Higher integration scores are associated with facial emotion perception differences in dissociative identity disorder
Introduction
Dissociative identity disorder (DID) is a posttraumatic coping response associated with chronic childhood trauma (Dalenberg et al., 2012; Putnam, 1997). Contrary to popular opinion, DID is relatively common, with an estimated 1–3% lifetime prevalence rate in the population (Dorahy et al., 2014), and upwards of 14% prevalence in psychiatric emergency departments (Şar et al., 2007). It is associated with both significant personal and societal burden. For example, individuals with dissociative disorders experience high levels of self-harm and suicidality (Foote et al., 2008). Approximately three-quarters of individuals with DID report a history of at least one suicide attempt (Putnam et al., 1986). A Canadian healthcare study estimated a $75,000 cost to treat one person with DID for one year if they had not yet been properly diagnosed (Ross and Dua, 1993). Costs drop considerably as individuals receive specialized treatment (Myrick et al., 2017). However, on average someone with DID takes seven years to be diagnosed correctly , and subsequently access this specialized treatment (Putnam et al., 1986; Ross and Dua, 1993). Despite high prevalence rates and substantial burden, DID and DID recovery have remained understudied.
In addition to other posttraumatic symptoms, individuals with DID experience profound identity alteration in which their own thoughts, emotions, feelings, memories, bodily experience, and behaviors can feel non-autobiographical (Dell, 2006; Dell and Lawson, 2009). This occurs because childhood trauma has disrupted the typical developmental process of building a cohesive sense of self (Putnam, 1997). During traumatic episodes, experiencing some thoughts, feelings, and behaviors as not happening to oneself serves a protective role by limiting the psychological and biological impact of the traumatic events (van der Hart et al., 2006; Weniger et al., 2013). This subjective experience suggests there has been an interruption in autobiographical memory formation. Because these same autobiographical memory systems are vital during development for building a cohesive sense of self, this acutely protective response may lead to long-term autobiographical memory dysfunction (Huntjens et al., 2014). Despite these consequences, this distancing effect from traumatic experiences and disruption in one's sense of self may also help preserve attachment bonds to abusive caretakers (Freyd, 1996).
In contrast, recovery from DID is associated with the process of integration. The process of integration includes the development of a sense of self-ownership over one's mental and bodily experience (i.e., “personification,” van der Hart et al., 2006). Past research has linked increased integration in DID samples to decreased amnesia, dissociative, somatoform, depressive, and posttraumatic stress disorder (PTSD) symptoms (Coons and Bowman, 2001; Ellason and Ross, 1997; Kluft, 1984). Behavioral tests also suggest integration is associated with a restoration of self-referential processing to one's own face for individuals with DID (Lebois et al., 2019). These findings suggest that at the core of feeling integrated are properly functioning autobiographical memory systems, and that increasing levels of integration, at least in part, may reflect the restoration of properly-functioning autobiographical memory systems. Despite this foundational work, the relationship between integration and the perception of other peoples' faces, in particular facial emotion perception, is unknown. Facial emotion perception is intricately tied to social perception and functioning (e.g., Chanes et al., 2018) – suggesting this might be a key behavioral marker of improved social functioning and recovery from DID.
There is reason to hypothesize that emotion perception may be impacted by the process of integration in DID. Namely, our emotion concepts are constructed over time based on stored memories of our prior experience (e.g., sensorimotor and interoceptive experience; Barrett and Simmons, 2015). These stored experiences are used to make predictions about incoming sensory input (Barrett and Simmons, 2015; Clark, 2013). In this way, our current (emotional) experience is a construction based on interplay between both stored knowledge (past experiences), and incoming sensory inputs (Barrett, 2017). Perception of another person's emotion is this same process unfolding dynamically between two people (Gendron and Barrett, 2018). Therefore, our perception of another person's emotion is shaped by our own prior experiences of that emotion. For individuals with DID, childhood maltreatment (da Silva Ferreira et al., 2014), and a felt lack of ownership over feelings and emotions may impact their emotion concepts, and therefore their perception of other people's emotions. Likewise, recovery from DID associated with increased integration might be accompanied by changes in emotion perception. To date, these associations remain unexplored. Greater understanding of the changes associated with integration would facilitate evaluation of treatment progress and point toward optimal or novel treatment strategies.
To conduct a conceptual replication of symptom reductions associated with integration, and to also conduct a novel test of the relationship between integration and emotion perception, we recruited individuals with co-occurring PTSD and DID to participate in a web-based study. Participants completed a battery of self-report symptom measures, including the Integration Measure, and a test of emotion perception called the Belmont Emotion Sensitivity Test, which measures sensitivity to facial expressions of happiness, anger, and fear (Rutter et al., 2019). We hypothesized higher integration would be associated with lower depression, PTSD, and dissociative symptoms. We also predicted participants’ integration level would interact with emotion category on the Belmont Emotion Sensitivity Test.
Section snippets
Participants
Participants were 125 respondents to a cross-sectional web-based study. Participants were excluded for not being fluent in English (N = 3), and not passing validity checks outlined below (N = 16). Of the remaining participants (N = 106), 82 met criteria for both provisional PTSD and DID diagnoses based on the PTSD Checklist for DSM-5 and the Multiscale Dissociation Inventory, respectively. The demographics and clinical characteristics of these 82 participants are outlined in Table 1, Table 2.
Integration and psychiatric symptoms
Correlation analyses revealed higher integration scores were associated with lower depression severity on the modified BDI-II, r(80) = −0.34, p = .002, lower overall PTSD symptom severity on the PCL-5, r(80) = −0.23, p = .014, and lower autobiographical memory disturbance severity on the MDI, r(80) = −0.27, p = .015. No associations were found between integration and childhood trauma severity or the other MDI dissociation subscales (p's > 0.05).
Belmont Emotion Sensitivity Test accuracy
We hypothesized there would be a significant
Discussion
Recovery from DID is associated with integration, a process that includes a felt sense of self-ownership over one's thoughts, emotions, and bodily experiences (van der Hart et al., 2006). A small body of foundational work suggests integration is associated with improvement in dissociative, PTSD, and depressive symptoms (Coons and Bowman, 2001; Ellason and Ross, 1997; Kluft, 1984), and increased self-referential processing to one's own face (Lebois et al., 2019). However, small sample sizes and
Conclusions and clinical implications
This was the first study of its kind to measure the impact of integration on facial emotion perception in co-occurring PTSD and DID. We have contributed to theoretical accounts of emotion in that our results suggest learning underlies emotion. That is, emotional conceptualizations entrenched in memory from repeated abuse and neglect may be changed by learning more adaptive conceptualizations over time (e.g., in psychotherapy). We have also identified a potential objective behavioral marker of
Funding sources
The work was supported by National Institute of Mental Health (NIMH) grant K01MH118457 to LAML, and the McLean Hospital Trauma Scholars and Trauma Initiative Funds to MLK.
Role of funding source
Funding sources had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Data sharing
The data that support the findings of this study are available from the corresponding author upon reasonable request.
CRediT authorship contribution statement
Lauren A.M. Lebois: Conceptualization, Methodology, Formal analysis, Investigation, Resources, Writing - original draft, Supervision, Project administration, Funding acquisition, Writing - review & editing. Cori A. Palermo: Writing - review & editing. Luke S. Scheuer: Software, Writing - review & editing. Evan P. Lebois: Data curation, Writing - review & editing. Sherry R. Winternitz: Writing - review & editing. Laura Germine: Conceptualization, Methodology, Software, Resources, Supervision,
Declaration of competing interest
The authors declared no conflicts of interest with respect to the authorship or the publication of this article. Dr. Lauren Lebois reports grants from the National Institute of Mental Health during the conduct of the study. Dr. Kaufman reports support from the Trauma Initiative Fund and the Trauma Scholars Fund at McLean Hospital during the conduct of the study.
Acknowledgments
The authors would like to thank our study participants, Jaime Pollack and an Infinite Mind for recruitment facilitation, and Kerry Ressler for feedback.
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