Letter From The President

Dear ESTD members,

Who’s afraid of DID? Who’s afraid of Schizophrenia?

In 1962, Edward Albee published a play called, ‘Who’s afraid of Virginia Woolf’, the title of which was a takeoff on the song, ‘Who’s afraid of the big bad wolf?’ from the Disney film, ‘Three Little Pigs’ (1933). Since that time, this expression has been used to address (and sometimes ridicule) fears and concerns people have about various issues.

Here I want to explore the different fears and concerns mental health clinicians and researchers have – in different ways and for different reasons – about DID and Schizophrenia.

For the past 20 years, I have been trying to build bridges between the fields of schizophrenia/ psychosis and trauma/dissociation. This has not always been easy, as there has been resistance, from many quarters, to the reality of DID and severe dissociative disorders. At the same time, there has also been resistance to viewing schizophrenia as potentially psychologically-caused, psychosis as possibly involving responses or adaptations to real life events, and psychological therapy as being effective for persons with this diagnosis.

I laid out some of these issues in a 2011 editorial for the Journal of Trauma and Dissociation, called ‘Schizophrenia, trauma, dissociation and scientific revolutions’, in which I suggested that Thomas Kuhn’s conceptions of ‘paradigms’ and ‘paradigm change’ could help us to understand the impasse in which we have found ourselves. Since that time, however, I have come to believe that there are more than political and philosophically-based ideas behind these resistances; there are powerful fears that drive these biases, fears which we must recognize and address if we hope for change in our field.

Fear of DID

First of all, we must recognize that we are living in a bit of a bubble. Since you are reading this, you are members of the European Society for Trauma and Dissociation. As such, you are likely to have worked with and/or studied about persons with childhood or adult trauma, and many of you will have had contact with persons with DID or severe dissociative disorders (or experienced yourself trauma or dissociation). It is hard to imagine that there is any member of our organization who ‘questions the reality’ of Dissociative Identity Disorder as a concept and diagnosis. Yet, in the broader psychiatric field, this is – astonishingly – a statement that one hears now and again (and yet, does anyone ‘not believe’ in anxiety disorders or depression?). And when DID is not outright denied, it is minimized – many clinicians not working in our field think the condition is ‘quite rare’. As a consequence, none of the major psychiatric assessment interviews, used in population studies for example, include dissociative disorders as one of the diagnoses assessed for, and dissociative disorders are almost never considered in studies of persons diagnosed with schizophrenia. But welldesigned studies of psychiatric patients which do look for dissociative disorders (and there are now at least ½ dozen of these) find a lot – at least 10% undiagnosed severe dissociative disorders (and often much more).

Why is DID so routinely ignored or discounted? And why can such an absurd notion as the so-called ‘socio-cognitive’ model of DID, which posits that bad therapists ‘create’ DID in vulnerable patients, gain traction when there is no evidence to support it, and much good research to rebut it? The passion with which this diagnosis is attacked leads me to believe that there is a powerful, perhaps irrational, fear behind it. While the stories of extensive and sometimes organized sexual abuse in many cases of DID are doubted in these quarters, I believe that it is the nature of DID – a person in the world with several ‘agents’ capable of controlling their actions – that is most threatening to these individuals. That the human self can be fractured and divided under overwhelming circumstances may well be profoundly threatening to those who wish to believe that they are firmly in control of their own lives, and that they do not have dark sides or shadows which can be expressed under some circumstances. This is, of course, simply speculation, but Martin Dorahy and I have put together a task force to examine these issues – the resistance to accepting DID and other severe dissociative disorders as legitimate psychiatric diagnoses. We hope that the results of this investigation will help to illuminate the forces behind such resistance, so that we as a field can better address them.

Fear of Schizophrenia

On the other hand, there is the fear of schizophrenia, which manifests in very different ways. The word itself, schizophrenia, has become highly stigmatized and strikes fear in many persons – not least because media and film portrayals often incorrectly associate it with violence toward strangers. Ironically, the word was originally coined, by the Swiss psychiatrist Eugen Bleuler in 1908, partly because the previous diagnosis dementia praecox was too negative and offered little hope. But he also chose the term, which as is well known means ‘split mind’, because he saw clear connections between this disorder and dissociation.

But these connections were lost as the diagnostic criteria changed through the 20th and 21st centuries, and now the diagnosis of Schizophrenia consists almost exclusively of psychotic symptoms. Why is this a problem? Because psychotic symptoms are common in many disorders, including posttraumatic and dissociative ones, and because many persons assume that psychosis and schizophrenia are one and the same thing. This problem is compounded when we consider that many symptoms normally associated with schizophrenia, particularly the so-called first rank symptoms such as hearing several voices talking with one another or feeling that one’s thoughts, emotions or actions are being controlled by an outside force, are more common in DID than in schizophrenia. But there is a fundamental difference between how these symptoms are viewed in DID, where they are seen as understandable expressions of a fractured self, and caused by life experiences, and in psychotic disorders such as schizophrenia, where they are typically seen as meaningless expressions of a brain disorder, or biological illness, and unrelated to life experiences.

Indeed, my co-author (along with Onno van der Hart) on a chapter about the meaning of the concepts trauma, dissociation and psychosis, Markus Heinimaa, has argued that hidden behind the word psychosis, as it is usually used, is the word ‘incomprehensible’ – meaning ‘not capable of being understood’. This is why the diagnostic manuals (such as the DSM-5) speak of ‘disorganized’ speech or behavior as being psychotic – when, at least sometimes, we probably simply do not recognize their inherent ‘organization’. This is also why, when people find psychotic symptoms in persons who have posttraumatic or dissociative disorders (or no diagnosis at all), the term ‘psychotic-like’ (or ‘quasidelusional’ or ‘pseudo-hallucinations’) is typically employed. But why should psychotic symptoms be meaningless, unconnected to a person’s life experiences? Perhaps we should ask, why should persons want to believe this? I would argue, as Markus Heinimaa has, that believing that psychotic symptoms cannot be understood means that one cannot relate to a psychotic person – that there is a fundamental barrier, a wall, between us. And if there is a wall, it would mean that this could not happen to me – ‘I’m safe. I cannot become mad.’

Again, I am simply speculating, but it seems to me that many persons, including some in our field, want to think of psychosis, of schizophrenia, as something other, something different from them, something that cannot affect (or infect!) them. But this is a convenient and self-serving belief and is, in my opinion, wrong.

The word comprehend is built on the Latin verb, prehendere, meaning ‘to grasp’. When we comprehend, or understand something, we hold it, look at it, contemplate it. People do not want to do this with psychosis, because it is scary and frightening. It is easier to insist that it cannot be understood, so why try? None of us wants to think that we could lose our mind; building a wall, instead of a bridge, between us and psychosis allows us to maintain this illusion.

How to move forward?

So, I would argue, resistances to both DID and schizophrenia are driven by personal fears – the fear that we are not unitary entities and the fear that, under the right circumstances, any of us could go mad (or choose to become mad… but that is another story). Both of these irrational fears need to be understood and confronted. Personal identity can become dissociated, more often than is recognized, and psychosis is (or is almost always) meaningfully connected to a person’s life experiences. All of us should work toward recognizing these biases in ourselves, and helping our colleagues to overcome them. We have to address these barriers if we hope to increase understanding and recognition of DID and other dissociative disorders in our colleagues, and increase awareness of the psychological causes, and effectiveness of psychological therapies, in schizophrenia. Those among us struggling with the consequences of these disorders deserve nothing less. µ

Best wishes,

Andrew Moskowitz

President, ESTD


From ESTD Newsletter Volume 6, Number 3, September 2017



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