Dissociation and dissociative disorders: Trauma, controversy, and clarifying evidence - R. J. Loewenstein's "Dissociation debates..." article

By: Tom Cloyd - 8 min. read (Published: 2025-04-16; reviewed: 2025-04-16:2131 Pacific Time (USA))

dissociative disorders research

Photo by Kaleidico on Unsplash

For over a hundred years, the origins and nature of psychological dissociation and the dissociative disorders have challenged our understanding.

We now have sufficient quality evidence to refute numerous myths and falsehoods about dissociation that have persisted for far too long, and to focus on trauma as the central cause of pathological dissociation. We also now have excellent basis for focusing on increased training of mental health professionals and funding of the research that informs them.

Page contents…

Focus article ^

Loewenstein, R. J. (2018). Dissociation debates: Everything you know is wrong. Dialogues in Clinical Neuroscience, 20(3), 229–242. https://pmc.ncbi.nlm.nih.gov/articles/PMC6296396/#sec13 See PDF here: https://pmc.ncbi.nlm.nih.gov/articles/PMC6296396/pdf/DialoguesClinNeurosci-20-229.pdf

 

Loewenstein’s article is of one of the most important ever written on dissociation and the dissociative disorders. This article has it all: history, controversy, scientific perspectives, and more.

In this section is a plain English summary of the article.

  1. Dissociation and the dissociative disorders have been controversial since the beginning of modern psychopathology and psychology.
  2. The controversy comes from and has been supported by lack of facts or denial of facts, as well as the continued assertion of ideas for which there is little or no factual support.
  3. Clear evidence of several kinds supports the association between trauma, especially childhood trauma, and subsequent dissociative mental illness.
  4. Well-executed research studies have shown significant reduction in the frequency and seriousness of symptoms when dissociative disorders are addressed with carefully structured community-based psychotherapy.
  5. Dissociation and dissociative disorders occur in the general population at a rate that is about 10 times that of schizophrenia (~9% prevalence versus <1% prevalence) yet receive a small fraction of research funding, public attention, and attention in professional training given to schizophrenia. A major public health initiative is needed to redress this neglect.

This extended and more technical summary1 was generated by NotebookLM Plus, the version of *NotebookLM available to Google One AI Premium subscribers. I have verified this summary for accuracy.*

The article begins by defining dissociation according to the DSM-5 as a disruption in the normal integration of behavior, memory, identity, consciousness, emotion, perception, body representation, and motor control.

It lists the DSM-5 dissociative disorders: Dissociative Identity Disorder (DID), Dissociative Amnesia (DA) (including Dissociative Fugue as a subtype), Depersonalization/Derealization Disorder (DPDRD), Other Specified Dissociative Disorders (OSDD), and Unspecified Dissociative Disorder (UDD). The inclusion of a Dissociative Subtype in PTSD (PTSD-DS) and dissociative amnesia as a symptom in DID and PTSD are also noted.

A key point is the long-standing debate about the etiology of dissociation and DD. The central question is whether they are fundamentally related to psychological trauma, especially cumulative and/or early life trauma, as proposed by the Trauma Model (TM), or if they are artefactual conditions produced by iatrogenesis (the Iatrogenic Model - IM), socio-cultural factors (the Sociocognitive Model - SCM), and/or the tendency to fantasize trauma (the Fantasy Model - FM). The author states that almost no research or clinical data support the skeptical view.

The TM posits that dissociation is a psycho-biological protective response to overwhelming traumatic experiences. It is often conceptualized as a continuum, but an alternative Taxon Model suggests two continua: normal and pathological dissociation, with the latter affecting a distinct group of highly traumatized individuals. The TM suggests dissociation mitigates the impact of trauma by sequestering information about it.

Empirically supported TM treatment models prioritize safety, stabilization, and modulation of symptoms, contrary to the skeptical belief that they focus on “hypnosis for memory recovery”.

Skeptics view DD as an unscientific fad and propose that conditions like DID are produced in suggestible patients (often with Borderline Personality Disorder - BPD) by clinicians using “risky” techniques like hypnosis to implant false memories of trauma (IM).

The SCM argues that North American culture and media portrayals are sufficient to cause suggestible individuals to believe they have DD. The FM views dissociation as a cognitive trait leading to fantasies of trauma.

These models claim minimal data support the trauma-dissociation link and suggest treating DD by ignoring trauma symptoms, debunking false memories, and focusing on other psychiatric disorders.

The article highlights that DD are among the oldest reported psychiatric disorders, with descriptions dating back to the late 18th and 19th centuries.

Historical controversies about hysteria in the 19th century parallel modern debates about the role of trauma and suggestion. While Charcot initially viewed hysteria as neurological but later included psychological factors, his successor Babinski attributed it to suggestion.

Pierre Janet, however, viewed trauma as central to hysteria and dissociation, with a model similar to the modern TM. Freud initially explored childhood trauma but later focused on Oedipal fantasies, and his followers have generally been skeptical of trauma-based dissociation.

Recent historical research on Charcot’s patients supports the TM by documenting extensive trauma in their lives. Wartime experiences throughout history have also consistently demonstrated dissociative symptoms in response to extreme stress.

Modern study began with increased attention to childhood maltreatment and the diagnosis of PTSD in the DSM-III. The development of reliable and valid assessment tools has allowed for international studies showing a strong link between trauma and dissociation/DD in various populations.

Epidemiological studies in general populations have found surprisingly high prevalence rates for DD, including DID. Studies in clinical populations across different settings also show significant prevalence of DD, often unrecognized.

These findings challenge the IM/SCM/FM paradigms as many identified individuals had no prior DD recognition or specialized treatment and limited exposure to North American media.

The article presents evidence supporting dissociation as a “freeze” response to life-threatening danger. Autonomic changes and the polyvagal theory are discussed. Genetic, developmental, neurobiological, and psychophysiological studies support a model where chronic trauma can lead to a preferential dissociative response.

Studies on PTSD-DS, DPDRD, DA, and DF show distinct neural network patterns involving frontal system activation and limbic inhibition. fMRI studies of DID patients reveal different brain activation patterns for trauma-related and neutral self-states, distinct from simulating controls. Reduced hippocampal and amygdalar volumes in DID patients, potentially linked to chronic stress and glucocorticoid release, are also noted.

Genetic studies suggest a complex interaction between genes (related to the HPA axis, serotonergic, dopaminergic, and BDNF systems) and trauma in the development of dissociation.

Acute dissociative responses to trauma and peritraumatic dissociation are associated with later PTSD.

Contrary to skeptical views, over 70 studies document amnesia for traumatic events. Research has found no difference in accuracy between trauma memories with delayed or continuous recall.

Factors like interpersonal trauma, early life trauma, and betrayal are associated with dissociative amnesia. Studies on the ACE Study population show a correlation between childhood adversity and autobiographical memory disturbance.

DID is conceptualized as a childhood-onset posttraumatic developmental disorder, consistently linked to the highest rates of severe and repeated childhood trauma (sexual and physical abuse) beginning before age 6. Comorbidities like PTSD, depression, and substance abuse are common, as is suicidal ideation and self-destructive behavior.

DID is often underdiagnosed, with patients spending years in the mental health system receiving incorrect diagnoses. The clinical presentation of DID is often subtle, characterized by overlapping states and inner voices rather than dramatic switching, contrary to media portrayals. The elaboration of external self-state characteristics is not essential to diagnosis and can be influenced by socio-cultural factors.

Psychological assessment suggests that early life dissociation can paradoxically be a protective factor, allowing for the preservation of certain capacities.

DID patients show differences from BPD patients, contradicting skeptical models. Studies validate DID as a distinct diagnostic entity.

A developmental model views DID as a failure to integrate a sense of self due to overwhelming early trauma, rather than a “shattered” personality.

Phasic trauma treatment models for DID have shown significant improvement in symptoms, reduced hospitalizations, decreased suicidal behavior, and lower treatment costs in prospective longitudinal studies.

DPDRD is less controversial but often underrecognized. It can have a chronic course and is strongly related to childhood emotional abuse. Effective treatments are still lacking.

The article concludes that there is compelling evidence supporting the posttraumatic basis of dissociation/DD, with meta-analyses refuting the fantasy proneness or confabulated memory arguments of skeptical models.

The author emphasizes the high prevalence of DD and the significant human and societal costs of misdiagnosis and lack of treatment. Elevated dissociation predicts poorer clinical outcomes if not directly treated. Treatment of DID has shown positive outcomes, including reduced self-destructive behavior and costs. The role of dissociation in intergenerational trauma transmission needs further exploration.

The article calls for increased awareness, education in mental health training programs, and funding for research on dissociation/DD. The author critiques the dismissal of DD as a “fantasy” and highlights the “real iatrogenesis” of failing to diagnose and treat these conditions.

Loewenstein, R. J. (2018). Dissociation debates: Everything you know is wrong. Dialogues in Clinical Neuroscience, 20(3), 229–242. https://pmc.ncbi.nlm.nih.gov/articles/PMC6296396/#sec13. See PDF here: https://pmc.ncbi.nlm.nih.gov/articles/PMC6296396/pdf/DialoguesClinNeurosci-20-229.pdf

Note ^

  1. These summaries are offered to address the problem that this article was written for professionals and is not an easy read for the general reader. ^

 

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