on increasingly stale controversies and points of disagreement across perspectives

will not advance the field forward in meaningful directions and will only further polarize the

discussion on the origins of dissociation. Clearly, the generally unimpressive link between

trauma and dissociation, when it is apparent, and limits in earlier sociocognitive accounts in

providing comprehensive modeling of DID (see Lynn et al., 2019a), underscores the necessity

of expanding our consideration of moderators and mediators of DID symptoms and other

dissociative conditions. We suggest that an “open” multifactorial approach, which integrates

the strengths of competing models (see Lynn et al., 2019a) and considers more recent data on

the roles of sleep disturbance; generalized stress (apart from trauma); deficits of self-

awareness, self-regulation, and representation; and hyperassociativity, provides the best

opportunity to capture the complexity of dissociative disorders and to delineate multiple

pathways to understanding and treating dissociative conditions.

23
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