eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect: Dissociative Identity Disorder

Author: Muhammad Waseem, MD, Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Coauthor(s): Muhammad Aslam, MD, Clinical Fellow, Department of Newborn Medicine, Children's Hospital Boston; Richard M Switzer, Jr, MD, Consulting Staff, Department of Pediatrics, Brooklyn Hospital Center; Orlando Perales, MD, Associate Director of Pediatric Emergency Services, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Contributor Information and Disclosures

Updated: Nov 28, 2007

Introduction

Background

Dissociation is the disruption of the normal integrative processes of consciousness, perception, memory, and identity that define selfhood.

Dissociative identity disorder is increasingly understood as a complex and chronic posttraumatic psychopathology closely related to severe, particularly early, child abuse. Many studies have revealed early severe abuse to be associated with an increased risk for various psychiatric conditions, including dissociative identity disorder. This condition manifests with an emergence of 2 or more personality states including auditory hallucinations, severe depression and suicidality, phobic anxiety, somatization, substance abuse, and borderline features that partially or fully predominate the psychologic function of the individual for a period.

The deleterious effects of childhood abusive experiences on growth and development have been well documented and are associated with various later mental health problems. Diagnosis of dissociative identity disorder is not usually made until adulthood, long after the extreme maltreatment thought to engender the condition has occurred. Therefore, although the most common cause of the disorder is agreed to be early, ongoing, extreme physical and/or sexual abuse, accounts of such abuse are usually provided retrospectively by the patient and lack objective verification. Researchers have shown that, in many instances, borderline personality disorder and posttraumatic stress disorder (PTSD) in adulthood may be traced to childhood abuse.

The existence of significant dissociative psychopathology related to physical and sexual abuse experienced in childhood was known to clinicians in the last century. However, only recently have modern mental health practitioners begun to appreciate implications of this forgotten linkage.

Clinical and research reports indicate that a history of physical and sexual abuse in childhood is more common among adults who develop major mental illness than previously suspected. Various degrees of dissociative disorders are recognized, ranging from passive disengagement and withdrawal from the active environment to multiple personality disorder (MPD), a severe dissociative disorder characterized by disturbances in both identity and memory and best understood as a posttraumatic, adaptive dissociative response to the fear and pain of overwhelming trauma, most commonly abuse. Fully expressed MPD is not often diagnosed as such in the pediatric population; however, other forms of dissociative disorders are not uncommon, as described in this article.

Pathophysiology

Dissociation is a psychophysiologic process that alters a person's thoughts, feelings, or actions so that, for a time, certain information is not associated or integrated with other information as it normally is. This process, which manifests along a continuum of severity, produces a range of clinical and behavioral phenomena involving alterations in memory and identity. In extreme cases, the process gives rise to a set of psychiatric syndromes known as dissociative disorders. Not all abused children develop a dissociation disorder; however, studies have shown that abused children demonstrate more dissociation than nonabused children do.^1,2

Regarding MPD, Kluft's reports from 1984 and 1987 view the condition as a chronic dissociative PTSD originating in childhood.^3,4 He has proposed a 4-factor theory to explain the genesis of MPD, as follows:

• Individuals have an innate potential to dissociate that is reflected in hypnotizability ratings.
• Traumatic experiences in early childhood may disturb personality development, leading to greater potential for psychodynamic dividedness.
• Individuals may be denied the chance to spontaneously recover because of continued emotional and/or social deprivation.
• Final presentation is shaped by psychodynamic and extrinsic factors, including psychosocial influences.

Frequency

United States

True prevalence is unknown; however, dissociative identity disorder has been shown to be more common than previously thought. Abuse may be the hidden feature in patients who are the most difficult to diagnose and treat. In 1984, by studying psychiatric inpatient charts, Carmen et al and Mills et al proposed a relationship between history of abuse and certain indicators of the severity of psychiatric symptoms.^5,6

Incidence of child sexual abuse is difficult to estimate, partly because of differences in its definition and the varied factors that can contribute to its impact, including the age of the victims (ie, very young children who are not able to verbally report it), the relationship to perpetrators, and the characteristics of the family. People who have been sexually abused are often unaware of the possible relationship between their presenting symptoms of dissociative disorder and the sexual abuse. Even when seeking psychotherapy, patients rarely disclose abuse; they may feel ashamed to talk about it.

Since mandated reporting began in the 1960s, the number of reports to children's protective services (CPS) and law enforcement agencies has steadily increased. Reports of all types of abuse increased from 669,000 children in 1976 to 3 million in 1995 (1 out of every 25 children).

International

Pathological dissociation is less well known in certain parts of the world, especially in China. It can be easily detected among psychiatric patients but is much less common in general population. It is more frequent among subsamples of population with previous evidence of emotional or psychiatric trauma.

Mortality/Morbidity

An estimated 2000 children die each year of abuse. Head trauma is the most common cause of death from physical abuse. Intra-abdominal injuries from impacts are the second most common cause of death.

Race

No racial group is exempt. Abuse has been reported from most racial, religious, and socioeconomic groups of people from most geographic, educational, and occupational backgrounds.

Sex

Girls experience childhood sexual abuse more commonly than boys, with a female-to-male ratio of 10:1. Girls, more than boys, are most at risk for sexual abuse. Edwards reported a significantly higher prevalence of childhood sexual abuse in women and a significantly higher prevalence of childhood physical abuse in men.⁷

Age

Because most abuse cases occur during the preschool years, children may be particularly vulnerable to dissociation during those years. In 1991, the National Child Abuse and Neglect Data System indicated that 24% of 838,232 reports were for physical abuse and that 7% of children who were abused were younger than 1 year, 27% were younger than 4 years, and 28% were aged 4-8 years. The rate of reports decreases for older children. Early age at onset was also correlated with a higher degree of dissociation.

Clinical

History

Because children normatively exhibit age-related differences in levels of dissociative behavior, exhibiting fantasy play and displaying various parts of their personalities in various settings, the clinician must determine if a particular behavior deviates from that of other children of the same age and if a child is exhibiting dissociative symptoms.

Children have a much poorer sense of continuity of their behavior and the flow of time than adults do. Symptoms such as the sense of loss of time are not easy for children to discern. Even well into adolescence, children may not recognize loss of time or discontinuity of experience as unusual or abnormal experiences. In fact, discontinuity of experience is probably the norm for young children; it is consistent with the cycle through sleep and drowsy states and is developmentally appropriate for children to find themselves in new or changed surroundings without awareness of passage of time. This is qualitatively distinct from the loss of time of dissociation, during which the individual is awake.

Dissociation reflects disruptions in the integration of memories, perception, and identity into a coherent sense of self. Disruptions in identity may assume the blurring of boundaries between a child's self and fantasy characters. Important to note, however, is that in young children, dissociation is often viewed as a normative process related to imagination and fantasy capacity.

Dissociative phenomena is divided into 2 categories: detachment and compartmentalization. These 2 factors have diverse natures and manifest as conversion disorder, hypnosis, dissociative amnesia, and dissociative identity disorder.

• Dissociative identity disorder is characterized by the existence of 2 or more personalities within the individual. Clinically, only one of the personalities is present at any given moment, and one of them is dominant most of the time.
• The various personalities are almost always quite discrepant and often seem to be opposite. The original personality usually has no knowledge of the other personality. When a given personality is dominant and interacting with the environment, the other personalities may not perceive all that is happening.
• Each personality is well integrated and is a complex aggregate of unique memories, behavior patterns, and social relationships that control each individual's function during its dominant intervals.
• Transition from one personality to another is sudden, often dramatic, and usually precipitated by stress.
• Patients with dissociative disorder have associated borderline personality disorder, somatization disorder, major depression, PTSD, and history of suicide attempt more often than other psychiatric patients. Childhood sexual abuse, physical neglect, and emotional abuse are strongly associated with dissociative disorders. 
• Other, more subtle, signs of dissociation may be present, such as episodes of amnesia or blackout in the absence of substance abuse, the patient referring to himself or herself as we, the patient being told by others of behavior he or she does not recall, or the patient being greeted by people he or she does not know. A patient may miss objects that cannot be accounted for or find objects or samples of strange handwriting.
• Fugue states, sleepwalking, and automatic writing may represent dissociation.
• A child who is experiencing dissociative symptoms may appear withdrawn, frightened, or uninvolved.
• Frequently, the child is identified as being "different" from other children, although referring clinicians, caseworkers, foster parents, and teachers are often at a loss to characterize the differences.
• Children with dissociative disorders exhibit a plethora of fluctuating abilities, moods, fears, and anxieties; shifting preferences; inconsistent knowledge; and other evidence of erratic access to information and skills.
• Auditory hallucinations are present in most children and adolescents with dissociative disorder; however, "phobic" hallucinations in severely stressed children and young adolescents do not necessarily indicate an enduring psychotic disorder and may be transient phenomena.
• Initial or short-term effects of abuse include early reactions occurring within the first 2 years of termination of abuse.
  • Emotional reactions and self-perceptions
    • In 1981, Anderson et al reviewed clinical charts of 155 female adolescent sexual assault victims and reported psychosocial complications in 63% of them.⁸
    • Tuft's researchers found differences in the amount of pathology reported for different age groups.⁹ The highest incidence of psychopathology was found in children aged 7-13 years. Of the group aged 4-6 years, 17% met the criteria for clinically significant pathology. The following reactions are found to be common among patients who have been abused: breaking down emotional impact into specific reactions, anger and hostility, and guilt and shame.
  • Effects of sexual abuse on sexuality: Reactions of inappropriate sexual behavior in patients who have been sexually abused are well documented. Patients with dissociative disorder are more likely to have experienced childhood physical abuse and childhood sexual abuse than patients with other psychiatric conditions.
  • Effects on social functioning: People who have experienced sexual abuse are also found to have problems in social functioning, including the following:
    • School difficulties
    • Truancy
    • Running away from home
    • Delinquency
• Long-term effects are noted in the same areas.
  • Emotional reactions and self-perceptions: Depression, anxiety, and tension are the most commonly reported long-term problems among adults who were molested as children.
  • Impact on interpersonal relations
    • Difficulty in parenting and responding to their own children
    • Difficulty trusting others
    • Fear, often undifferentiated
    • Hostility
    • Sense of betrayal
  • Effects on sexuality
    • Problems with sexual adjustment
    • Promiscuity (increased level of sexual behavior)
  • Effects on social functioning
    • Prostitution
    • Substance abuse

Physical

• Suspect physical abuse when a child who presents with possible dissociate disorder has an injury is unexplained, unexplainable, or implausible.
• Bruises are the most common manifestation of child abuse and may be found on any body surface.
• Approximately 10% of cases of physical abuse involve burns. A burn's shape or pattern may be diagnostic when it reflects the pattern of an object or method of injury.

Causes

• No evidence suggests any biological cause for dissociative identity disorders.
• Traumatic experiences in childhood may enhance the individual's ability to dissociate. In 1986, Putnam et al reported the highest correlative figures; 97% of patients with MPD were reported by their clinicians to have a history of abuse in childhood.¹⁰ Sexual abuse, usually incest, was reported in 75% of those cases.
• Middleton provided early photographs and school reports that provided further suggestive evidence of childhood disturbance.¹¹
• In 2001, Macifie documented that maltreated children, especially children who were physically and/or sexually abused, demonstrated more dissociation than did normally treated children.¹²
• Gast reported high prevalence of traumatic experiences during childhood.¹³ Of the participants in this study, 85% reported some sort of childhood trauma.
• In Sar et al's 2004 study, the rates of reported childhood physical and sexual abuse were 44.7% and 26.3%, respectively.¹⁴
• MPD tends to have its origin in early childhood, from age 2.5-8 years, and issues arise during adolescence. Traumatic childhood experiences, especially of physical abuse and neglect, are reported to be common in people who develop MPD. How these traumatic experiences lead to a presentation of MPD in later life is unclear.
• The effects of exposure to situations of extreme ambivalence and abuse in early childhood may be coped with in a psychodynamic formulation by an elaborate form of denial so that the child believes the event to be happening to someone else. This process may be facilitated in childhood, a time with a rich fantasy life that often includes imaginary companions.

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