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pseudogenic, iatrogenic or traumagenic? how do we know that DID is real?

carolyn spring

Pseudogenic, iatrogenic or
traumagenic? how do we
know that DID is real?
So Im curious. On what do you base me but also for hundreds of people I
your belief in DID? have come across in the last couple of
This was a tweet I received from a
fellow twit based in the US a few I had never heard of the terms Carolyn Spring
months ago. The more I use social dissociation or dissociative identity
media, the more I realise how disorder until just a few years ago. I Carolyn Spring is a freelance
controversial Dissociative Identity hadnt even come across multiple writer and trainer and is a DID
Disorder is. For me, after the last 5 or personality disorder and I first read survivor of extreme childhood
6 years, it is normal. I write about it, the book Sybil about three years ago,
abuse. She is also Director of
I train about it, I read about it and and watched the film for the first time
most importantly of all, I live it on a just a couple of years ago. I hadnt PODS and TASC.
daily basis. So Im always surprised been exposed to any other media
when I come across the DID-deniers, representation of DID that I am aware
the majority of whom seem to be of. Despite my wide reading and This case has been the subject of the
based in America. If I do a search for education, Gollum and Smagol are spotlight in recent months as a new
dissociative identity disorder on the nearest I had come to it, and book has been published. Written by
Twitter, on a daily basis I can come certainly no-one was using technical Debbie Nathan and entitled Sybil
across dozens of tweets from people terms to describe them. Exposed: The Extraordinary Story
mocking it, making a joke out of it Behind the Famous Multiple
One of the arguments against DID is
(some of them stupefyingly tasteless, Personality Case (2011), it gives
that it is a disorder created by therapy
some actually quite amusing), and proof that the allegedly true story
it is iatrogenic; literally, its origin is
most of all attacking its credibility as was fabricated. (I am yet to
in the treatment. So someone may
a psychiatric diagnosis and in fact its understand why anyone thinks a true
go into hospital for a back operation
very existence. story is true when Hollywood is
during which the bowel is ruptured.
So when someone I have never met The ensuing problems with the bowel involved ) But a number of
tweeted me to say, So Im curious are iatrogenic they were caused by newspapers, magazines and websites
on what do you base your belief in the surgery, the treatment itself. And have devoted numerous column
DID? it got me thinking. How to one of the arguments is that DID is inches to discuss the books findings
answer? How can I take the totality caused by the therapist, planting the and some have therefore by
of my life, the first-hand, this-is-it suggestion that we have multiple extension decided that DID does not
experience I have had over the last personalities. Either consciously in exist at all as a valid diagnosis.
few years, and construct out of it order to please, or at a completely I stand up in public on a regular basis,
some argument that would prove unconscious level, we then develop have written numerous articles, am in
that DID exists? the symptoms expected of us. This is the process of writing a book about
the argument levelled at Sybil, and DID, and yet I got a cold shiver down
The reality is that all of us will believe
Simone Reinders, a neuroscientist my spine when I first read about the
what we want to believe, and all of us
involved in studying DID (and who expos of Sybil. The thoughts that
will deny what we want to deny, and
does in fact believe that DID is a valid ran through my head were: Am I
if I am responding to sceptics in the
diagnosis), concedes that Sybil was a making it all up too? Am I a fraud, a
hope that I can change their mind, I
manufactured iatrogenic case of fake? Is this all a case of false
am wasting my time. What interests
multiple personalities Sybil was memories and am I just
me more is thinking about the
manufactured through hypnosis, subconsciously trying to please my
journey that I myself have been on
pentothal and a close involvement therapist? Am I in fact more mad and
that has got me to this point of
between subject and more bad than I realised?
believing that DID is a valid diagnosis
therapist (Reinders, 2008, p.45).
and a very real experience not just for

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pseudogenic, iatrogenic or traumagenic? how do we know that DID is real? carolyn spring

I know a lot of people with DID, and a pregnancies and tell people because a therapists room.
lot of them struggle to believe that of their own emotional needs that
I had what I would term my first
they have DID. They struggle to they are having a baby when they are
breakdown during my second year
believe that they had a traumatic not. Just because this is the case
at University. For several weeks I was
history, and they struggle to believe doesnt mean to say that pregnancy
found at various times by various
that the plethora of symptoms which does not exist. The evidence for that
friends in College wandering around
plague their lives on a daily basis are is a little bit obvious. So Im not
vaguely in the middle of the night,
anything other than a sign that they particularly fussed about whether the
staring into space or rocking, and
are intrinsically bad or hopelessly case of Sybil is proved to be true or
acting and speaking in a childlike
mad. Many of us with DID hate our false. Some may argue that it is a
manner. They reported that I was
diagnosis, are deeply ashamed of it, public relations disaster for DID, but I
not myself, that I seemed to be
and as a result dont want anyone dont think it is. I actually think that
afraid of the men coming, that I
else to know about it. When people the further away we can move from a
didnt like the ropes and so on. I had
start writing articles in newspapers, stereotype of multiplicity, and the
absolutely no motivation whatsoever
magazines and blogs claiming that model of Sybil as a kind of gold
to do this for attention or secondary
DID doesnt even exist, it is deeply standard for DID, the better it will be
gain at the time it remains one of
distressing to us. On the one hand, for all of us. There is no doubt that
the most painfully embarrassing and
we would like nothing more than to Sybil the book, but especially the
shameful times of my life. I was at
discover that we dont have DID after film brought Multiple Personality
Cambridge University, a high-flying
all that we dont have multiple
student with significant academic
personalities; that we dont have a
potential, and I was acting mad and
horrific history of childhood trauma
in a way that just resulted in me
or neglect; that we dont have the further away we being ostracised from my peer group
fundamental divisions in our psyche
and brought me to the stern and
between Apparently Normal can move from a unforgiving attention of the College
Personalities and Emotional
Personalities (van der Hart et al, stereotype of tutors, whose pastoral care of me
had as its only goal my achieving a
2006). On the other hand, we would multiplicity, and the First. I was mortified at what was
be terrified: if this label, weird and
reported back to me about what had
incomprehensible though at times it model of Sybil as a kind taken place during these episodes of
is, doesnt describe what is going on
of gold standard for lost time. I would have done
for us in our daily lives, what on earth
anything to stop them happening
is wrong with us? And if we just think
we have parts or alters (or whatever
DID, the better it will be and for me not to suffer the loss of
respect and reputation that resulted
other term we prefer to use), when for all of us. in that most demanding of
actually they arent real and they
have just been created by the
therapist who was supposed to be After I left College a couple of years
helping us then what hope is there Disorder into public consciousness. later, again I suffered a kind of
for recovery for us, when we are But there is also an argument that it breakdown during which suicidality
suffering from a non-existent provided a skewed representation of and self-harm were once more high
disorder, and the people who are what Dissociative Identity Disorder on the agenda. Friends would report
supposed to be helping are actually actually is a caricature that it is very strange behaviour, especially that
the ones causing the problem in the difficult for us all now to get away which would appear to be from a
first place? from. much younger part of me,
accompanied by inconsolable terror
Of course, there is some false logic in So, firstly then, is DID real? The and accounts of horrific abuse. I did
the argument that just because Sybil iatrogenic argument for DID, also my best to hide it all. I didnt want
was a manufactured iatrogenic case know as the sociocognitive model, is anyone to know. I was shamefully
of multiple personalities (Reinders, that either at a conscious or an afraid that I was insane and that if I
2008, p.45) and lets face it, just unconscious level, the dissociative went to a GP about it, I would be
because a journalist says that it was, phenomena such as multiple parts of admitted to a psychiatric ward and
doesnt make it so it doesnt mean the personality are created, or never let out again. I feared for my
that genuine DID doesnt exist. encouraged, or exaggerated as a job, my career, my ability ever to
Sometimes in our black-and-white, result of expectations from the form a relationship or marry or have
splitting mentality, we strive to therapist. Where this argument kids. I didnt want anyone to know,
adopt a position that is totally true immediately falls down in my case is so my bizarre behaviours were kept
or totally false. There are some that I had dissociative symptoms to a couple of discreet friends, one of
people who experience pseudo- many, many years before I first sat in whom was my housemate and from

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pseudogenic, iatrogenic or traumagenic? how do we know that DID is real? carolyn spring

whom it was impossible to hide quite that I could just get better quickly either of us that there might be a
so much insanity. and quietly. name for it, a label to describe it, and
that it was something that other
It was over ten years later before I It took about 3 months for parts, or
people did too. I think I just assumed
began to have counselling. By then, alters to appear in counselling. I was
that it was part of my inherent
in 2005, I had suffered a catastrophic mortified to realise that I didnt know
badness and that I needed to keep
breakdown which affected every area what had gone on for most of the
on trying, and maybe a bit harder, to
of my life, and for nearly a year I session that day. Perhaps it was
stop it.
teetered on the edge of existence, because wed had to use a different
trying to cope with life by day whilst room. I dont know what triggered it, And then one day in my session,
at night a whole series of alter but I did have towards the end of the towards the end, my therapist
personalities or parts made session that familiar sense of waking produced a booklet about trauma
themselves known to my husband up from a deep dream and not being and dissociation, and suggested I
and one close friend. Again, we hid able to quite remember what we had read it. I took it away and devoured it
everything. I didnt want anyone to just been talking about. In private, I instantly, and there was that awful,
know. I was deeply ashamed. I berated myself, lectured myself in a stomach-sinking feeling that I was
wouldnt even see the GP about must do better kind of a way, and reading something that described
normal stuff, in case she somehow hoped against all hope that I hadnt me. Suddenly it it being the
figured out what else was going on. messed the whole thing up by acting madness of my behaviour had a
My husband met parts of me called weird. It was the Summer months name: Dissociative Identity
Diddy, who was 4 years old, and anyway and so sessions were a little Disorder. I sat and tried to argue
Charlie who was an 8-year-old boy, more ad hoc than they had been up with it, pointing out all the ways that I
and Switch, who was again male to that point. I was relieved, because wasnt an exact match and that it
and about 12. And then, eventually, it gave me a break to pull myself didnt really apply to me, but at the
at the end of ourselves, after 13 together and make sure that I didnt beginning of my next session, we
months of chaos and not being able lose time again. talked about it together. Is this
to keep it hidden any longer, I started me? I asked. What do you think?
And Im not sure what happened
counselling. came back the reply. Is this what
next, but I do know that lost time
Ive got? And again: What do you
But I entered therapy with the became a feature of our sessions and
think? I shrugged. Maybe. I
express intention of not that it became a kind of talked-about
hoped: Maybe not.
dissociating. I dont know where I -but-not-talked-about thing. It just
had picked the word up from. I had seemed a natural and logical A few months later I started to see a
read a lot of books to try to make extension of what had gone on in our new therapist. This new one had lots
sense of what I was experiencing, and earlier sessions, where I had watched of experience working with DID. I
was shocked to realise that the myself talking but from a distance decided to play it cool, try to get her
flashbacks of abuse I was and wondered what on earth I was to realise that I wasnt mad, that I was
experiencing, the guilt, the shame, going to say next, because I had no just a normal member of society, just
the self-harm, the anger, the idea. I had listened to myself talk like her. But by the end of the first
insomnia, the physical pain, the about a rape in a stables, and I really assessment session, to my horror, 14
edginess, the hypervigilance, the and literally didnt know what of my alters had introduced
startle reflex, the panic, the confusion happened next until I said it. Then I themselves to her. I came back into
all of it was normal. The nearest I would go home and beat myself up the room with that foggy sense of
could get to an accurate label was for lying and making it all up, and yet having been somewhere but I
post traumatic stress disorder. with a deeply anxious sense that I couldnt quite remember where, just
wasnt, and that it was true, and that I like in a dream. Do you think Ive got
But somehow, somewhere, the word
knew it was. But on an emotional DID? I asked. I was desperately
dissociation played a role even
level it was certainly easier to believe hoping that she would say no,
though I didnt know what it was.
that I was just making it all up. because then I wouldnt have a label,
And I went into counselling very
I wouldnt have this thing hung
much determined not to mention the A few months went by and the puzzle
around my neck like a millstone that
fact that I had these little episodes of of what I was, the puzzle of what my
marked me apart from normal
lost time, during which my husband behaviour meant, was getting bigger
people and placed me on the other
dealt with a child part hiding under as my behaviour became more
side of the table as I saw it at the
the table who didnt want her wrists bizarre and I lost more and more time
time. In my professional career, I had
to be tied any more. I wanted this during sessions. My husband was
always been on the right side of the
counsellor to help me, not think I was used to it at home, and we look back
table, and I had seen the way that
mad and that I was untreatable. I now and wonder why we never really
people on the other side were
fully intended to be thoroughly tried to figure out what was going on.
treated and referred to, especially
normal while I was in counselling so It just was. It didnt really occur to

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pseudogenic, iatrogenic or traumagenic? how do we know that DID is real? carolyn spring

when they werent there. I never ever that is to say that it was caused by saying is true when you hear
wanted to be on the other side, and early, chronic, extreme abuse, which yourself saying it from a distance and
yet by having a label, having a occurred on an existing fault-line of at the very same moment youre
psychiatric diagnosis, I knew that I disorganised attachment. thinking, But I didnt know that.
would be and I hated it. The experience of co-consciousness,
But I do also believe that we can be
of having two separate and distinct
Oh yes, the therapist replied consciously or unconsciously
but co-existing streams of
breezily, absolutely no doubt about encouraged to present in a more
consciousness, is a very strange
it at all. And she seemed so dramatic way than we need to. We
concept and not one that is easy to
nonchalant about it, as if Id asked can feel the pressure to fit in, to be
explain to people who do not
her if I had brown hair, that somehow proper DID and act and behave
experience it. I have met many,
some of the shame receded, but I still accordingly. This is a fear that many
many people who fear that they are
recoiled inside with that awful sense professionals have, and sometimes
simulating DID because they
that I couldnt get away from facing rightly so, about what happens when
observe themselves as separate
that reality any more. dissociative survivors meet together.
parts of the personality. And often
Will we encourage one another to
According to the iatrogenic model, I what happens is that, because we are
act out, will we simulate each
shouldnt have had any parts or so averse to the dissociative
others symptoms, and imitate what
alters until I started therapy. But diagnosis, and so phobic of the
we think we should be like for
they were there over ten years realities of the abuse that led to that
example, by pretending to switch to a
previously, at College, and afterwards dissociation in the first place, we
younger alter, or exaggerating a
when I left and shared a house with a often declare to ourselves and
switch or childlike behaviour? I think
friend. They were there for a whole especially to our therapists that,
that on occasions this does happen.
year, my annus horribilis of Were not really DID after all were
breakdown and utter insanity, before making it all up. This is one of the
I entered therapy for the first time. arguments used to prove that Sybil
My first therapist, for nearly a year, was making it all up because she
observed what was happening and The experience of co- said so. I dont know the truth in that
eventually, tentatively, suggested a particular case, but it did make me
label that seemed to fit. But she consciousness, of having smile because its a self-directed
wouldnt be definitive about it. It was two separate and distinct accusation I hear on a very regular
left to me to decide that the glove basis from many genuine DID people.
fitted. It was a glove that, if Id but co-existing streams If only we could convince people
wanted to, I could have thrown away, (ourselves included) that we are
and I could have just kept talking of consciousness, is a normal!
about suffering from a breakdown
or even post traumatic stress
very strange concept . But I do also believe that there are
cases of false DID. Some of the
literature on this subject (Reinders,
I eventually completed some 2008; Brand et al, 2006) divide DID
screening tools and when I was cases into traumagenic (ie genuine),
After all, it happens in all groups,
discussing the results of them with iatrogenic (caused by the therapy) or
where there is a convergence of
my GP she started tapping away on pseudogenic (falsified). There is a
behaviour in order to fit in. And the
her computer. How do you spell it? certain amount of research and
same can be true of dissociative
she asked, and dutifully typed in what debate around the issue of
groups. But the same can be true in a
I told her. I sort of wanted something pseudogenic diagnoses, and most
positive sense as well, in that if what
more official than that, but I was also people divide it into two types.
is modelled is good coping strategies,
mortified at even that brief Firstly there is malingering, which is
and control over switching, taking
description appearing on my medical where symptoms are feigned for
responsibility for ourselves and
records. I have since found out that financial, legal or other gain,
appropriate relating, then that can
its best not to volunteer mental including exculpation for crimes. And
have a positive impact and empower
health information if you ever want secondly there is factitious
dissociative survivors to cope well
to get reasonably-priced life presentation, where the person
with their symptoms too.
insurance. feigns symptoms not for financial
I think the vast majority of people reasons, but in order to assume the
The case of Sybil suggests that
with DID that I have met are sick role, to meet personal or
iatrogenic DID is a possibility. I am
genuinely dissociative. And most of emotional needs, or to avoid
equally convinced that in my case,
us worry that we have made it all up, responsibility. This can be at either a
and in the case of many people that I
especially when we are co-conscious. conscious or unconscious level.
know, that is not what has happened.
Its hard to believe that what you are
I believe that my DID is traumagenic,

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pseudogenic, iatrogenic or traumagenic? how do we know that DID is real? carolyn spring

Rogers (1997) estimated that 7-17% p.66). So people who are faking it are the experience of being DID as well.
of psychiatric diagnoses are often a bit over-the-top about it It is fantastical switching between
malingered. As far as factitious they exaggerate. One study personalities, the abuse we suffered
psychiatric diagnoses are concerned, (Welburn et al, 2003) also showed as children, is often so far beyond
that rate is between 0.5% and 6%. that genuine DID patients showed peoples imagination that it seems
Factitious presentation of more signs of distress and that it cannot, must not be real. And
dissociative disorders are somewhere dissociation during the assessment yet it is. Just because something
between 2% and 14% according to interviews than people who were doesnt seem real doesnt mean that
Brand et al (2006). So the research faking it. Boon and Draijer (1999) it isnt: just look at the controversy
literature clearly points to the fact point out in their study that they caused by the revelation that the
that some cases of mental health were able to distinguish between earth is round.
diagnoses, including dissociative genuine and simulated DID because
The other issue that I think is
disorders and DID, are clearly false. real DID people evidenced higher
important is to what extent we may
However, Nijenhuis and van der Hart levels of anxiety, more shame and
hide our symptoms (going one way
make an interesting point that, more conflict over their diagnosis.
down a spectrum), or exaggerate
These problems of malingering, This very much fits with my
them (going the opposite way up that
factitious disorders, and simulation experience of DID its not
same spectrum) in order to have our
are not at all unique to or heightened something that most of us want to
needs met. I am reassured by Klufts
in DID but occur with similar shout from the rooftops and its not
finding that only 6% make their DID
frequency in other genuine mental something that we find easy to talk
obvious on an ongoing basis (2009,
disorders (Nijenhuis & van der Hart about. The majority of people I know
p.600), because this is my experience
2009, p.467). So, yes there is such a are highly conflicted about admitting
of living with DID although I speak
thing as fake DID but at no higher
publicly about having DID, no-one
level than people feigning other
apart from my therapist and my
husband sees my parts. None of my
Again with our black-and-white need friends, none of my colleagues, none
to split, within the DID world we want although I speak of the people in my locality see any
to believe that everyone we meet evidence of me being dissociative,
who claims to have DID is real DID, publicly about having unless there is a perfect storm of
not factitious or malingered, but circumstances and Ive failed to take
clearly a percentage are
DID, no-one apart from notice of the signs that I am heading
subconsciously or consciously making my therapist and my out of my window of tolerance and it
it up. Those of us with trauma has got to the point of being out of
backgrounds generally struggle husband sees my parts. control. Several years ago, that
enough with suspicion, paranoia and happened fairly regularly but
mistrust as it is, so to figure that nowadays it is a rare occurrence as I
maybe around 10% of people we have learned communication and co-
meet who claim to have DID may not operation between the different parts
actually do so is worrying. So can we of me. Generally, its a private thing.
to having DID, and although I am
tell the real cases from the fake ones?
nowadays very public about my But its a reality that everyone
A research study by Coons and experience, that wasnt an easy place people with or without psychiatric
Milstein in 1994 was based on 112 to come to and still has its difficulties conditions will hide their symptoms
consecutive admissions to a for me now. There remain people in if its adaptive to do so. If we need to
dissociative disorders unit and they my normal life whom I dont want to be well to do a presentation at work
found that 10% of them had tell, and from whom I still hide. that has repercussions for our career,
factitious or malingered DID. So how we are likely to mask our symptoms
So is it straightforward then to tell
did they distinguish the real from the as much as we can, even if those are
fake cases of DID from real ones?
fake? An exaggerated, highly only symptoms of a cold. But if we
Well, not really, no. Because as
dramatic clinical presentation, need to make a point to the doctor to
Brand goes on to say, A small group
combined with classic symptoms of get what we need in terms of
(less than 10%) of genuine DID
malingering characterised the medication or treatment or referral,
patients are reported to present in a
malingered or factitious DID cases we all tend to exaggerate our
dramatic fashion, so this indicator
Malingerers often had a history of symptoms. That is normal. And the
may not be reliable (Brand, 2006,
lying, made claims of fantastic and same thing happens within DID as
p.67). In other words, people who are
unbelievable psychological well. Mostly I would say that we try
faking DID seem to have extravagant
symptoms, and refused to allow to hide our symptoms because as
claims to their psychological
information to be obtained from Elizabeth Howell says, DID is a
symptoms, but that is actually part of
collateral sources (Brand, 2006, disorder of hiddenness (2011), but

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pseudogenic, iatrogenic or traumagenic? how do we know that DID is real? carolyn spring

sometimes some of us will compared to a neutral script. The hypotheses such as the theory of
exaggerate our dissociative ANPs had the same kind of blood structural dissociation (van der Hart
symptoms in order to get our needs flow when listening to both types of et al, 2006). I believe that certain
met, and I believe that some of this is script, but there was a difference cases of DID can be iatrogenic. And I
behind what people might label as when the EPs listened to the also believe that it can be
iatrogenic DID. It is not that we do traumatic material in comparison to pseudogenic either factitious (for
not have DID at all and are the neutral script, suggesting that emotional gain, often unconsciously),
pretending (pseudogenic DID, either EPs process or think about traumatic or malingered (for financial or other
factitious or malingering). It is that material differently to ANPs. This fits gain, often consciously).
we can feel that there is a certain way with my experience as an ANP where
But just because some people make it
to be in order to be proper DID, and I can listen to even my own traumatic
up, consciously or otherwise, doesnt
that can be affected by media material and have no emotional
mean to say that it doesnt exist, just
representations such as Sybil and reaction to it, as if it were non-
like the analogy of pseudo-
more recent publications, or by the traumatic. Its as if the brain when
pregnancy. If we could get away
role models around us. Im an ANP does not register trauma
from the Sybil stereotypes, it might
as traumatic its dissociated. Its
So is DID real? Well there is a help, but the sad thing is that we
my EPs who react normally in that
growing body of research to suggest suffered disbelief and denial as
sense to traumatic material,
that you cant fake DID to a children and this is re-enacted for us
responding to it with high anxiety
neuroscientist. There have been a in so many contexts again as adults.
and distress (increased activation in
large number of brain imaging It is distressing enough to suffer from
certain parts of my brain). The ANP
studies using various neuroimaging DID as it is, without the added weight
is actually not normal because they
techniques, including structural of people not believing that it even
are not distressed by distressing
magnetic resonance imaging (sMRI), exists. I am reassured that rates for
material. Thats why we can continue
positron emission tomography (PET false DID are no higher than for any
with normal life as if this stuff isnt
scan) and single photon emission other psychiatric diagnosis. I am also
going on for us, totally switched off
computed tomography (SPECT). It is reassured that there are bodies such
from it.
always hard to speculate about the as the ISSTD and ESTD (European
precise brain mechanisms involved But all the science in the world wont Society for Trauma and Dissociation)
due to the wide diversity of convince people just think global and that they have produced
neuroimaging techniques used and warming nowadays or the dangers of guidelines for treating DID there are
the methodology and focus of the cigarette smoking in the 1960s. At lots of people who take this condition
studies. But there have been four the end of the day I am convinced seriously nowadays. But perhaps, as I
rigorous, larger-scale studies that DID is real because it is part of say on training days, denial of the
(Vermetten et al, 2006; Reinders et my day-to-day existence. I am syndrome is part of the syndrome,
al, 2003, 2006; Sar et al, 2001, 2007) reassured that there are some and so the hardest battle is for us to
which basically suggest that there are scientific studies emerging that believe it ourselves.
differences in the brains of people validate my experience, as well as
with DID compared to others.
For example, Vermetten et al (2006)
looked at the volume of the
hippocampus and amygdala and
found that hippocampal volumes
were 19.2% smaller in people with
DID, and amygdalar volumes were
31.6% smaller in people with DID
compared to those without DID. The
researchers think that the Do you shop at Amazon?
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january 2012 Volume 2 Number 1 multiple parts 24